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Normal Personality Development and Personality Disorders
Janet E. Johnson, MD, MPH Tulane University School of Medicine
Department of Psychiatry and Behavioral Sciences
Learning Objectives
Be able to describe the various personality disorders
Be able to apply the personality disorder categories to patient scenarios
Personality
Defined as the totality of emotional and behavioral traits that characterize the person in day-to-day living under ordinary conditions.
Usual manner of thinking, feeling, behaving and relating to others
Relatively stable and predictable. Blend of inborn temperament, genetic strengths
and vulnerabilities, and impact of positive and negative life experiences.
Normal Personality Development
Second half of 1st year: attachment Internalization: mechanism for building
psychological structure Stable pattern of a child’s temperament
becomes established during second year. Nature versus nurture? Behavioral genetics revealing pervasive genetic
influences on normal and abnormal personality.
What is Normal?
Who’s to say? Circumstances, culture/sub-culture,
setting/location, timing, age
Who’s Normal?
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Who’s Normal? Personality assessment
Meyers-Brigg Five Factor Model Cloninger’s Seven-Factor Model Biogenic Spectrum Model
Myers Brigg
Questionnaire designed to measure psychological preferences in how people perceive the world and make decisions.
Widely utilized Extrapolated from Jung’s theories. Two pairs of cognitive functions:
Rational functions: thinking and feeling Irrational functions: sensing and intuition
Dichotomies
Extraversion (E) – (I) Introversion Sensing (S) – (N) Intuition Thinking (T) – (F) Feeling Judgment (J) – (P) Perception
16 possible types Example: ESTJ
Five Factor Model
Neuroticism (anxiety, depression, vulnerability, hostility)
Extraversion (warmth, assertiveness, activity, gregariousness)
Openness (feelings, fantasy, ideas, values)
Agreeableness (trust, altruism, modesty)
Conscientiousness (dutifulness, self- discipline, deliberation)
Seven-Factor Model of Temperament and Character Harm avoidance Reward dependence Novelty seeking Persistence Character factor Self-directedness Cooperativeness Self-transcendence
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Temperament Factors (harm avoidance, reward dependence, novelty seeking, persistence
Independently heritable Manifested early in life Involved in perceptual memory and habit
formation Associated with biologic features
Novelty seeking decreased dopaminergic activity Harm Avoidance -> high serotonergic activity Reward dependence low noradrenergic activity
Personality Disorders
A personality disorder is a variant of those character traits that goes beyond the range found in most people.
When personality traits are inflexible and maladaptive and cause either significant functional impairment or subjective distress they constitute a class of personality disorder.
Patients with personality disorders show deeply ingrained, inflexible, and maladaptive patterns of relating to and perceiving both the environment and themselves
General Diagnostic Criteria
An enduring pattern of inner experience and behavior that deviates markedly from the expectation of the individual’s culture. The pattern is manifested in two or more of the following areas: Cognition (perceiving and interpreting self, other
people and events) Affectivity (range, intensity, lability appropriateness
of emotional response) Interpersonal functioning Impulse control
General Diagnostic Criteria
The enduring pattern is inflexible and pervasive across a broad range of personal and social situations.
The enduring pattern leads to clinically significant distress or impairment in social, occupational or other important areas of functioning.
The pattern is stable and of long duration, and its onset can be traced back at least to adolescence or early adulthood.
The enduring pattern is not better accounted for as a manifestation or consequence of another mental disorder.
The enduring pattern is not due to the direct effects of a substance or a general medical condition.
Personality Disorders
More likely to refuse psychiatric help than other psychiatric disorders
Ego-syntonic Regarded as unmotivated for treatment Grouped into three clusters: A, B, C Other: Not otherwise specified and mixed Diagnosed on Axis II Elevated rates of divorce, unemployment,
homelessness, perpetration of child abuse, child custody proceedings, separation
Personality Disorders
Common in general population Prevalence of 10-18% Outpatient 30-50% Inpatient > 50% co-morbidity
Males and females equal overall Etiology
Genetics Psychoanalytic theories
Freud: psychosexual development Reich: defense mechanisms
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Common Defense Mechanisms Projection Splitting Regression Fantasy Dissociation Intellectualization Isolation Reaction formation Repression Acting out Passive aggression
Cluster A: Paranoid, Schizoid, Schizotypal
Odd, eccentric (“weird”) Key clinical features: social deficits, absence of
close relationships Treatment: structure, rehabilitation, support,
medication Course: stable Prognosis: poor Genetics:
More common in the biological relatives of schizophrenic patients than among control groups.
Paranoid Personality Disorder
Pervasive distrust and suspiciousness of others such that their motives are interpreted as malevolent, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following:
Paranoid Diagnostic Criteria
Suspects, without sufficient basis, that others are exploiting, harming, or deceiving him or her.
Is preoccupied with unjustified doubts about the loyalty or trustworthiness of friends/associates.
Is reluctant to confide in others because of unwarranted fear that the information will be used maliciously against him or her.
Reads hidden demeaning or threatening meanings into benign remarks or events.
Persistently bears grudges, i.e., is unforgiving of insults, injuries, or slights.
Paranoid Diagnostic Criteria
Perceives attacks on his or her character or reputation that are not apparent to others and is quick to react angrily or to counterattack.
Has recurrent suspicions, without justification, regarding fidelity of spouse or sexual partner.
Does not occur exclusively during the course of schizophrenia, a mood disorder with psychotic features, or another psychotic disorder, and is not due to the direct physiological effects of a general medical condition.
Paranoid Personality Disorder
Characterized by long-standing suspiciousness and mistrust of people in general.
Refuse responsibility for their own feelings; are often angry, hostile, irritable. Bigot, injustice collector, pathologically
jealous spouse, litigious crank Prevalence 0.5-2.5 % Male > female Differential diagnosis: schizotypal pd,
schizophrenia, delusional d/o Antipsychotic meds sometimes useful
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Schizoid Personality Disorder
A pervasive pattern of detachment from social relationships and a restricted range of expression of emotions in interpersonal settings, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following:
Schizoid Diagnostic Criteria
Neither desires nor enjoys close relationships, including being part of a family.
Almost always chooses solitary activities. Has little, if any, interest in having sexual
experiences with another person. Takes pleasure in few, if any, activities. Lacks close friends or confidents other than
first-degree relatives. Appears indifferent to the praise or criticism of
others. Shows emotional coldness, detachment, or
flattened affectivity.
Schizoid Personality Disorder
1-7.5% of population Males diagnosed 2x females Intact reality testing Most function relatively well, generally do
not require clinical intervention Psychotherapy treatment of choice
(supportive), but rarely seek treatment Differential diagnosis: schizotypal pd,
avoidant pd
Schizotypal Personality Disorder A pervasive pattern of
social and interpersonal deficits marked by acute discomfort with, and reduced capacity for, close relationships, as well as by cognitive or perceptual distortions and eccentricities of behavior, beginning by early adulthood and present in a variety of contexts:
Schizotypal Diagnostic Criteria
Indicated by five or more of the following: Ideas of reference. Odd beliefs or magical thinking that influences behavior
and is inconsistent with sub-cultural norms (superstitiousness, clairvoyance, telepathy).
Unusual perceptual experiences, including bodily illusions.
Odd thinking and speech (vague, metaphorical, stereotyped, circumstantial).
Suspiciousness or paranoid ideation. Inappropriate or constricted affect. Behavior or appearance that is odd, eccentric or peculiar.
Schizotypal Personality Disorder Lack of close friends or confidants other than
first degree relatives. Excessive social anxiety that does not diminish
with familiarity and tends to be associated with paranoid fears rather than negative judgments about self.
Does not occur exclusively during the course of schizophrenia, a mood disorder with psychotic features, another psychotic disorder or a pervasive developmental disorder.
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Schizotypal Personality Disorder Schizophrenia spectrum disorder Some forms involve biologic abnormalities
characteristic of schizophrenia Prevalence: 3% of population Males > females Approximately 10% commit suicide Differential diagnosis: schizophrenia, paranoid
pd, schizoid pd, avoidant pd Low dose antipsychotics may be helpful
CLUSTER B: Antisocial, Borderline,
Narcissistic, Histrionic B for “bad” Dramatic, emotional, erratic, “wild” Key clinical features: social and interpersonal instability Treatment: support, exploration, sociotherapy, individual
therapy, medication Course: unstable Prognosis: some remission with age Genetics:
More family members with mood disorders Group see most frequently in clinical practice
Borderline Personality Disorder A pervasive pattern of
instability of interpersonal relationships, self-image, and affects, and marked impulsivity by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:
Borderline Diagnostic Criteria
Frantic efforts to avoid real or imagined abandonment. A pattern of unstable and intense interpersonal
relationships characterized by alternating between extremes of idealization and devaluation.
Identity disturbance: markedly and persistently unstable self-image or sense of self.
Impulsivity in at least two areas that are potentially self-damaging: (spending, sex, substance abuse, reckless driving, binge eating).
Borderline Diagnostic Criteria
Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior.
Affective instability due to a marked reactivity of mood. Chronic feelings of emptiness. Inappropriate, intense anger or difficulty controlling anger
(frequent displays of temper, constant anger, recurrent physical fights).
Transient, stress-related paranoid ideation or severe dissociative symptoms.
Borderline Personality Disorder Prevalence: 2-3% of the population 2:1 female:male ratio Most prevalent personality disorder in all clinical settings
(12-15%) 51% of all inpatients 27% of all outpatients with a personality disorder
Increased risk for co-morbid mood disorders, eating disorders, substance abuse, PTSD
Up to 10% will have completed suicide by age 30 years Increased prevalence of mood disorders in families of
borderline patients
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Borderline Personality Disorder Usually diagnosed by age 40 years Course is variable but rarely changes over time Some patients improve in middle age Treatment: several modes of psychotherapy
Dialectical behavioral therapy (DBT) Instill intense counter-transference
Differential dx: bipolar disorder, schizotypal pd, histrionic pd, narcissistic pd, dependent pd, psychotic disorders
Antisocial Personality Disorder
Pervasive pattern of disregard for and violation of the rights of others occurring since age 15 years, as indicated by three (or more):
Antisocial Diagnostic Criteria
Failure to conform to social norms with respect to lawful behaviors as indicated by repeatedly performing acts that are grounds for arrest.
Deceitfulness, as indicated by repeated lying, use of aliases, conning others for personal profit,pleasure
Impulsivity or failure to plan ahead.
Antisocial Diagnostic Criteria
Irritability & aggressiveness, as indicated by repeated failure to sustain consistent work behavior or honor financial obligations.
Lack of remorse, as indicated by being indifferent to, or rationalizing having hurt, mistreated, or stolen from another.
The individual is at least 18 years old. There is evidence of conduct disorder with onset before
age 15 years. The occurrence of antisocial behavior is not exclusively
during the course of schizophrenia or a manic episode.
Antisocial Personality Disorder
Sociopath, “morally bankrupt” Disregard for rights of others and lack of
remorse Prevalence: 3% male; 1% female Up to 75% of prison population Occurs 5x more commonly in first-degree
relatives of males with the disorder Variable course Differential dx: other Cluster B pd, substance
abuse disorders, mania, mental retardation Difficult if not impossible to treat
Histrionic Personality Disorder
A pervasive pattern of excessive emotionality and attention seeking, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:
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Histrionic Diagnostic Criteria
Is uncomfortable in situations in which he or she is not the center of attention.
Interaction with others is often characterized by inappropriate sexually seductive or provocative behavior.
Displays rapidly shifting and shallow expression of emotions.
Consistently uses physical appearance to draw attention to self.
Has a style of speech that is excessively impressionistic and lacking in detail.
Histrionic Diagnostic Criteria
Shows self-dramatization, theatricality, and exaggerated expression of emotion.
Is suggestible, i.e., easily influenced by others or circumstances.
Considers relationships to be more intimate than they actually are.
Histrionic Personality Disorder
2-3% of the population Females diagnosed more often Males probably under-diagnosed Variable course, often softens with age Treatment is individual psychotherapy Low dose benzodiazepines are useful for
transient emotional states Differential dx: dependent pd, borderline pd,
narcissistic pd, somatization disorder
Narcissistic Personality Disorder
A pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:
Narcissistic Diagnostic Criteria
Has a grandiose sense of self-importance (e.g. exaggerates achievements and talents, expects to be recognized as superior without commensurate achievements).
Is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love.
Believes that he or she is “special” and unique and can only be understood by, or should associate with, other special or high-status people.
Narcissistic Diagnostic Criteria
Requires excessive admiration. Has a sense of entitlement, i.e., unreasonable
expectations of especially favorable treatment or automatic compliance with his or her expectations.
Is interpersonally exploitative, i.e., takes advantage of others to achieve his or her own ends.
Lacks empathy, is unwilling to recognize or identify with the feelings and needs of others.
Is often envious of others or believes that others are envious of him or her.
Shows arrogant, haughty behaviors or attitudes.
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Narcissistic Personality Disorder Overwhelming, pathological self-absorption Primary motivation is power Prevalence unknown; <1% general population, 2-15%
clinical population Chronic course Co-morbid mood disorders common Aging ultimate blow to self-esteem, prone to severe mid-
life crises Treatment individual psychotherapy Do not tolerate group therapy Differential dx: borderline pd, histrionic pd, antisocial pd
Cluster C: Avoidant, Dependant, Obsessive-Compulsive
Anxious and fearful, (“wimpy”) Key clinical features: interpersonal and
intrapsychic conflicts Treatment: exploration, individual therapy,
group therapy Course: modifiable Prognosis: good Genetics:
More relatives with anxiety disorders
Avoidant Personality Disorder
A pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following:
Avoidant Diagnostic Criteria
Avoids occupational activities that involve significant interpersonal contact, because of fears of criticism, disapproval, or rejection.
Is unwilling to get involved with people unless certain of being liked.
Shows restraint within intimate relationships because of the fear of being shamed or ridiculed.
Is preoccupied with being criticized or rejected in social situations.
Is inhibited in new interpersonal situations because of feelings of inadequacy.
Avoidant Diagnostic Criteria
Views self as socially inept, personally unappealing, or inferior to others.
Is unusually reluctant to take personal risks or to engage in any new activities because they may prove embarrassing.
“Pathologically shy”
Avoidant Personality Disorder
Common, 1-10% of population Temperament and disfiguring physical illnesses
may be predisposing factors Males = females High risk for anxiety disorders Once assured of acceptance and safety,
respond to virtually all forms of therapy. Group therapy, SSRIs, anxiolytics Differential dx: social phobia, dependent pd,
schizoid pd
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Dependant Personality Disorder A pervasive and
excessive need to be taken care of that leads to submissive and clinging behavior and fears of separation, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:
Dependent Diagnostic Criteria
Has difficulty making everyday decisions without an excessive amount of advice and reassurance from others.
Needs others to assume responsibility for most major areas of his/her life.
Has difficulty expressing disagreement with others because of fear of loss of support or approval.
Has difficulty initiating projects or doing things on his or her own (because of a lack of self-confidence in judgment or abilities rather than a lack of motivation or energy).
Goes to excessive lengths to obtain nurturance and support from others, to the point of volunteering to do things that are unpleasant.
Dependent Diagnostic Criteria
Feels uncomfortable or helpless when alone because of exaggerated fears of being unable to care for himself/herself.
Urgently seeks another relationship as a source of care and support when a close relationship ends.
Is unrealistically preoccupied with fears of being left to take care of himself or herself.
Dependent Personality Disorder Prevalence: 2-4% of general population 2.5% of all personality disorders Females more commonly affected than males Patients with a history of childhood separation anxiety or
chronic illness may be predisposed Many patients have co-morbid dysthymia, major
depression and alcohol abuse Respond well to group therapy, assertiveness training,
social skills training, SSRIs, benzodiazepines Differential diagnosis: histrionic pd, borderline pd,
avoidant pd, agoraphobia
Obsessive-Compulsive Personality Disorder
A pervasive pattern of preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness, and efficiency, beginning by early adulthood and present in a variety of contexts:
OCPD Diagnostic Criteria
Indicated by four or more of the following: Is preoccupied with details, rules, lists, organizations, or
schedules to the extent that the major point of the activity is lost.
Shows perfectionism that interferes with task completion (e.g. is unable to complete a project because his or her own overly strict standards are not met).
Is excessively devoted to work and productivity to the exclusion of leisure activities and friendships (not accounted for by obvious economic necessity).
Is over conscientious, scrupulous, and inflexible about matters of morality, ethics, or values (not accounted for by cultural or religious identification).
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OCPD Diagnostic Criteria
Is unable to discard worn-out or worthless objects even when they have no sentimental value.
Is reluctant to delegate tasks or to work with others unless they submit to exactly his or her way of doing things.
Adopts a miserly spending style toward both self and others; money is viewed as something to be hoarded for future catastrophes.
Shows rigidity and stubbornness.
Obsessive Compulsive PD
“Anal retentive” Common in general population, exact
prevalence unknown Males > females More common among first-degree relatives with
this disorder Unlike other personality disorders, these
patients often realize the impact of their behavior and seek treatment on their own
Group therapy may be very helpful Differential dx: OCD, narcissistic pd
Other Personality Disorders
Not otherwise specified (NOS) Mixed Depressive personality disorder
Hippocrates: “black gall” Negativistic personality disorder
“passive-aggressive” personality disorder Self-defeating personality disorder
Subject of much controversy Concern it will be applied to victimized and abused
women
Conclusion
Placed on separate Axis Indicates unique psychosocial and
treatment considerations Personality disorders are common Significant impact on all areas of health
and life More research need into etiology and
treatment