Personality disorders Abdallah Ayyoub MS What we are

Personality disorders Abdallah Ayyoub, MS

What we are gonna talk about. . 1. Definition of personality trait. 2. Definition of personality disorder. 3. Clusters of personality disorders.

Personality Trait • Fixed pattern of behavior • Way of interacting with environment • Positive traits: kind, confident • Negative traits: lazy, rude • Person often aware of own traits

Personality Disorder • Fixed pattern of behavior • Fixed way of interacting with environment • Cause distress or impaired function • Person often unaware • Difficult to treat (“enduring”) • Often strains doctor-patient relationship

Cluster A (Weird) • Paranoid, schizotypal • Odd and eccentric behavior Cluster B (Wild) • Antisocial, borderline, histrionic, narcissistic • Dramatic, erratic behavior Cluster C (Wacky) • Avoidant, Obsessive-compulsive, dependent • Anxious, fearful behavior Three clusters: A, B, C; remember as Weird, Wild, and Wacky, respectively, based on symptoms

Paranoid (Accusatory) Schizoid (Aloof) Schizotypal (Awkward)

Paranoid Personality Disorder (PPD) • Distrust of others even friends/family • Guarded • Suspicious • Struggles to build close relationships • Hallmark ego defense: projection 1 -Attributing unacceptable thoughts to others 2 -Often accuses others of being suspicious • Prevalence: 0. 5 to 2. 5% • Men are more likely to have PPD than women. • Psychotherapy is the treatment of choice.

DSM-5 diagnosis of PPD Diagnosis requires a general distrust of others, beginning by early adulthood and present in a variety of contexts. At least four of the following must also be present: 1. Suspicion (without evidence) that others are exploiting or deceiving him or her 2. Preoccupation with doubts of loyalty or trustworthiness of acquaintances 3. Reluctance to confide in others 4. Interpretation of benign remarks as threatening or demeaning 5. Persistence of grudges 6. Perception of attacks on his or her character that are not apparent to others; quick to counterattack 7. Recurrence of suspicions regarding fidelity of spouse or lover

Schizoid Personality Disorder • Chooses social isolation: More comfortable alone • Does not enjoy close relationships • Little/no interest in sexual experiences • Few/no pleasure activities (hobbies) • Lacks close friends • Detachment • Flat affect • Prevalence: Approximately 7% • Men are two times as likely to have schizoid personality disorder as women. • Psychotherapy is the treatment of choice.

DSM-5 diagnosis of Schizoid : A pattern of voluntary social withdrawal and restricted range of emotional expression, beginning by early adulthood and present in a variety of contexts. Four or more of the following must also be present: 1. Neither enjoying nor desiring close relationships (including family) 2. Generally choosing solitary activities 3. Little (if any) interest in sexual activity with another person 4. Taking pleasure in few activities (if any) 5. Few close friends or confidants (if any) 6. Indifference to praise or criticism 7. Emotional coldness, detachment, or flattened affect

Schizotypal Personality Disorder • Fear of social interactions and few close friends • Odd beliefs or magical thinking - Superstitious - Believes in telepathy, sixth sense • Ideas of reference -Believe events and happenings somehow related to them • Key feature: open to challenges to beliefs - May reconsider superstitions, etc. -Contrast with delusions in schizophrenia - Also no hallucinations, cognitive impairment

B 1 -Antisocial: Bad 2 -Borderline, 3 -Histrionic: flam. Boyant, 4 -Narcissistic: must be the Best (corresponding alphabetically).

Antisocial Personality Disorder • More common in men • Disregard for rights of others • Often breaks the law • Impulsive and lacks remorse • Child (<18) version: conduct disorder - 25% girls and 40% boys with CD → ASPD • Must be at least age 18 years old • Must have evidence of conduct disorder before 15 • Prevalence: 3% in men and 1% in women • Higher incidence in poor urban areas and in prisoners • Genetic component: Five times increased risk among first-degree relatives

DSM-5 diagnosis of Antisocial : Pattern of disregard for others and violation of the rights of others since age 15. Patients must be at least 18 years old for this diagnosis; history of behavior as a child/adolescent must be consistent with conduct disorder. Three or more of the following should be present: 1. Failure to conform to social norms by committing unlawful acts 2. Deceitfulness/repeated lying/manipulating others for personal gain 3. Impulsivity/failure to plan ahead 4. Irritability and aggressiveness/repeated fights or assaults 5. Recklessness and disregard for safety of self or others 6. Irresponsibility/failure to sustain work or honor financial obligations 7. Lack of remorse for actions

Antisocial personality disorder has frequently been discussed on the show, and the primary character, Gregory House, was diagnosed with the disorder in Broken. House often projects his disorder onto patients, fellows and colleagues, and is often gratified when they act in an anti-social manner, such as lying or breaking off their relationships

Conduct disorder Repetitive, pervasive behavior violating societal norms or the basic rights of others (eg, aggression to people and animals, destruction of property, theft). After age 18, often reclassified as antisocial personality disorder. Treatment for both: psychotherapy (eg, CBT).

Borderline Personality Disorder • Unstable personal relationships - All people are very good or very bad - Stormy relationships - “My boyfriend is the greatest guy in the world!” - “My boyfriend is the devil!” • Fear of abandonment - May accuse others of abandoning them • Prevalence: 1 to 2% • Women are two times as likely to have BPD as men. • 10% suicide rate

Splitting • Major defense mechanism in borderline PD • Black and white thinking (always-never) • Cannot hold opposing views • Patent's physician may be great or terrible • All people-things-events wonderful or horrible

DSM-5 diagnosis of Borderline personality disorder Pervasive pattern of impulsivity and unstable relationships, affects, self-image, and behaviors, present by early adulthood and in a variety of contexts. At least five of the following must be present: 1. Desperate efforts to avoid real or imagined abandonment 2. Unstable, intense interpersonal relationships 3. Unstable self-image 4. Impulsivity in at least two potentially harmful ways (spending, sexual activity, substance use, etc. ) 5. Recurrent suicidal threats or attempts or self-mutilation (you don’t care about me so I will kill my self) 6. Unstable mood/affect 7. General feeling of emptiness 8. Difficulty controlling anger 9. Transient, stress-related paranoid ideation or dissociative symptoms

Dialectical Behavior Therapy • Form of cognitive behavioral treatment • Designed to treat chronical suicidality • Gold standard for borderline personality disorder • Weekly therapy for 1 -2 years - Mindfulness - Distress tolerance - Emotion regulation

Borderline personality: (IMPULSIVE) Impulsive Moody Paranoid under stress Unstable self image Labile, intense relationships Suicidal Inappropriate anger Vulnerable to abandonment Emptines (IMPULSIVE )

Histrionic Personality Disorder • Wants to be the center of attention Talks loudly, tells wild stories, uses hand gestures • Inappropriate sexually provocative behavior -Often wears provocative clothing -Touching others frequently • Very concerned with physical appearance -Exotic outfits, shoes, hats • Prevalence: 2%. • Women are more likely to have HPD than men.

Diagnosis and DSM-5 Criteria Pattern of excessive emotionality and attention seeking, present by early adulthood and in a variety of contexts. At least five of the following must be present: 1. Uncomfortable when not the center of attention 2. Inappropriately seductive or provocative behavior 3. Rapidly shifting but shallow expression of emotion 4. Uses physical appearance to draw attention to self 5. Speech that is impressionistic and lacking in detail 6. Theatrical and exaggerated expression of emotion 7. Easily influenced by others or situation 8. Perceives relationships as more intimate than they actually are

Narcissistic Personality Disorder • Inflated sense of self - Brags, thinks everything he does is great - Lacks empathy for others - Other people are competitors • Wants to hear they are great • They consider themselves “special” and will exploit others for their own gain. • Despite their grandiosity, however, these patients often have fragile self-esteem, Overreacts to criticism with anger/rage • Prevalence is 6%.

Diagnosis and DSM-5 Criteria Pattern of grandiosity, need for admiration, and lack of empathy beginning by early adulthood and present in a variety of contexts. Five or more of the following must be present: 1 -Exaggerated sense of self-importance 2 -Preoccupation with fantasies of unlimited money, success, brilliance, etc. 3 -Believes that he or she is “special” or unique and can associate only with other high-status individuals 4 -Requires excessive admiration 4 -Has sense of entitlement 5 -Takes advantage of others for self-gain 6 -Lacks empathy 7 -Envious of others or believes others are envious of him or her 8 -Arrogant or haughty

Usually has a chronic course; higher incidence of depression and midlife crises since these patients put such a high value on youth and power. Treatment -Psychotherapy is the treatment of choice. -Antidepressants may be used if a comorbid mood disorder is diagnosed

C 1. Avoidant: Coward 2. Obsessive-Compulsive 3. Dependent: Clingy.

Avoidant Personality Disorder • Avoids social interactions • “Social inhibition” • Feels inadequate • Afraid people won’t like them • Afraid of embarrassment • Struggles with intimate relationships -“Maybe he/she doesn’t like me” • Different from schizoid: wants to socialize but can’t • Schizoid prefers to be alone (aloof) • 2. 4%. • Equally frequent in males and females

Treatment -Psychotherapy, including assertiveness and social skills training, is most effective. -Group therapy may also be beneficial. - Selective serotonin reuptake inhibitors (SSRIs) may be prescribed for comorbid social anxiety disorder or major depression.

Obsessive-Compulsive Personality Disorder • Preoccupied with order and control - Loves “To Do” lists - Always needs a plan • Inflexible at work or in relationships • Behaviors help to achieve goals (contrast with OCD) • Prevalence is 1– 2%. • Men are two times more likely to have OCPD than women

Ego: • Mediates id (desire) and super-ego (rules, society) Egosyntonic: • Behaviors that achieve goals of the ego • Obsessions/compulsions used to achieve goals • Seen in obsessive-compulsive personality disorder Egodystonic: • Behaviors that conflict with goals of the ego • Obsessions/compulsions are barriers to goals • Seen in obsessive-compulsive disorder

Diagnosis and DSM-5 Criteria Pattern of preoccupation with orderliness, control, and perfectionism at the expense of efficiency and flexibility, present by early adulthood and in a variety of contexts. At least four of the following must be present: 1. Preoccupation with details, rules, lists, and organization such that the major point of the activity is lost 2. Perfectionism that is detrimental to completion of task 3. Excessive devotion to work 4. Excessive conscientiousness and scrupulousness about morals and ethics 5. Will not delegate tasks 6. Unable to discard worthless objects 7. Miserly spending style 8. Rigid

Dependent Personality Disorder • Clingy • Low self-confidence • Struggle to care for themselves • Depend on others excessively - Rarely alone, always in a relationship • Hard to make decisions on their own - Want someone to tell them what to do • Difficulty expressing an opinion • May be involved in abusive relationships

A 23 -year-old medical student attempted to slit her wrist because things did not work out with a guy she was going out with over the past 3 weeks. She states that guys are jerks and “not worth her time. ” She often feels that she is “alone in this world. ” Borderline personality disorder

A 30 -year-old unemployed male has been accused of killing three senior citizens robbing them. He is surprisingly charming in the interview. In his adolescence, he was arrested several times for stealing cars and assaulting other kids. Antisocial personality disorder

A 35 -year-old man dresses in a space suit every Tuesday and Thursday. He has computers set up in his basement to “detect the precise time of alien invasion. ” He has no evidence of auditory or visual hallucinations. Schiztotypal personality disorder

Borderline personality disorder is called in Arabic: ﺍﺿﻄﺮﺍﺏ ﺍﻟﺸﺨﺼﻴﺔ ﺍﻟﺤﺪﻳﺔ