Personality disorders By: Dr

1. Personality disordersBy:Dr/ Doaa Ahmed KhalifaMD in Psychiatry

2. Personality disorders Personality Global descriptive label for a person's observable behavior and his or her subjectively reportable inner experiences Personality disorder It is the pervasive, maladaptive , inflexible patterns of behavior and inner experiences that are deviation from cultural experiences lead to subjective distress or socioprofessional functional impairment or both

3. Personality disorders The pattern manifested by 2 or more of the following: - Cognition Ways of perceiving and interpreting self and other people and events - Affectivity - Appropriateness of emotional response - Interpersonal functioning - Impulse control Characteristics - No specific onset - Before 18 years old - Leads to disturbance of functioning

4. Personality disorders Epidemiology 6-9 % have disorders Female = Male Classification Cluster A Odd- Eccentric 1-Paranoid personality disorders 2-Schizoid personality disorders 3-Schizotypal personality disorders Cluster B Emotional or erratic 1-Histrionic personality disorders 2-Narcissistic personality disorders 3-Antisocial personality disorders 4- Borderline personality disorders

5. Cluster C Anxious, fearful 1- Avoidant personality disorders 2- Dependant personality disorders 3- Obsessive compulsive personality disorders 2 New categories - Passive aggressive personality disorders - Depressive personality disorders DD Temperament Character - Automatic - intentional - Habits and skills - Goals and values - Limbic system - Neocortex - Heritable -Less heritable ( Social and cultural factors

6. Etiology 1- Biological A- Genetic Twin studies concordance rate high in monozygotic twins Family studies Cluster A especially schizotypal more common in relatives of schizophrenic cases Cluster B ASPD in relatives of patients with alcohol use Histrionic in relatives of patients with somatization disorder BLPD in relatives of patients with depression 10 genes are isolated related to impulsivity B- Endocrine High levels of testosterone and estrogen associated with high aggression and sexual behavior in BLPD

7. C- Neurotransmitters High endorphins results in phlegmatic personality Low Serotonin results in suicide , impulsive and aggressive behavior High dopamine in schizotypal personality disorder Low nor epinephrine in violence D- Electrophysiology ( EEG ) Slow wave activity in ASPD, and BLPD E- MRI In schizotypal personality disorder enlarged ventricle and prefrontal atrophy F- Cognitive impairment In schizotypal personality disorder Attentional impairment, impaired information processing, and abnormal P300 In BLPD Lower IQ, and poor performance in different tasks

8. 2- Psychological A- Psychoanalytical B- Cognitive Unrealistic sense of grandiosity, overestimation of the persons ability, misinterpretation of benign stimulus as harmful, Lack of sense of security, seductive behavior C- Behavioral( imitation and modeling ) 3- Social A- Temperament If the child temperament is fearful predispose to avoidant PD B- Family pathology 1- parents give their children unrealistic sense of grandiosity with narcissistic PD 2- Imitation and modeling 3- chronic physical illness with dependant PD 4- Traumatic experience ( physical , sexual abuse, hostility, neglect, parental loss ) predispose to BLPD C- Culture: Families encourages aggression predispose to ASPD in their children

9. Clinical picture Cluster A 1- Paranoid PD Men> women - Senses that others are harming him - Preoccupied by the loyalty of others - Mistrust others - Reads threatening in benign remarks of others - Unforgiving for insults - Counteracts others claiming that they attacked him - Suspicious in his or her spouse without sufficient basis - Sensitive and makes hills out of molls DD Delusional disorder, paranoid schizophrenia, other PD as BLPD, ASPD, and schizoid PD

10. Cluster A 2- Schizoid PD Men > Women - Do not enjoy close relations - Prefers Solitary activities - No or little sexual interest - Takes pleasure in few activities - No close friends - Lack of social skills,excessive day dreaming - Indifferent to criticism or praise - Emotional coldness and flat affect DD Schizophrenia, Schizotypal PD, and Avoidant PD

11. Cluster A 3- Schizotypal PD Various eccentricities and abnormalities of thought, perception and speech - More in relatives of schizophrenic patients - Ideas of reference - Magical thinking (superstitious,telepathy, bizare fantacies) - Odd thinking and speech (vague, circumstantial, metaphorical) - Odd behavior and appearance - Suspiciousness and paranoid ideation - Constricted affect - Unusual perceptual experiences including bodily illusions , sense of presence - No friends - Excessive social anxiety associated with paranoid fears

12. May have attacks of anxiety, depression, and sometimes psychosis, scientists believe it should be part of psychotic spectrum DD: Schizophrenia, schizoid, paranoid, avoidant PD

13. Cluster B 1- Borderline PD Women twice as men - Real or imagined abandonment - Unstable and intense interpersonal relations - Identity disturbance - Impulsivity in two areas ( spending, sex, substance, reckless driving, or binge eating ) - Suicidal or self mutilation - Affective instability with rapid shift of mood within few hours - Chronic feeling of emptiness - Difficulty in controlling anger - Stress related paranoid ideation DD Schizophrenia, Schizotypal PD, Paranoid PD

14. Cluster B 2- Antisocial PD More in men 75% in prisons Common in poor urban areas, large families, relatives of patient with ASPD - Failure to conform to social norms - Repeated lying - Impulsivity - Irritability and aggressiveness ( repeated fights ) - Reckless disregard of safety of self and others - Irresponsible in home , work - Lack of remorse and guilt DD Substance abuse

15. Cluster B 3- Histrionic PD Women more affected than men - Selfish: distress when not the centre of attention - Sexually seductive inappropriate behavior - Use physical appearance to draw attention - Impressionistic speech - Self dramatizing exaggeration of emotions - Consider more intimate relations - Rapidly shifting expression of emotions - Easily suggestible: behave according to their emotions and not logic - Dissociation: under stress to escape from certain situation DD Borderline PD, Somatization disorder

16. Cluster B 4- Narcissistic PD Males>females - Sense of self importance (grandiosity) - Fantasies of unlimited success and power - Believes that he or she is unique and special - Is interpersonally exploitative - Require excess admiration and praise - Sense of entitlement - Lacks empathy - Often envious - Shows arrogant attitude DD Borderline PD, Histrionic PD, Antisocial PD

17. Cluster C 1- Avoidant PD No sex difference - Avoid activities for fear of disapproval and criticism - Unwilling to be involved with people unless certain of being liked - No new relations for fear of disapproval - Preoccupied by being criticized and rejected - Feeling inadequacy in his relations - View self as inferior to others - Reluctant to take risks of new activities DD Schizoid PD, dependant PD

18. Cluster C 2- Dependant PD More in children with chronic physical illness - Difficulty in making everyday decision, lack of self confidence - Need others to assume his responsibilities - Difficulty expressing his disagreement - Difficulty in initiating any task or project - Ask for support from others even in trivial things - Felt helplessness when alone - Urgently seeks another relation to gain care if a current relation ends DD Histrionic PD, Borderline PD, Patients with agoraphobia

19. Cluster C 3- Obsessive-Compulsive PD - Preoccupied with details and routine - Perfectionism that interfere with task completion - Devoted to work and productivity - Inflexible about matters of morality, ethics and values - Reluctant to delegate tasks unless they submit to his orders - Rigidity and stubbornness - Adopts a miserly spending style - Indecisiveness - Repeat things to be sure of their actions

20. Personality disorder not otherwise specified 1-Passive- Aggressive PD - Resist routine tasks - Complains of misunderstood - Argumentative - Criticized authority - Express envy - Alternating between hostility and guilt - Complains of bad luck and misfortune 2-Depressive PD - Introverted - Pessimistic - Self reproach and criticism - Hard to please - Feeling of inadequacy and preoccupied with negative events

21. Personality change due to general medical condition Etiology - Trauma: head trauma, post concussion - Cerebrovascular disorders - Heavy metal poisoning ( manganese, mercury) - Infections( neurosyphilis, AIDS) - Cerebral tumors - Demyelinaing disease as M.S - Cerebral tumors especially frontal - Epilepsy( complex partial seizures)

22. Clinical picture Evidence from history, examination and investigation of CNS or systemic cause preceding the onset of personality change No affection of memory or consciousness - Impaired control of impulses or emotional expression - Euphoria - Shallow and labile emotions - Temper outbursts - Frontal lobe syndrome (apathy, indifference, hyperphagia, over inclusion, circumstantialities) - Temporal lobe epilepsy ( hypergraphia, hyper religiosity, humorless, aggression) DD: Dementia (cognitive and behavior are affected)

23. Treatment Combined Pharmacotherapy + Psychotherapy 1- Cluster A a- Psychotherapy in group or individual Aim: Improve social skills training through +ve and �ve reinforcement Decrease suspiciousness b- Pharmacotherapy according to symptoms i-Antipsychotic if delusional thinking Small doses of haloperidol or pimozide ii-Antidepressant to decrease sensitivity and rejection or if co morbid depressive symptoms iii- Anxiolytics as benzodiazepines to reduce anxiety and agitation

24. 2- Cluster B A- Psychotherapy i- Insight oriented psychotherapy Uncover unconscious conflicts Explore the used defense mechanisms ii- Behavioral therapy Social skill training iii- Cognitive therapy Modify cognitive distortions, provide more rational and flexible schemata B- Pharmacotherapy If impulsive behavior:AED e.g Tegretol or depakene If mood swings: mood stabilizer as lithium If short psychotic symptoms: antipsychotics

25. 3- Cluster C A- Avoidant PD i- Behavioral psychotherapy - Assignments to exercise new social skills - Assertiveness training - Group therapy ii- Pharmacotherapy Beta blockers if with anxiety and increased autonomic nervous system activity SSRI for rejection and sensitivity

26. 3- Cluster C B- Dependant PD Psychotherapy i- Insight oriented psychotherapy Aim : make patient more assertive and self reliant ii- Behavioral therapy iii- Family therapy iv- Group therapy Pharmacotherapy If high anxiety on separation: imipramine, BDZ, or SSRI

27. 3- Cluster C C- Obsessive-compulsive PD - Cognitive behavioral therapy - Pharmacotherapy Clomipramine Clonazepam SSRI Personality change due to general medical condition - Treat underlying cause - Imipramine- fluoxetine