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Personality Disorders

I. Characteristics of Personality Disorders

1. Personality disorders involve inflexible and maladaptive responses to stress. For convenience, these disorders can be grouped into odd/eccentric, dramatic/histrionic, and anxious/fearful clusters, depending ca which maladaptive responses to stress are most prominent.

2. Personality disorders are global; they affect nearly all areas of a person's life, so that he or she is severely handicapped in working and loving. By contrast, neurotic persons' problems are confined to discrete aspects of their lives, while other aspects remain.

3. People with personality disorders commonly feel the problem lies not within themselves but in their environment (eg, "No one understands me!" or "Everyone thwarts my plans?). Neurotic persons are more likely to locate the source.

4. Personality disorders do not involve psychosis. Brief psychotic episodes occur, but florid lapses in reality testing are the exception rather than the rule. Most people with personality disorders are in touch with reality.

5. People with personality disorders are often untroubled by their illness, for they fail to see themselves as others see them. In fact, they may feel themselves to be in the best of emotional health, while others are quite distressed by their behavior. They may be dragged to mental health care facilities by others; the vast majority never seek treatment.

6. People with personality disorders have an uncanny ability to get under the skin of others. They are likely, therefore, to be rejected by those close to them. They invariably 'restate the mental health professionals who try to treat them. Treatment is difficult and failure is common.

7. The complications associated with personality disorders are many. The most common are depression, suicide, violence and antisocial behavior, brief psychotic episodes, and multiple drug abuse.

8. Treatment for other psychiatric disorders (eg, depression or substance abuse) is typically more difficult when a personality disorder is also present.

9. Medical problems (eg, breast cancer) may take longer to treat in people with personality disorders because the patient is more fearful and has greater conflicts over basic issues of being care for.

A. Etiology

Little is known.

Environmental factors

•Psychoanalytic theorists have focused primarily ca the significance of childhood experiences within the family.

• Few good large-scale studies have correlated early deprived or traumatic childhoods with later personality disorders.

Genetic factors

Some evidence for the heritability of certain character traits (eg, emotional expressiveness, introverted personality traits, obsessive-compulsive traits, and attention-seeking tendencies).

Other constitutional factors

• Physical illness, especially chronic illness in childhood.

• Neurological disorders-particularly birth-related trauma, encephalitis, and temporal lobe epilepsy--associated with increased incidence and the severity of personality disorders.

• A history of minimal brain dysfunction (a childhood syndrome that includes such symptoms as learning disabilities and "hyperactivity') or the presence of soft (nonspecific) signs of neurological dysfunction (eg, abnormal movements of arms or legs, incoordination, left-right confusion) in childhood correlates with an increased incidence of personality disorders in adolescence and adulthood.

B. Course and Prognosis

Personality disorders usually become evident in adolescence, or somtimes earlier. Clinical lore holds that once you have a personality disorder, you have it for life. However, surprisingly little is known about the course of these illnesses, but outcome studies suggest quite variable courses ranging from recovery to increasing severity over the lifespan.

C. Diagnosis

The diagnostic criteria for the personality disorders are described below. Diagnosis is often difficult. The following are points to keep in mind in your assessments:

1. Personality disorders do not begin suddenly. A history of sudden change in character should alert you to the possibility of some other illness, especially a central nervous system (CNS) disorder (eg, tumor, cerebral vascular accident), incipient psychosis, or drug or alcohol abuse. Any of these can mimic a personality disorder.

2. Be curious about why someone with a personality disorder comes to you at a particular time. Look for some change in important relationships that upset the former balance and suddenly made the disordered personality obvious to the patient or others.

3. Pay attention to your feelings about the patient.

4. Beware of overdiagnosing personality disorders in people who are ethnically and culturally different from you. Behavior is more likely to look abnormal outside its social context

Personality Disorders are organized in 3 clusters in DSM-IV:

1) patients who appear withdrawn, odd or eccentric;

2) patients who appear dramatic, emotional, or impulsive; and 3) patients who are primarily anxious or fearful.

II. Odd or Eccentric - Cluster A

A. Paranoid Personality Disorder

1. Profile

• Keen observers, disregarding facts that do not confirm their suspicions.

• Appear tense, guarded, and secretive; often litigious and highly moralistic, usually humorless and overly serious.

• May, under stress, become floridly delusional. As a rule, however, psychotic episodes are brief and transient.

• Defense: projection, attributing own motives, thought, or feelings to someone else because they are unacceptable in oneself.

2. Diagnosis

DSM IV criteria

3. Etiology

• Prevalence increased m families with delusional disorders.

• No conclusive genetic links.

• Psychodynamic formulations:

-in childhood, child is object of parental rages

-families of origin are overly constricted emotionally

4. Epidemiology

Little known about incidence or prevalence - many never seek treatment.

Estimated prevalence of 0.5 to 2.5% of population

More common m men than women

• Increased frequency in biological relatives of schizophrenia. Possible genetic link with delusional disorder.

5. Course and Prognosis

• No good outcome studies have been done

• Some "grow out of it" with age

• Some go on to develop schizophrenia

6. Differential Diagnosis

• Delusional Disorder, persecutory type - persistent psychotic symptoms that are NOT present in PPD

• Schizophrenia - persistent psychotic symptoms that are NOT present in PPD

• Borderline Personality Disorder - PPD people are aloof and distant from others, while borderline individuals are more often over involved in chaotic relationships.

• Antisocial Personality Disorder - PPD individuals do not have the lifelong history of antisocial behavior that characterizes APD

7. Treatment

• Use open, straightforward, not-overly-warm manner

• Use humor sparingly if at all

• Set limits on any threatening behavior early

B. Schizoid Personality Disorder

1. Profile

• Odd and withdrawn, but without chronically disordered thinking

• Avoid human contact

• Choose solitary jobs

• Uncomfortable in interview

• Defense: withdrawal into fantasy

2. Diagnosis

DSM IV criteria .

3. Etiology

• Unknown

• Psychodynamic theory- bleak childhoods devoid of warmth

• Possible genetic predisposition

• No good studies

4. Epidemiology

• Prevalence may be as high as 2% of general population

• More frequent m males than females

• Most never come to clinical attention

5. Course and Prognosis

• Not known - thought to be a life-long disorder