PERSONALITY

DISORDERS
CLINICAL FEATURES AND
MANAGEMENT

MODERATOR:
DR. ADARSH TRIPATHI, MD
PRESENTER:
DR.AVNEENDRA SINGH, JR-1
 (2)

(1) DSM
DEFINITION CLASSIFIC
ATION

(3) SPECIFIC (4) OTHER

PERSONALITY PERSONALITY
DISORDERS DISORDERS

CONTENTS
(5)
MANAGEMENT

Presentation Title
 DEFINITION
• An enduring pattern of behavior and inner
experiences, deviates significantly from the
individual’s cultural standards, is rigidly
pervasive; onset in adolescence or early
adulthood; is stable through time; leads to
unhappiness and impairment, and manifests
in 2 of the following four areas: cognition,
affectivity, interpersonal function, or
impulse control. (DSM-5)
 CLASSIFICATION OF SPECIFIC
PERSONALITY DISORDERS
CLUSTER – A CLUSTER - B CLUSTER - C
personality disorders with
personality disorders with personality disorders
dramatic, impulsive and
odd, aloof features sharing anxious and fearful
erratic features
features
NARCISSISTIC
PARANOID PERSONALITY OBSESSIVE COMPULSIVE
PERSONALITY
DISORDERS PERSONALITY
DISORDERS
DISORDER
SCHIZOTYPAL
BORDERLINE PD
PERSONALITYDISORDERS DEPENDENT PD
ANTISOCIAL PD
SCHIZOID PERSONALITY AVOIDANT PD
DISORDERS.
HISTRIONIC PD
 1. PARANOID
PERSONALITY
DISORDERS

CLUSTER – A 2. SCHIZOTYPAL
PERSONALITY
PERSONALITY DISORDERS
DISORDERS
3. SCHIZOID
PERSONALITY
DISORDERS
PARANOID
PERSONALITY
DISORDER
1)EPIDEMIOLOGY:
-Prevalence is 0.5-4.4% in the general population
-higher incidence in relatives of patients with schizophrenia
-More common in men than women.

2)ETIOLOGY:
-Negative childhood experiences, including physical, sexual, and
emotional abuse
-Greater morbid risk in first-degree relatives of an index case with the
delusional disorder than schizophrenia or medical illness.
3)CLINICAL FEATURES

-excessive suspiciousness,
-distrust of others,
-a pervasive tendency to view others’ behavior as malicious, threatening,
exploiting, or deceptive.
-frequently dispute without any justification, friends’ or associates’ loyalty or
trustworthiness.
-They are pathologically jealous without any reason, and question fidelity or
spouses.
-They attribute to others the impulses or thoughts that they cannot accept in
themselves.
-affectively restricted and appear to be unemotional,
-hyper vigilant upon actual insults or betrayals tend to bear grudges
for life.
-They pride themselves on being rational and objective;
-lack warmth and impressed with power and rank.

4)COURSE & PROGNOSIS:

-Disorder is life long,
-frequent problems of working and living with others , along with
marital and occupational problems.
(5)TREATMENT

Psychotherapy.
-treatment of choice
-the first aim is to build trust, as because of mistrust they avoid treatment.
-group psychotherapy can be useful for improving social skills and diminishing
suspiciousness through role-playing.

Pharmacotherapy
-little evidence about the use of pharmacotherapy
-target symptoms, such as the use of low-dose antipsychotics for psychotic
symptoms or the use of anticonvulsants for irritability.
SCHIZOID
PERSONALITY
DISORDER
 (1) EPIDEMIOLOGY :
-rare and affects 3.1 to 4.9% of general population.
-men to women ratio is 2:1

(2)CLINICAL FEATURES:

-have inability to relate to others in a meaningful way.

-Have little or no desire for relationships with others and,
-remains extremely socially isolated with few or no close friends or
confidants.
-Prefer solitary activities, often intellectual such as computer games, puzzles
-often create a fantasy world that they retreat into and substitute for
relationships with real people.
-They rarely marry, have little interest in sex, and
-often work at jobs requiring little interpersonal interaction eg: night
watchman.
-lack emotional expression or affect, usually appear cold, detached,
constricted.
-invests enormous affective energy in nonhuman interests such as
math and astronomy, and may be very attached to animals.
-Although they appear self-absorbed they have a normal capacity to
realize reality.
-As violent activities are rarely part of their normal responses, most
real or imagined threats are met with projected omnipotence or
surrender.

(3)COURSE & PROGNOSIS:

-Onset usually occurs in early childhood or adolescence,
-long lasting but not necessarily lifelong.
(4)TREATMENT
Psychotherapy
-similar to that with a paranoid personality disorder.
- As trust develops, patients who are schizoid, uncover plenty of dreams,
fanciful companions, and fears of dependency
-in group therapy, patients with schizoid personality disorder may be silent for
long periods but they do become involved after a time.

Pharmacotherapy
Limited evidence
The use of psychotropics to target specific symptoms, such as social and
emotional detachment, may be appropriate.
SCHIZOTYPAL
PERSONALITY
DISORDER:
(1)EPIDEMIOLOGY:
-occurs in about 4-6% of the population.
-No gender difference seen.
-Greater association among biological relatives of patients with
schizophrenia
-higher incidence among monozygotic twins (33% v/s 4%.)

(2)ETIOLOGY:
-Considered a schizophrenia spectrum disorder;
-Higher CSF and plasma homo-vanillic acid concentrations correlated with
psychotic symptoms

-lower concentrations correlated with deficit-like symptoms have been found.

-For the above reason it has been classified along with schizophrenia in the
ICD-10 classification.

-greater frontal lobe capacity and reduced striatal dopaminergic reactivity

might protect these patients from developing psychosis and severe cognitive
and social deterioration of chronic schizophrenia.
(3)CLINICAL FEATURES :

-They experience cognitive or perceptual distortions(positive),

-behave in an eccentric manner, socially withdrawn, anxious, disturbed

thinking and communicating(negative).

-distortions include ideas of reference, bodily illusions, unusual telepathic

experiences, inconsistent with cultural norms,

-Their speech is odd, affect constricted, and inappropriate; laugh

inappropriately while discussing their problems.

-Are socially uncomfortable, have few friends, isolation which is due to

eccentric cognitions and behavior,
-lack of desire for relationships due to suspiciousness and persecutory
thoughts
-Patient with severe cases of this disorder may exhibit anhedonia and
severe depression.

(4)COURSE AND PROGNOSIS:

-Lifelong course
-but some marry and work despite their oddities.
-10% eventually commit suicide.
(5)TREATMENT

Psychotherapy
-The treatment does not differ from those of schizoid personality disorder, but
clinicians must deal sensitively with the former
-mainly using care to avoid judging patients’ odd beliefs.

Pharmacotherapy
-Antipsychotic medication may be useful for dealing with ideas of reference,
and illusions, and can be an adjunct to psychotherapy.
-Antidepressants are useful when a depressive component of the personality is
present.
 1.ANTISOCIAL
PERSONALITY DISORDER

2.BORDERLINE
PERSONALITY DISORDER,
CLUSTER – B
PERSONALITY 3.HISTRIONIC
PERSONALITY DISORDER
DISORDERS
4.NARCISSISTIC
PERSONALITY DISORDER
ANTISOCIAL
PERSONALITY
DISORDER
(1)EPIDEMIOLOGY:
-Prevalence is 0.2-3%.
-More common in men than women.
-Highest prevalence in alcohol use disorders, prison populations,
upto75%.
-Onset is before the age of 15 years.
-five times more common in first-degree relatives with the above
disorder.

(2)ETIOLOGY:
-Reductions in whole brain volumes, in temporal lobe in particular,
-brain activation in limbic system is deficient during fear conditioning.
-Neurocognitive impairments in spatial and memory functioning
found.
-Early family lives have absent, inconsistent or abusive parenting.
(3)CLINICAL FEATURES:

-seem normal but have histories of lying, running away from home, thefts,
fights, substance abuse, illegal activities from beginning of childhood.

-They exhibit no anxiety or depression, differ with their situation, although

suicide threats and somatic concerns are common.

-absence of delusions and other signs of irrational thinking

-heightened sense of reality testing and good verbal intelligence.

-Extremely manipulative, talk to others in participating in schemes, which lead

usually to financial losses.

-Promiscuity, child abuse, spousal abuse, substance abuse are common and
notable lack of remorse is seen.
(4)COURSE & PROGNOSIS:

- antisocial behavior usually occurring in late adolescence.

-Prognosis varies.

-Symptoms decrease as person gets older.

-Many have somatization disorder and multiple physical complaints.

-Depressive disorder, alcohol and other substance use disorders are

common as well.
(5)TREATMENT

Psychotherapy
-limited evidence suggests that these individuals seem to respond better to
contingency management and other reward-based interventions than they do to
cognitive behavioral therapy.

Pharmacotherapy.
-For symptoms such as anxiety, rage, and depression, but they often misuse
substances.

-anticonvulsants to treat aggressive behaviors

-Beta-adrenergic receptor antagonists, lithium, and antipsychotics may also

reduce aggression.
BORDERLINE
PERSONALITY
DISORDER
(1)EPIDEMIOLOGY:
-1-2% in general population;
-more common almost twice in women than men.
-An increased incidence of depressive disorder, alcohol use disorders and
substance use is found in first degree relatives.

(2)ETIOLOGY:
-insecure attachments; high frequency of traumatic early abandonment,
physical and sexual abuse,
-69% heritability in twin study.
-Evidence of serotonergic dysfunction causing impulsivity.
-Reduction in frontal and orbitofrontal lobe volume may cause disinhibited
impulses,
-hyperactivity of the amygdala may cause hyper-emotional behavior.
(3)CLINICAL FEATURES:

-Patients always appear in a state of crisis.

-Mood swings are common, argumentative at one moment and depressed at the
other.

-Patients can have short-lived psychotic episodes and psychotic symptoms are
fleeting and circumscribed.

-Behaviour is highly unpredictable, and repetitive self-destructive acts like

slashing wrists, etc.
-As they feel both dependent and hostile they tend to have tumulus
interpersonal relationships.

-To assuage loneliness, only for short periods accept strangers as a

friend or behave promiscuously. They often complain of a chronic
feeling of emptiness and boredom.

(4)COURSE & PROGNOSIS:

-fairly stable throughout life,

-have a high incidence of major depressive episodes.

-Diagnosis is usually made before 40 when patients attempt to make

occupational, marital, and other choices but cannot deal with normal life
cycle stages.
(5)TREATMENT

Psychotherapy
behavior therapy help to manage their impulses, angry outbursts and
reduce their sensitivity to criticism and rejection.
Social skills training helps patients to see how their actions affect others
and thereby improve their interpersonal behavior.
Dialectical behavior therapy (DBT)
most empirical support.
four primary modes of treatment in DBT: group skill training, individual
therapy, phone consultation, and consultation team.
Patients are seen weekly, with the goal of improving interpersonal skills
and decreasing self-destructive behavior
Mentalization-based therapy (MBT).
Is a social construct, that allows a person to be aware of mental
processes and subjective states that arise in interpersonal interactions.
Transference-focused psychotherapy:
Therapist relies on two; firstly clarification in which transference is analyzed
more directly and patient becomes aware of his distortions about therapist,
secondly confrontation where in therapist point out how these transferential
distortions interfere with interpersonal relations.

Pharmacotherapy
-Antipsychotics may help control anger, hostility, and brief psychotic
episodes.
-Antidepressants improve the depressed mood common in patients with a
borderline personality disorder.
-Benzodiazepines should be avoided due to the risk of abuse, also patients
may become disinhibited with this class of drugs.
-Anticonvulsants, such as carbamazepine, may improve functioning for some
patients.
-Serotonergic agents, such as (SSRIs), have been helpful in some cases.
HISTRIONIC
PERSONALITY
DISORDER:
(1)EPIDEMIOLOGY:
-Occurs in 1-2% of the general population.
-More frequent in women than men.
-Association with somatization disorder and alcohol use disorder have been
found.

(2)CLINICAL FEATURES:
-Eager to give out a history
-gestures and dramatic punctuations are common, make frequent slip of tongue,
and language is colorful.
-Affective display is common and when asked to express feelings may respond
with surprise, indignation, or denial.
-Show high attention-seeking behavior, exaggerate their thoughts, and feelings,
temper tantrums, tears and accusations when not the center of attention.
 -Seductive behavior is common in both sexes.
-Relationships tend to be superficial.
-Major defenses are repression and dissociation.

(3)COURSE AND PROGNOSIS:

-With age symptoms reduce, because they lack the energy of earlier
years
-sensation seekers, may get into trouble with the law, abuse
substances, and act promiscuously.

Presentation title 36
(4)TREATMENT
Psychotherapy
-unaware of their real feelings; clarification of their inner feelings is a
necessary therapeutic process.
-Psychoanalytically oriented psychotherapy is probably the treatment of
choice for histrionic personality disorder.

Pharmacotherapy
-adjunctive to target symptoms (e.g., the use of antidepressants for depression
and somatic complaints, antianxiety agents for anxiety, and antipsychotics for
derealization and illusions).
NARCISSISTIC
PERSONALITY
DISORDER
(1)EPIDEMIOLOGY:
-0.5-1% in general population.
-More common in men then women.

(2)ETIOLOGY:
-develops in persons who have fears, failures, or dependency
-responded to criticism.
-They develop a veneer of invulnerability and self-sufficiency that
mask their underlying emptiness and constricts their capacity to feel
deeply.
(3)CLINICAL FEATURES:

-have a grandiose sense of self-importance, consider themselves special, and

expect special treatment,

-fantasies of unlimited potential, a sense of entitlement, need for admiration.

-Handle criticism poorly and become enraged when someone criticises them or
appears indifferent to it.

-They want their own way and are frequently ambitious to achieve fame and
fortune.

-Their relationships are tenuous and can make others furious by obeying
conventional rules of behavior.
-They lack empathy for others and feign sympathy only to achieve their selfish
ends.
-Because of their fragile self-esteem they are susceptible to depression.
-Interpersonal difficulties, occupational problems, rejection, and loss are
common.

(4)COURSE AND PROGNOSIS

-persistent and difficult to treat
-patients handle aging poorly, they esteem excellence, strength, and energetic
traits, which they grip improperly.
-narcissistic symptoms generally reduce after 40 years of age, when pessimism
usually develops.
-Impairment is frequently severe and may include social withdrawal, depressed
mood, and dysthymic or major depressive disorder in reaction to criticism or
failure
(5)TREATMENT

Psychotherapy
-challenging.
-group therapy may help patients to learn how to share with others and, under
ideal circumstances, can develop an empathic response to others.

Pharmacotherapy
-Lithium can help if mood swings are present.
-as they are susceptible to depression, antidepressants, especially serotonergic
drugs, may also be of use.
 1. AVOIDANT
PERSONALITY
DISORDER

CLUSTER – C 2. DEPENDENT
PERSONALITY
PERSONALITY DISORDER
DISORDERS
3. OBSESSIVE-
COMPULSIVE
PERSONALITY
DISORDER
AVOIDANT
PERSONALITY
DISORDER
(1)EPIDEMIOLOGY:

-2-3% in general population.

-May be more common in women then men.

(2)ETIOLOGY:

-Negative childhood memories like isolation, rejection, poorer athletic

performance, less popularity and prenatal neglect.

-inborn temperament - children as young as 21 months manifest increased

physiological arousal and avoidant traits in social situations ex, avoidance of
interaction with strangers; and this social inhibition tends to persist.

-high levels of trait and social anxiety in first degree relatives with generalized
social phobia.
(3)CLINICAL FEATURES:

-Hypersensitive to criticism, and the main trait is timidity.

-Desire warmth of human companionship but avoid due to fear of rejection.

-express uncertainty, show a lack of confidence,

-As they are hyper-vigilant to rejection they are afraid to speak in public or to
make requests to others.

-Misinterpret others’ comments as disrespectful, which leads to feeling hurt and

withdrawn.

-Rarely attain much advancement or exercise authority and seem shy and eager
to please.
-Generally unwilling to enter relationships unless given a strong
guarantee of uncritical acceptance. So don’t have close friends and
confidants.

(4)COURSE AND PROGNOSIS:

-Many are able to function in a protected environment.

-Some marry and live surrounded by just family and if the support
system fails, subject to depression, anger and anxiety.

-Phobic avoidance is common and may give a history of social

phobia.
(5)TREATMENT

Psychotherapy.

- Group therapy help patients understand how their sensitivity to rejection

affects them and others.
-Assertiveness training teaches patients to express their needs openly and to
enlarge their self-esteem.

Pharmacotherapy
- Beta-adrenergic receptor antagonists, such as atenolol, to manage autonomic
nervous system hyperactivity high when they approach feared situations.
- Serotonergic agents may help with rejection sensitivity.
DEPENDENT
PERSONALITY
DISORDER
(1)EPIDEMIOLOGY:
-Occurs in 0.5-0.6% of the general population.
-Much more common among women than men.

(2)ETIOLOGY:
-Genetic or constitutional factors, such as submissiveness, may
contribute.
-Twin’s study found the heritability of 45% measuring
submissiveness, 35% for insecure attachment, and 49% for
anxiousness.
(3)CLINICAL FEATURES:

-Pervasive pattern of dependent and submissive behavior.

-Can’t make their own decisions without an excessive amount of advice and
reassurance from others.

-Low self-esteem and doubts about their effectiveness make them avoid positions
of responsibility and get anxious to assume leadership roles.

-Find easy performing tasks for someone else.

-Seek others whom they can depend on and don’t stay alone.

-Although they can stay alone they doubt their abilities and judgment and view
others as much stronger and more capable.
-Always agree on whom they depend and tend to be excessively passive and
self-sacrificing
-They may indiscriminately begin another relationship so that they can be
provided with direction and nurturance; an unfilling or even abusive relationship
may seem better.

(4)COURSE AND PROGNOSIS:

-Little is known about the course.
-Occupational functioning is impaired as they can’t act independently without
close supervision.
-Social relationships are limited to the person on whom they depend, may suffer
physical or mental abuse.
-Risk of major depressive disorder if they lose the person whom they depend on
but with treatment prognosis is favorable.
(5)TREATMENT

Psychotherapy.

-Insight-oriented therapies help patients to understand the antecedents of their

behavior.
-Behavioral therapy, assertiveness training, family therapy, and group therapy
have successful outcomes in many cases

Pharmacotherapy

-symptoms targeted pharmacotherapy help deal with specific symptoms, such

as anxiety and depression, commonly associated with a dependent personality
disorder.
OBSESSIVE-
COMPULSIVE
PERSONALITY
DISORDER
(1)EPIDEMIOLOGY:

-Most common with prevalence ranging from 2-8%.

-More common in men than women.

(2)ETIOLOGY:

-Occurs frequently in first-degree relatives of persons with this disorder.

-Often have backgrounds characterized by harsh discipline.

-Freud hypothesized that it is associated with difficulties in the anal stage of

sexual development generally around the age of 2.

-An increase in serotonergic activity has been associated with perfectionism

and compulsivity.
(3)CLINICAL FEATURES:

-Are preoccupied with rules, regulations, orderliness, neatness, details, and

achievement of perfection.

-Insist on rules to be followed rigidly and can’t tolerate what they consider
imperfection.

-They lack flexibility and are intolerant.

-Have limited interpersonal skills.

-Are formal, and serious. Lack of sense of humor.

-As they fear making mistakes, are indecisive, and ruminate about making
decisions.
 -Although stable marriages and occupations are common, they have few
friends.
-Anything that threatens their routine can precipitate anxiety to them.

(4)COURSE AND PROGNOSIS:

-Course is variable and unpredictable.
-From time to time may develop obsessions and compulsions. Some can be
either harbinger of schizophrenia or decades later exacerbated by the aging
process can have a major depressive disorder.
(5)TREATMENT:

PSYCHOTHERAPY:

-cognitive therapy or cognitive behavioral therapy, delivered either individually

or in a group.
-interpersonal psychotherapy may improve depressive symptoms in these patients

PHARMACOTHERAPY:

-little evidence, Some studies suggested benefits from fluvoxamine and

carbamazepine
-in patients with comorbid depression, citalopram may be helpful
OTHER
PERSONALITY
DISORDERS
In DSM 5 this category is reserved for disorders that do not fit into any
specific personality disorder.

personality disturbance -change in one`s previous personality pattern occurs

as a result of medical condition.
The clinical history, physical examination, and lab tests must provide
evidence for a direct pathophysiological relationship between the above two.
In addition must,
1) cause significant distress or impairment in social, occupational, or other
important areas of functioning,
2) not be better explained by another mental disorder,
3) not occurring exclusively during delirium.
Predominant features can be specified by ‘type’:
labile, disinhibited, aggressive, apathetic, paranoid, other, combined or
unspecified.

When symptoms present but don’t meet the criteria for specific PD, a
diagnosis of other personality disorders or unspecified personality disorders is
made.
MANAGEMENT
MANAGEMENT
General Principles of Treating Personality Disorders

-require a multifaceted treatment plan that often combines psychotherapy

and pharmacotherapy.

-Psychotherapy and pharmacotherapy have a bidirectional relationship

-As the first step, pharmacotherapy stabilizes affects and ensures safety of
the patient,

-Psychotherapy ultimately leads to the development of integrated, less

fragmented, and more realistic perceptions of self and objects.
The four stages in the treatment of a patient with PD

(1)Crisis management and stabilization

-This initial stage deals with the presenting problem and stressors
-patient get into a calm enough state and
-a working alliance with the psychiatrist.

(2) awakening of a positive perspective

-The second stage involves a spiritual awakening often neglected in strictly
cognitive-behavioral or psychodynamic approaches

-without this, there is little capacity for fundamental change in the quality of
life and personal values in life,
(3) other-centered awareness,
-involves increases in self-awareness and
-capacity for contemplation that elevates a person’s usual thoughts, feelings, and
relationships in a wide range of conditions

(4) integrated intelligence

-It allows a person to be mature and happy under conditions that were previously
stressful

-Patients with PDs can pass through these stages on their own (i.e., remit
spontaneously) or be guided through these stages
CHOICE OF MEDICATIONS FOR STABILIZATION

Symptomatic pharmacotherapy is not focused on individual subtypes of PD but

rather on the following four domains shared by all subtypes:

(i) mood and anxiety dysregulation, related most strongly to Harm Avoidance,

(ii) aggression and impulse control, related most strongly to Novelty Seeking,

(iii) social and emotional detachment, related most strongly to Reward

Dependence, and

(iv) psychotic symptoms and cognitive distortions, related most strongly to

intellectual reasoning and Persistence
TARGET DRUGS/ TREATMENT OF NOT
SYMPTOMS CHOICE RECOMMENDED0
MOOD DYSREGULATION
AND ANXIETY
1. ANXIETY
CHRONIC PSYCHOTHERAPY Benzodiazepines and ethanol
COGNITIVE (risk of abuse/addiction)
LOW DOSE NOVEL PSYCHOTROPICS
(ARIPIPRAZOLE, QUETIAPINE)
SSRIs, SNRIs, MAOIs

CHRONIC SOMATIC MAOIs, SNRIs (duloxetine) If used—benzodiazepines with

long half-life and short trials
preferred
ACUTE AND MIRTAZAPINE, NOVEL PSYCHOTROPICS
SEVERE (quetiapine, aripiprazole, clozapine)

OBSESSIONS SSRIs, PSYCHOTROPICS (quetiapine) TCAs

(clomipramine)
TARGET DRUGS/ TREATMENT OF NOT
SYMPTOMS CHOICE RECOMMENDED
2.Behaviour dyscontrol LITHIUM, SSRIs, ANTICONVULSANTS Benzodiazepines (disinhibition)
Aggression/impulsivity Low-dose novel psychotropics

3.SOCIAL AND Benzodiazepines and ethanol (risk

EMOTIONAL LOW DOSE NOVEL PSYCHOTROPICS of abuse/addiction)
DETACHMENT (ARIPIPRAZOLE, OLANZAPINE, LOW
DOSE CLOZAPINE, SULPIRIDE)

4.Cognitive-perceptual NOVEL PSYCHOTROPICS (Risperidone,

distortions/psychotic olanzapine)
symptoms Typical neuroleptics (for the duration of
psychosis)
THANK
YOU