Personality Disorders

Assistant Professor,
Raunaq Chawla
What according to you is a
personality disorder?
• A person’s broadly characteristic traits,
coping styles, and ways of interacting in the Personality
social environment emerge during childhood
and normally crystallize into established
patterns by the end of adolescence or early
adulthood.
• These patterns constitute the individual’s
personality—the set of unique traits and
behaviors that characterize the individual.
• Today there is reasonably broad agreement
among personality researchers that about
five basic personality trait dimensions can be
used to characterize normal personality;
neuroticism, extraversion/introversion,
openness to experience, agreeableness/
antagonism, and conscientiousness (e.g.,
Goldberg, 1990; John & Naumann, 2008;
McCrae & Costa, 2008).
 Clinical Features of Personality Disorders

• There are certain people who, although

they do not necessarily display obvious
symptoms of an Axis I disorder,
nevertheless have certain traits that are so
inflexible and maladaptive that they are
unable to perform adequately at least some
of the varied roles expected of them by
their society, in which case we may say that
they have a personality disorder (formerly
known as a character disorder).
• Two of the general features that
characterize most personality disorders are
chronic interpersonal difficulties and
problems with one’s identity or sense of
• According to general DSM-IV-TR criteria for
diagnosing a personality disorder, the person’s
enduring pattern of behavior must be
pervasive and inflexible, as well as stable and
of long duration. It must also cause either
clinically significant distress or impairment in
functioning and be manifested in at least two
of the following areas: cognition, affectivity,
interpersonal functioning, or impulse control.
• From a clinical standpoint, personality
disorders often cause at least as much
difficulty in the lives of others as in their own
lives. Other people tend to find the behavior
of individuals with personality disorders
confusing, exasperating, unpredictable, and,
to varying degrees, unacceptable
 Case Study (Narcisstic Personality Disorder )
• Bob, age 21, comes to the psychiatrist’s office accompanied by his parents. He begins the interview by announcing
he has no problems . . . . The psychiatrist was able to obtain the following story from Bob and his parents. Bob had
apparently spread malicious and false rumors about several of the teachers who had given him poor grades,
implying that they were having homosexual affairs with students. This, as well as increasingly erratic attendance at
his classes over the past term, following the loss of a girlfriend, prompted the school counselor to suggest to Bob
and his parents that help was urgently needed. Bob claimed that his academic problems were exaggerated, his
success in theatrical productions was being overlooked, and he was in full control of the situation. He did not deny
that he spread the false rumors but showed no remorse or apprehension about possible repercussions for himself.
Bob is a tall, stylishly dressed young man. His manner is distant but charming . . . . However, he assumes a
condescending, cynical, and bemused manner toward the psychiatrist and the evaluation process. He conveys a
sense of superiority and control over the evaluation . . . . His mother . . . described Bob as having been a beautiful,
joyful baby who was gifted and brilliant. The father . . . noted that Bob had become progressively more resentful
with the births of his two siblings. The father laughingly commented that Bob “would have liked to have been the
only child.” . . . In his early school years, Bob seemed to play and interact less with other children than most others
do. In fifth grade, after a change in teachers, he become arrogant and withdrawn and refused to participate in class.
Nevertheless, he maintained excellent grades . . . . It became clear that Bob had never been “one of the boys.” . . .
When asked, he professed to take pride in “being different” from his peers . . . . Though he was well known to
classmates, the relationships he had with them were generally under circumstances in which he was looked up to for
his intellectual or dramatic talents. Bob conceded that others viewed him as cold or insensitive . . . but he dismissed
this as unimportant. This represented strength to him. He went on to note that when others complained about
these qualities in him, it was largely because of their own weakness. In his view, they envied him and longed to have
him care about them. He believed they sought to gain by having an association with him
 How do Personality Disorders
develop?
• Personality disorders typically do not stem from debilitating reactions to
stress in the recent past, as do posttraumatic stress disorder or many cases
of major depression.
• Rather, these disorders stem largely from the gradual development of
inflexible and distorted personality and behavioral patterns that result in
persistently maladaptive ways of perceiving, thinking about, and relating to
the world.
• In many cases, major stressful life events early in life help set the stage for
the development of these inflexible and distorted personality patterns. The
category of personality disorders is broad, encompassing behavioral
problems that differ greatly in form and severity.
• In the milder cases we find people who generally function adequately but
who would be described by their relatives, friends, or associates as
troublesome, eccentric, or hard to get to know
 Clusters of Personality
Disorders
• Cluster A: Includes paranoid, schizoid, and schizotypal personality disorders.
People with these disorders often seem odd or eccentric, with unusual
behavior ranging from distrust and suspiciousness to social detachment.
• ● Cluster B: Includes histrionic, narcissistic, antisocial, and borderline
personality disorders. Individuals with these disorders share a tendency to be
dramatic, emotional, and erratic.
• ● Cluster C: Includes avoidant, dependent, and obsessive compulsive
personality disorders. In contrast to the other two clusters, people with these
disorders often show anxiety and fearfulness
• Two additional personality disorders— depressive and passive-aggressive
personality disorder.
 Personality Disorders: An
Overview
• Enduring and pervasive predispositions
• Perceiving
• Relating
• Thinking
• Inflexible and maladaptive
• Distress
• Impairment
• Coded on Axis II
• 10 specific personality disorders
• Several under review for DSM-V
• 3 clusters
• High comorbidity with Axis I disorders
• Poorer prognosis
Personality Disorders: Gender
Differences
• Differences in diagnostic rates
• Borderline (75% female)
• Maybe due to Clinician bias and Assessment bias
• Measures
• Criterion bias
• Histrionic = extreme “stereotypical female”
• No “macho” disorder
Personality Disorders: Gender
Differences
Personality Disorders Under Study
• Individual disorders
• Sadistic
• Self-defeating

• Categories of disorders
• Depressive
• Negativistic
• Passive aggressive
Dramatic/Erratic Cluster B
• Antisocial Personality Disorder
• Borderline Personality Disorder
• Histrionic Personality Disorder
• Narcissistic Personality Disorder
 Anti-social Personality
• Antisocial Personality Disorder Individuals (ASPD) continually violate and show
disregard for the rights of others through deceitful, aggressive, or antisocial
behavior, typically without remorse or loyalty to anyone.
• Impulsive, irritable, and aggressive and to show a pattern of generally
irresponsible behavior.
• This pattern of behavior must have been occurring since the age of 15, and before
age 15 the person must have had symptoms of conduct disorder, a similar
disorder occurring in children and young adolescents who show persistent
patterns of aggression toward people or animals, destruction of property,
deceitfulness or theft, and serious violation of rules at home or in school
• Because this personality disorder and its causes have been studied far more
extensively than the others, and because of its enormous costs to society.
 Case Study
Mark, a 22-year-old, was awaiting trial for car theft and armed
robbery. His case records included a long history of arrests beginning
at age 9, when he had been picked up for vandalism. He had been
expelled from high school for truancy and disruptive behavior. On a
number of occasions he had run away from home for days or weeks at
a time—always returning in a disheveled and “rundown” condition. To
date he had not held a job for more than a few days at a time even
though his generally charming manner enabled him to obtain work
readily. He was described as a loner with few friends. Although
initially charming, Mark usually soon antagonized those he met with
his aggressive, self-oriented behavior. Shortly after his first therapy
session, he skipped bail and presumably left town to avoid his trial
Video on ASPD
• Antisocial Personality Disorder, Causes , Signs and Symptoms, Diagnos
is and Treatment. – YouTube

• Characters with Antisocial Personality Disorder – YouTube

• Antisocial Personality Disorder Video - YouTube

Antisocial Personality Disorder
• Pervasive disregard for the rights of others
• Pattern of irresponsible behaviors
• Poor work record, breaking laws, being irritable and physically
aggressive, defaulting on debts, being reckless and impulsive,
neglecting to plan ahead, little regard for truth, and little remorse for
misdeeds

• Evidence of conduct disorder before age 15

• Much more common in men than women
• Comorbid substance use very common
© 2015 John Wiley & Sons, Inc. All rights reserved.
Antisocial Personality Disorder
• Focuses on internal thoughts and feelings
• Poverty of emotion
• Negative emotions
• Lacks shame, remorse and anxiety; does not learn from mistakes
• Positive emotions
• Merely an act used to manipulate others; superficially charming

• Impulsivity
• Behave irresponsibly for thrills

© 2015 John Wiley & Sons, Inc. All rights reserved.

Diagnostic Criteria for:
Antisocial Personality Disorder
• Age at least 18
• Evidence of conduct disorder before age 15
• Pervasive pattern of disregard for the rights of others since
the age of 15 as shown by at least three of the following:
• 1. Repeated law breaking
• 2. Deceitfulness, lying
• 3. Impulsivity
• 4. Irritability and aggressiveness
• 5. Reckless disregard for own safety and that of others
• 6. Irresponsibility as seen in unreliable employment or financial
history
• 7. Lack of remorse
© 2015 John Wiley & Sons, Inc. All rights reserved.
Etiology of Antisocial Personality Disorder
• Problems with research
• Conducted with mostly with criminals
• Different measurements (APD vs. psychopathy)
• Genetics
• Antisocial behavior heritable (40-50%)
• Genetic risk for APD, psychopathy, conduct disorder, and substance
abuse related
• Family environment
• Lack of warmth, high negativity, and parental inconsistency predict
APD
• Poverty, exposure to violence
• Family environment interacts with genetics
Etiology of Antisocial Personality Disorder

• Fearlessness
• Lack of fear or anxiety
• Low baseline levels of skin conductance; less reactive to
aversive stimuli
• Impulsivity
• Lack of response to threat when pursuing rewards
• Deficits in empathy
• Not in tune with the emotional reactions of others
Borderline Personality Disorder (BPD)
• Impulsive, self-damaging behaviors
• Unstable, stormy, intense relationships
• Emotional reactivity
• Feelings towards others can change drastically and inexplicably very quickly
• Emotions are intense, erratic, shift abruptly—often from passionate idealization to
contemptuous anger
• Frantic efforts to avoid abandonment
• Unstable sense of self
• Anger-control problems
• Chronic feelings of emptiness
• Recurrent suicidal gestures
• Transient psychotic or dissociative symptoms
Borderline Personality Disorder (BPD)

• Cormorbidity high with PTSD, MDD, substance-related, eating

disorders, and schizotypal PD
• Comorbidity predicts less chance of symptom remission
 Diagnostic Criteria for
Borderline Personality Disorder
• Presence of five or more of the following in many contexts beginning in early
adulthood:
• Frantic efforts to avoid abandonment
• Unstable interpersonal relationships in which others are either idealized or devalued
• Unstable sense of self
• Self-damaging, impulsive behaviors in at least two areas, such as spending, sex, substance
abuse, reckless driving, binge eating
• Recurrent suicidal behavior, gestures, or self-injurious behavior (e.g., cutting self)
• Chronic feelings of emptiness
• Recurrent bouts of intense or poorly controlled anger
• During stress, a tendency to experience transient paranoid thoughts and dissociative symptoms
Videos on Borderline Personality
Disorder
• What is Borderline Personality Disorder? – YouTube

• Borderline Personality Disorder BPD Presented Cinematically - YouTub

e
Etiology of Borderline Personality Disorder (BPD):
Neurobiological Factors

• Genetic component
• Highly heritable (60%)
• May play a role in impulsivity and emotional dysregulation
• Decreased functioning of serotonin system
• Increased activation of amygdala
Etiology of Borderline Personality Disorder (BPD):
Social Environmental Factors
• Parental separation, verbal and emotional abuse during
childhood
• Linehan’s Diathesis-Stress Theory
• Individuals with BPD have difficulty controlling their emotions
(emotional dysregulation)
• Possible biological diathesis
• Family invalidates or discounts emotional experiences and
expression
• Interaction between extreme emotional reactivity and invalidating
family → BPD
Figure 15.3:
Linehan’s Diathesis-Stress Theory of BPD
 Borderline Personality Disorder
• According to DSMIV-TR (APA, 2000), individuals with borderline personality disorder (BPD)
show a pattern of behavior characterized by impulsivity and instability in interpersonal
relationships, self-image, and moods. However, the term borderline personality has a long
and rather confusing history (Hooley, Cole, & Gironde, in press).
• Originally it was most often used to refer to a condition that was thought to occupy the
“border” between neurotic and psychotic disorders (as in the term borderline
schizophrenia).
• Later, however, this sense of the term borderline became identified with schizotypal
personality disorder, which (as we noted earlier) is biologically related to schizophrenia.
The current diagnosis of borderline personality disorder is no longer considered to be
biologically related to schizophrenia.
• The central characteristic of BPD is affective instability, manifested by unusually intense
emotional responses to environmental triggers, with delayed recovery to a baseline
emotional state. Affective instability is also characterized by drastic and rapid shifts from
one emotion to another (Livesley, 2008; Paris, 2007).
 Borderline Personality Disorder
• In addition, people with borderline personality disorder have a highly unstable self-image
or sense of self, which is sometimes described as “impoverished and/or fragmented”
(Livesley, 2008, p. 44). Given their affective instability combined with unstable self-image,
it is not surprising that these people have highly unstable interpersonal relationships.
• These relationships tend to be intense but stormy, typically involving overidealizations of
friends or lovers that later end in bitter disillusionment, disappointment, and anger
(Gunderson et al., 1995; Lieb et al., 2004). Nevertheless, they may make desperate efforts
to avoid real or imagined abandonment, perhaps because their fears of abandonment are
so intense (Lieb et al., 2004; Livesley, 2008).
• Recent experimental research supports a causal link between the perception of rejection
and intense, uncontrollable rage in BPD (Berenson et al., 2011).
• Another very important feature of borderline personality disorder is impulsivity
characterized by rapid responding to environmental triggers without thinking (or caring)
about long-term consequences (Paris, 2007).
 BPD
• These individuals’ high levels of impulsivity combined with their extreme affective
instability often lead to erratic, self-destructive behaviors such as gambling sprees or
reckless driving. Suicide attempts, often flagrantly manipulative, are frequently part of
the clinical picture (Paris, 1999, 2007).
• However, such attempts are not always simply manipulative; prospective studies
suggest that approximately 8 to 10 percent may ultimately complete suicide (Oldham,
2006; Skodol, Gunderson et al., 2002).
• Self-mutilation (such as repetitive cutting behavior) is another characteristic feature of
borderline personality. In some cases the self-injurious behavior is associated with relief
from anxiety or dysphoria, and it also serves to communicate the person’s level of
distress to others (Paris, 2007).
• Research has document that BPD cases have analgesia in as many as 70 to 80 percent
of women with BPD (analgesia is the absence of the experience of pain in the presence
of a theoretically painful stimulus; Figueroa & Silk, 1997; Schmahl et al., 2004).
 Case Study
• A 26-year-old unemployed woman was referred for admission to a hospital by her
therapist because of intense suicidal preoccupation and urges to mutilate herself with a
razor. The patient was apparently well until her junior year in high school, when she
became preoccupied with religion and philosophy, avoided friends, and was filled with
doubt about who she was. Academically she did well, but later, during college, her
performance declined. In college she began to use a variety of drugs, abandoned the
religion of her family, and seemed to be searching for a charismatic religious figure with
whom to identify. At times, massive anxiety swept over her, and she found it would
suddenly vanish if she cut her forearm with a razor blade. Three years ago she began
psychotherapy and initially rapidly idealized her therapist as being incredibly intuitive and
empathic. Later she became hostile and demanding of him, requiring more and more
sessions, sometimes two in one day. Her life centered on her therapist, by this time to the
exclusion of everyone else. Although her hostility toward her therapist was obvious, she
could neither see it nor control it. Her difficulties with her therapist culminated in many
episodes of her forearm cutting and suicidal threats, which led to the referral for
admission.
 Cluster B: Antisocial Personality Disorder

Psychopaths are
people who
demonstrate
psychopathy. That's
not a diagnosis but a
set of traits. The
criteria for
psychopathy include
psychological
symptoms and certain
specific behaviors.
The measures of
antisocial personality
disorder, on the other
hand, focus mostly on
behaviors you can
see
Cluster B: Antisocial Personality Disorder
 Treatment of Personality
Disorders
• Personality disorders are generally very difficult to treat, in part because they
are, by definition, relatively enduring, pervasive, and inflexible patterns of
behavior and inner experience.
• Moreover, many different goals of treatment can be formulated, and some
are more difficult to achieve than others.
Goals might include:
• reducing subjective distress,
• changing specific dysfunctional behaviors,
• changing whole patterns of behavior
• the entire structure of the personality.
 Problems in treating Personality Disorders

• People with personality disorder often think they don’t have any problem.
• The people with borderline personality and anti-social disorder have general
difficulties in forming and maintaining good relationships, including with a
therapist.
• For those from the erratic/dramatic, the pattern of acting out typical in their
other relationships is carried into the therapy situation, and instead of dealing
with their problems at the verbal level they may become angry at their
therapist and loudly disrupt the sessions.
• Noncompletion of treatment is a particular problem in the treatment of
personality disorders; a recent review of the research reported that an average
of 37 percent of personality disorder patients drop out of therapy prematurely
(McMurran et al., 2010).
 Treating Borderline Personality

• The most clinical and research attention has been paid to the
treatment of borderline personality disorder, partly because the
treatment prognosis is not clear because of these patients’ long-
standing problems and extreme instability.
• Treatment often involves a judicious use of both psychological and
biological treatment methods, with drugs being used as an adjunct to
psychological treatment, which is considered essential.
 Treating Borderline Personality
• Medication use is controversial with this disorder because it is so frequently
associated with suicidal behavior.
• Antidepressant medications (SSRI) are considered most safe and useful for treating
rapid mood shifts, anger, and anxiety (Lieb et al., 2004), as well as for impulsivity
symptoms including impulsive aggression such as self-mutilation (Koenigsberg et
al., 2002, 2007; Markovitz, 2004).
• Low doses of antipsychotic medication have modest but significant effects that is,
patients show some improvement in depression, anxiety, suicidality, impulsive
aggression, rejection sensitivity, and especially transient psychotic symptoms
(Koenigsberg et al., 2007; Markovitz, 2001, 2004).
• Finally, mood-stabilizing medications such as carbazemine may be useful in
reducing irritability, suicidality, and impulsive aggressive behavior (Koenigsberg et
al., 2007; Lieb et al., 2004). Drugs are only mildly beneficial for borderline
personality disorder (Paris, 2009)
 Psychosocial Treatment for Borderline
Personality Disorder
• Clinical trials suggest that several types of psychotherapy may be effective for borderline personality disorder.
Weakness: their relative complexity and long duration, which makes them difficult to disseminate to the broader
population
• Linehan’s very promising dialectical behavior therapy is a unique kind of cognitive and behavioral therapy
specifically adapted for this disorder.
• Linehan believes that patients’ inability to tolerate strong states of negative affect is central to this disorder, and
one of the primary goals of treatment is to encourage patients to accept this negative affect without engaging in
self-destructive or other maladaptive behaviors.
• Accordingly, she has developed a problem-focused treatment based on a clear hierarchy of goals, which
prioritizes decreasing suicidal and self-harming behavior and increasing coping skills.
• The therapy combines individual and group components as well as phone coaching. In the group setting,
patients learn interpersonal effectiveness, emotion regulation, and distress tolerance skills.
• The individual therapist, in turn, uses therapy sessions and phone coaching to help the patient identify and
change problematic behavior patterns and apply newly learned skills effectively. Dialectical behavior therapy
 Psychosocial Treatment for Borderline
Personality Disorder
• Patients receiving dialectical behavior therapy show reductions in self-destructive and suicidal behaviors as well
as in levels of anger (Linehan et al., 2006; Lynch et al., 2007). Evidence also suggests that these gains are
sustainable (Zanarini et al., 2005).

• Other psychosocial treatments for BPD involve variants of psychodynamic psychotherapy adapted for the
particular problems of persons with this disorder. For example, Kernberg (1985, 1996) and colleagues
(Koenigsberg et al., 2000; see also Clarkin et al., 2004) have developed a form of psycho dynamic psychotherapy
that is much more directive than is typical of psychodynamic treatment.

• The primary goal is seen as strengthening the weak egos of these individuals, with a particular focus on their
primary primitive defense mechanism of splitting, which leads them to black-and-white, all or-none thinking, as
well as to rapid shifts in their reactions to themselves and to other people (including the therapist) as “all good”
or “all bad.”

• One major goal is to help them see the shades of gray between these extremes and integrate positive and negative
views of themselves and others into more nuanced views.

• Although this treatment is often expensive and time-consuming (often lasting a number of years), it has been
shown in at least one study to be as effective as dialectical
 Lets see the DBT
• Dialectical Behavior Therapy (DBT) – YouTube

• (317) What is Dialectical behavior therapy for adolescents (DBT)? - Yo

uTube