PERSONALITY DISORDER

1. PERSONALITY DISORDER

2. The term personality refers to enduring qualities of an individual shown in his ways of behaving in a wide variety of circumstances. All doctors should be able to assess personality so that they can predict how patients are likely to behave when ill. The psychiatrist shares this general concern about the personality of his patients but his interests go further. This is because among psychiatric patients personality not only determines how they react when ill; it can also prepare the ground for illness and can sometimes be mistaken for illness.

3. Features of personality make some people more vulnerable to develop emotional disorder when experiencing stressful events. Thus when faced with difficulties, a person who has always worried about minor problems is more likely to develop an anxiety disorder than a person who is less prone to worry. With this degree of vulnerability in the personality, abnormal behaviour occurs only in response to stressful events. In more abnormal personalities, unusual behaviour occurs even in the absence of stressful events. At times, these anomalies of behaviour may be so great that it is difficult to decide, solely on the patient�s state at the time, whether they are due to personality or to mental disorder.

4. The conceptual distinction between personality and mental disorders is valuable in everyday clinical practice, but it is not always easy to make. Central to the concept is the duration of the unusual behaviour in question. If the person previously behaved normally and then begins to behave abnormally, he is said to have a mental disorder. If his behaviour has always been as abnormal as it is now, he is said to have a personality disorder. The distinction is easy when behaviour changes quickly (as in an acute manic disorder), but difficult when it changes slowly (as in some cases of schizophrenia).

5. Some German psychiatrists (for example, Jaspers 1963) added a third criterion, that illness arises from causes within the person and is not a reaction to circumstances. This led, in turn, to the idea that conditions clearly provoked by stressful events should not be regarded as illness but as reactions of the personality. Although there is some merit in this idea, it can no longer be sustained because recent research shows that stressful events also occur before the onset of some conditions (such as schizophrenia) that were regarded as illnesses rather than reactions by the earlier authors.

6.  In the assessment of personality  Two points need to be mentioned. The first is that judgements of personality of the kind made in everyday life should not be applied to patients. If we meet a new colleague at work, we are likely to judge his personality largely from his behaviour in the first few weeks of meeting him. We assume that this represents his habitual way of behaving. Occasionally we are wrong; for example, the new colleague may have been more guarded than he usually is. Generally, however, this sort of everyday assessment is accurate.  The personality of patients cannot be judged in the same way. It is a common mistake to place too much weight on the pattern of behaviour observed in the ward or in the out-patient clinic where behaviour is likely to reflect a combination of personality and mental disorder. Personality can be judged only from reliable accounts of past behaviour.

7. The second point concerns psychological tests. It is tempting to suppose that they give better information about personality than the clinician can obtain from interviews with the patient and informants. This is not so, because most personality tests are affected by the presence of mental disorder, and because they measure traits that are seldom important in clinical practice. In the assessment of personality there is no substitute for careful interviewing of the patient and other informants.

8. The concept of abnormal personality  Some personalities are obviously abnormal: for example those of violent and sadistic people who repeatedly harm others and show no remorse. It is, however, impossible to draw a sharp dividing line between the normal and the abnormal. Indeed, it is even difficult to decide what criterion should be used to make this distinction. Two criteria have been suggested, the first statistical and the second social. On the statistical criterion, abnormal personalities are quantitative variations from the normal, and diving line is decided by a cut-off score. In principle, this scheme is attractive, as it parallels the approach used successfully in defining abnormalities of intelligence. It has obvious value in research where tests are required to measure personality in groups of patients. However, in clinical work with individual patients it is of limited value.

9. The second approach can also be applied to a scheme in which abnormal personalities are regarded as quantitative variations from the normal. However, the arbitrary dividing line is determined by social criteria rather than by a statistical cut-off. The criteria are that the individual suffers from his own personality or that other people suffer from it. Thus someone with an abnormally sensitive and gloomy personality suffers himself, while a person who is emotionally sensitive and gloomy personality suffers himself, while a person who is emotionally cold and aggressive makes other people suffer. Although such criteria are subjective and lack the precision of the first approach, they correspond well with the realities of clinical practice and they have been adopted widely.

10. Given the conceptual problems involved, it is hardly surprising that it is difficult to frame a satisfactory definition of abnormal personality. The definition in the International Classification of Diseases is not without difficulties but is widely accepted: �deeply ingrained maladaptive patterns of behaviour recognizable by the time of adolescence or earlier and continuing through most of adult life, although often becoming less obvious in middle or old age. The personality is abnormal either in the balance of its components, their quality and expression or in its total aspect. Because of this � the patient suffers or others have to suffer and there is an adverse effect on the individual or on society�.

11. It is important to recognize that people with abnormal personalities may have favourable as well as unfavourable traits. No matter how abnormal the personality, enquiries should always be made about positive features as well as unfavourable ones. These are particularly important in planning treartment.

12. CLINICAL FEATURES OF ABNORMAL PERSONALITIES  This section contains an account of the abnormal personalities that appear in the International Classification of Diseases. This is followed by a brief review of the additional or alternate classes used in DSM-III-R. Although the account given here follows the broad scheme of the International Classification of Diseases, the various kinds of abnormal personality are not described in the same order. Instead obsessional and histrionic personality disorders first, because they can be related most easily to observations of people in everyday life.

13. DIAGNOSIS  According to ICD-10, the diagnostic guidelines for specific personality disorder include conditions not directly attributable to gross brain damage or disease, or to another psychiatric disorder, meeting the following criteria: 1.Markedly disharmonious attitudes and behaviour, involving usually several areas of functioning, e.g. affectivity, arousal, impulse control, ways of perceiving and thinking, and style of relating to others: 2.The abnormal behaviour pattern is enduring, of long standing, and not limited to episodes of mental illness;

14. 3.The abnormal behaviour pattern is pervasive and clearly maladaptive to a broad range of personal and social situations; 4.The above manifestations always appear during childhood or adolescence and continue into adulthood; 5.The disorder leads to considerable personal distress but this may only become apparent late in its course; 6.The disorder is usually, but not invariably, associated with significant problems in occupational and social performance.

15. HISTRIONIC PERSONALITY DISORDER The important features of this kind of personality are self-dramatization, a craving for novelty and excitement, and a self-centred approach to personal relationships. In a normal personality, minor histrionic traits can be socially advantageous. People with such traits make lively, engaging company, and are popular guests; they do well in amateur dramatics, and are entertaining public speakers. They tend to wear their emotions on their sleeves and are easily moved to joy or tears, but the feelings soon pass.

16. When these qualities are exaggerated in histrionic personality disorder, they become less acceptable. The person dramatizes himself as a larger than life character; he seems to be playing a part, incapable of being himself. He often seems unaware that other people can see through his defences. Instead of enjoyment of novelty found in a person with histrionic personality traits, in histrionic personality disorder there is a restless search for new experiences, coupled with short-lived enthusiasms, readiness to boredom and craving for novelty. The tendency to be self-centred may be greatly exaggerated in histrionic personality disorder. The person lacks consideration for others, appearing to think only of his own interests and enjoyment.

17. He appears vain, inconsiderate, and demanding and may go to extreme lengths to force other people to fall in with his wishes. Emotional �blackmail�, angry scenes, and demonstrative suicide attempts are all part of the stock-in-trade of such a person. He displays emotions readily, exhausting others with tantrums of rage or dramatic expressions of despair. He seems to feel little of the emotions he expresses; he recovers quickly and often seems surprised that other people are not prepared to forget the scenes as quickly as he is himself. With these qualities is combined a capacity for self-deception that can at times reach astounding proportions. The person goes on believing himself to be in the right when all the facts show that he is not. He is able to maintain elaborate lies long after other people have seen through them. This pattern of behaviour is observed in its most extreme form in �pathological liars� and swindlers.

18. Some of these qualities are normal in children, particularly the transient enthusiasms, the easy change from laughter to tears, the enjoyment of make-believe and egocentricity. This had led some psychiatrists to apply the term immature to this type of personality. However, the term is imprecise and is best avoided. In histrionic personality disorder, the sexual life is also affected. Especially in women there is often sexual provocation combined with frigidity. The engage in displays of affection and are flirtatious, but they are often incapable of deep feelings and may fail to reach orgasm.

19. According to ICD-10, the diagnostic guidelines for paranoid personality disorder include the following features (in addition to features of personality disorders in general, described above). A clear evidence is usually required of the presence of at least three of the traits or behaviours given in the clinical description.  1.Self-dramatization, theatrically, exaggerated expression of emotions (dramatic emotionality). 2.Suggestibility, easily influenced by others or by circumstances. 3.Shallow and labile affectivity. 4.Continual seeking for excitement, appreciation by others, and activity in which the person is the center of attention (attention-seeking attitude). 5.Inappropriate seductiveness in appearance or behaviour. 6.Overconcern with physical attractiveness.

20. Associated features may include egocentricity, self-indulgence, continuous longing for appreciation, feelings that are easily hurt, and persistent manipulative behaviour to achieve own needs.  Tantrums or anger outbursts are common. The actions are not planned for any long-term goals; instead they seek instant satisfaction and approval. Exhibitionistic traits like dressing flamboyantly, mannerisms of speech and motor hehaviour are present. There is an attempt to look charming, beautiful and seductive. Suicidal gestures may be made at times. Interpersonal relationships are often stormy and ungratifying.

21. This disorder is more common in female gender. Hysteria (conversion and dissociation disorder) was previously thought to be more common in the presence of histrionic personality disorder, but recent studies have failed to prove this relationship.  Psychodynamically, there are usually intense dependency needs. The defense mechanisms used most often are acting out and dissociation.

22. PARANOID PERSONALITY DISORDER The central features of this kind of abnormal personality are suspiciousness and sensitivity. As already mentioned, minor obsessional and histrionic traits can add socially desirable qualities to a normal personality. There is no such positive side to paranoid traits. Even when these traits form only small part of the personality, they add a distrust that goes beyond ordinary caution and a sensitivity to rebuff that is a handicap to social relationships. In the paranoid personality disorder, this suspiciousness can be shown in several ways.

23. The person may be constantly on the look out for attempts by others to get the better of him, to deceive him or play tricks on him. He may doubt the loyalty of other people and be unable to put his trust in them. As a result, he appears touchy and suspicious. He does not make friendships easily and may avoid involvement in groups. He may be perceived by other people as secretive, devious, and self-sufficient to a fault. He seems to have little sense of humour or capacity for enjoyment. Such personality traits are fertile for jealousy.

24. People with paranoid personalities appear argumentative and stubborn. Presented with a new proposal, they are overcautious and look for ways in which in might be designed to harm their own interests. Some engage in litigation that is prolonged long after any non-paranoid person would have abandoned it. An important feature of the paranoid personality is a strong sense of self-importance. The person often has a powerful inner conviction that he is usually talented and capable of great achievements. This idea is maintained, in the face of modest accomplishments, by paranoid beliefs that other people have prevented him from fulfilling his real potential, that he has been let down, tricked, swindled, or deceived. Sometimes, these self-important ideas are crystallized round a central overvalued idea that persist for many years.

25. Sensitivity is another important aspect of the paranoid personality. People of this kind readily feel shame and humiliation. They take offence easily and see rebuffs where none are intended. As a result, other people find them difficult, prickly and unreasonable.  According to ICD-10, the diagnostic guidelines for paranoid personality disorder include the following features (in addition to features of personality disorders in general, described above). A clear evidence is usually required of the presence of at least three of the traits or behaviours given in the clinical description.

26. 1.Excessive sensitiveness to setbacks and rebuffs.2.Tendency to bear grudges persistently, i.e. refusal to forgive insults and injuries or slights.3.Suspiciousness and a pervasive tendency ti distort experience by misconstruing the neutral or friendly actions of others as hostile and contemptuous.4.A combative and tenacious sense of personal �right�, out of keeping with the actual situation.

27. 5.Recurrent suspicious, without justification, regarding sexual fidelity of spouse or sexual partner.  6.Tendency to experience excessive self-importance, manifest in a persistent self-referential attitude.  7.Preoccupation with unsubstantiated �conspiratorial� explanations of events, both immediate to the patient and in the world at large.  Psychodynamically, the underlying defense mechanism is projection.

28. The paranoid personality disorder is common in the premorbid personality of some patients of paranoid schizophrenia. However, whether its presence predisposes to the development of paranoid schizophrenia, is not known.  Treatment a)Individual psychotherapy. b)Supportive psychotherapy.  The response to treatment is usually poor.The patients often do not seek treatment on their own and may resent treatment.Drug treatment has a very limited role.

29. SCHIZOID PERSONALITY DISORDER In this disorder, the person is introspective and prone to engage in fantasy rather then take action. He is emotionally cold, self-sufficient, and detached from other people. The name schizoid was suggested by Kretchmer (1939), who held that there is an aetiological relationship between this kind of personality and schizophrenia. However, the two are not associated invariably, and the term should be used descriptively without implying any causal relationship with schizophrenia.

30. The most striking feature is lack of emotional warmth and rapport. People with this disorder appear detached, aloof and humourless, and seem incapable of expressing affection or tenderness. As a result, they do not make intimate friendships and often remain unmarried. They show little concern for the opinions of other people and pursue a lonely course through life. Their hobbies and interests are solitary and are more often intellectual than practical.  These people tend to be introspective. Their inner world of fantasy is often extensive but it lacks emotional content. They are more likely to be concerned with intellectual problems than with ideas about other people

31. If the disorder is extreme, the individual is seen as cold, callous, seclusive, ill at ease in company, and without friends. Lesser degrees of the same traits, appearing as part of a normal personality, may confer advantages in some ways of life. For example, some forms of academic work may be carried out more effectively by a person who can detach himself from social activities for long periods, and can concentrate in a detached and unemotional way on intellectual problems.

32. According to ICD-10, the diagnostic guidelines for paranoid personality disorder include the following features (in addition to features of personality disorders in general, described above). A clear evidence is usually required of the presence of at least three of the traits or behaviours given in the clinical description.  1) Few, if any, activities, provide pleasure. 2) Emotional coldness, detachment or flattened affectivity. 3) Limited capacity to express either warm, tender feelings or anger towards others.

33. 4) Apparent indifference to either praise or criticism.5) Little interest in having sexual experiences with another person (taking into account the person`s age).6) Almost invariable preference for solitary activities.7) Excessive preoccupation with fantasy and introspection.8) Lack of close friends or confiding relationships (or having only one) and of desire for such relationships.Marked insensitivity to prevailing social norms and conventions.

34. Psychotic features are typically absent. The disorder is usually more common in men.  Psychodynamically, the disorder is supposed to result from �cold and aloof� parenting in a child with introverted temperament. However, this hypothesis is far from proven in the research conducted so far.  Like all personality disorders, schizoid personality disorder has an onset in early childhood with stable course over the years. Earlier, it was believed to predispose to the development of schizophrenia, but later studies have failed to replicate the findings.

35. Treatment 1. Individual psychotherapy. 2. Psychoanalysis or Psychoanalytical psychotherapy. 3. Gradual involvement in group psychotherapy. The patients often do not seek treatment on their own. The response to treatment is usually not good. Drug treatment clearly has a very limited role.

36. DYSSOCIAL (ANTISOCIAL) PERSONALITY DISORDER  People with this disorder show a bewildering variety of abnormal features. Several attempts have been made to identify an essential core to the disorder. The most useful of these recognizes four features: failure to make loving relationships, impulsive actions, lack of guilt, and failure to learn from adverse experiences. The failure to make loving relationships is accompanied by self-centredness and heartlessness. In its extreme form there is a degree of callousness that allows the person to inflict cruel, painful, or degrading acts on others.

37. This lack of feeling is often in striking contrast to a superficial charm, which enables the person to make shallow and passing relationships. Sexual activity is carried on without evidence of tender feelings. Marriage is often marked by lack of concern for the partner, and sometimes by physical violence. Many marriages end in separation or divorce.  The characteristic impulsive behaviour is often reflected in an unstable work record marked by frequent dismissals. It is also shown in the whole pattern of life, which seems to lack any plan or persistent striving towards a goal.

38. This impulsive behaviour, coupled with a lack of guilt or remorse, is often associated with repeated offences against the law. Such offences begin in adolescence with petty acts of delinquency, lying, and vandalism; many of them show a striking indifference to the feelings of other people, and some include acts of violence or callous neglect. Often the behaviour is made more extreme by the effects of alcohol and drugs. People with sociopathic personality make seriously inadequate parents, and may neglect or abuse their children. Some have difficulty in managing their finances or in organizing family life in other ways.

39. According to ICD-10, the diagnostic guidelines for paranoid personality disorder include the following features (in addition to features of personality disorders in general, described above). A clear evidence is usually required of the presence of at least three of the traits or behaviours given in the clinical description. This disorder is synonymous with previously used terms like psychopathy and sociopathy, but does not always mean criminal behaviour. 1. Callous unconcern for the feelings of others.  2. Gross and persistent attitude of irresponsibility and disregard for social norms, rules and obligations.

40. 3. Incapacity to maintain enduring relationships, though having no difficulty in establishing them.4. Very low tolerance to frustration and low threshold for discharge of aggression, including violence.5. Incapacity to experience guilt and to profit from experience, particularly punishment.6. Marked proneness to blame others, or to offer plausible rationalizations, for the behaviour that has brought the patient in to conflict with society.

41. They may also be persistent irritability as an associated feature. History of conduct disorder in childhood and adolescence, though no invariably present, may further support the diagnosis. There are no psychotic features in this disorder. Although no clear etiology is known, several genetic, environmental and biological factors are associated with this disorder. These factors include more than a �normal� prevalence of antisocial personality disorder in father; presence of impulsive and inconsistent parents; presence of soft neurological signs, non-specific EEG abnormalities; and presence of conduct and/or attention deficit disorder in childhood.

42. This disorder is diagnosed more commonly in males. The course is usually chronic; however, there is some decrease in the symptoms after the fifth decade of life in some patients.  Treatment Patients often do not seek psychiatric help and if they do, it is usually under pressure from the legal authorities. The therapeutic alliance is often not sustained. The treatment methods include:  1.Individual psychotherapy.  2.Psychoanalysis or Psychoanalytical psychotherapy.  3.Group psychotherapy and self-help groups.  4.Drug therapy: Pharmacotherapy is of little help. Earlier claims, of beneficial effect of pericyazine (an antipsychotic drug) in certain behaviour patterns of antisocial personality disorder, have not been substantiated.

43. EMOTIONALLY UNSTABLE PERSONALITY DISORDER  According to ICD-10, emotionally unstable personality disorder is described as a disorder in which there is a marked tendency to act impulsively without consideration of the consequences, together with affective instability. This disorder is further classified in to two types: impulsive type and borderline type.

44. IMPULSIVE PERSONALITY DISORDER  People with this kind of personality disorder cannot control their emotions adequately, and are subject to sudden unrestrained outpourings of anger. These outbursts are not always confined to words, but may include physical violence leading at times to serious injury. Unlike people with antisocial personalities, who also exhibit explosions of anger, this group do not have other difficulties in their relationships. Outbursts of violence or threatening behaviour are common, particularly in response to criticism by others.

45. BORDERLINE TYPE The borderline type is characterized by emotional instability. In addition, patient`s own self-image, aims, and internal preferences (including sexual) are often unclear or disturbed. There are usually chronic feelings of emptiness. A liability to become involved in intense and unstable relationships may cause repeated emotional crises and may be associated with excessive efforts to avoid abandonment and a series of suicidal threats or acts of self-harm, (although these may occur without obvious precipitants).

46. The borderline type is also known as borderline personality disorder, the characteristic features of which include the following:  1.Significant and persistent disturbance of identity of self, e.g. �who am I�. There is marked uncertainty about major issues in life. 2.Unstable and intense interpersonal relationship patterns. 3.Impulsivity. 4.Unstable emotional responses, with rapid shifts. Anger outbursts may occur. 5.Chronic feelings of boredom or emptiness with inability to stay alone. 6.Deliberate self harm is common in the form of self-mutilation, suicidal gestures, or accident-proneness.

47. The term borderline personality disorder currently includes ambulatory schizophrenia and pseudoneurotic schizophrenia, which were earlier thought to be subtypes of schizophrenia.  Psychodynamically, splitting is the primary defense mechanism employed in borderline personality disorder.  There is a considerable overlap between borderline, narcissistic and antisocial (dissocial) personality disorders. Major depressive episodes occur commonly in this disorder.

48. Treatment  1.Psychoanalysis or Psychoanalytical psychotherapy.  2.Supportive psychotherapy.  3.Drug therapy: Antidepressants have been used with success in certain patients with depression. Major depressive episode, if occurs, necessitates antidepressant therapy. Occasionally antipsychotics, lithium, and carbamazepine have been used when aggression and impulsivity are prominent.  Drug therapy is not the treatment of first choice in borderline disorder.

49. ANXIOUS (AVOIDANT) PERSONALITY DISORDER  These people are persistently anxious. They are ill at ease in company, fearing disapproval or criticism, and worrying that they will be embarrassed. They are cautious about new experiences and meeting people they do not know, and timid in the face of everyday hazards. As a result they have few close friends and avoid social demands such as taking new responsibilities at work. These people differ from schizoid personalities because they are not emotionally cold; indeed they crave the social relationships that they cannot attain. According to ICD-10, the diagnostic guidelines for paranoid personality disorder include the following features (in addition to features of personality disorders in general, described above). A clear evidence is usually required of the presence of at least three of the traits or behaviours given in the clinical description.

50. 1.Persistent and pervasive feeling of tension and apprehension.2.Belief that one is socially inept, personally unappealing, or inferior to others.3.Excessive preoccupation with being criticized or rejected in social situations.4.Unwillingness to become involved with people unless certain of being liked.5.Restrictions in lifestyle because of need to have physical security.6.Avoidance of social or occupational activities that involve significant interpersonal contact because of fear of criticism, disapproval, or rejection.

51. Associated features may include hypersensitivity to rejection and criticism. These patients do not enter into interpersonal relationships unless they are very sure of uncritical approval. This disorder is an epitome of what is often called as inferiority complex. Understandably, secondary depression is very common. Treatment 1.Individual psychotherapy. 2.Grope psychotherapy.  3.Behaviour therapy: In particular, social skills training and assertiveness training are useful.  4.CBT: The focus is on negative thoughts and negative self-appraisal. The response to treatment is usually satisfactory.

52. DEPENDENT PERSONALITY DISORDER  People with this disorder appear weak-willed and unduly compliant, falling in passively with the wishes of others. They lack vigour and show little capacity for enjoyment. They avoid responsibility and lack self-reliance. Some dependent people are more determined, but achieve their aims by persuading other people to assist them, whilst protesting their own helplessness. In married, such people may be protected from the full effects of their personality by support from a more energetic and determined spouse who is willing to make decisions and arrange activities. Left to themselves, some drift down the social scale and others are found among the long-term unemployed and the homeless.

53. According to ICD-10, the diagnostic guidelines for paranoid personality disorder include the following features (in addition to features of personality disorders in general, described above). A clear evidence is usually required of the presence of at least three of the traits or behaviours given in the clinical description.  1.Encouraging or allowing others to make most of one`s important decisions. 2.Subordination of one`s own needs to those of others on whom one is dependent, and undue compliance with their wishes. 3.Unwillingness to make even reasonable demands on the people one depends on. 4.Feeling uncomfortable or helpless when alone, because of exaggerated fears of inability to care for oneself.

54. 5.Preoccupation with fears of being abandoned by a person with whom one has a close relationship, and of being left to care for oneself. 6.Limited capacity to make everyday decisions without an excessive amount of advice and reassurance from others. Associated features may include perceiving one-self as helpless, incompetent, and lacking stamina.  There may be an overlap with avoidant and passive-aggressive personality disorder. Some patients exhibit masochistic character. They repetitively establish close interpersonal relationships which result in punishment.

55. Treatment 1. Individual psychotherapy. 2. Group psychotherapy.  3. Behaviour therapy in the form of assertiveness training and social skills training are useful.  4. CBT: The focus is on negative thoughts and negative self-appraisal. The response to treatment is usually good.

56. OBSESSIVE-COMPULSIVE (ANANKASTIC) PERSONALITY DISORDER In ICD10 (draft) the preferred term for this personality disorder is anankastic following the usage of Kahn (1928). The only advantage of this term is that it avoids the erroneous implication of an inevitable link between this type of personality and obsessional disorders. (People with this kind of personality are also liable to develop anxiety and depressive disorders.)

57. Before describing obsessive-compulsive personality disorder, it is useful to review the expression of obsessional traits in someone with a normal personality. Such a person is dependable, precise, and punctual. He sets high standards and keeps to social rules. He is determined and persists at his tasks, despite difficulties. His moods are stable so that he can be relied upon to be the same from day to day. However, even within a normal personality, these qualities have another side; at times determination may give way to obstinacy, precision to preoccupation with unimportant detail, and high moral standards to bigotry. Moreover the qualities that make for stable moods can be expressed as a humourless approach to life.

58. In obsessive-compulsive personality disorder, these features are more extreme. One of the most striking is a lack of adaptability to new situations. The person is rigid in his views and inflexible in his approach to problems. Change upsets him and prefers a safe routine that he knows. Such a person lacks imagination and fails to take advantage of opportunities. The qualities that make for reliability in a normal personality, are expressed in an obsessive-compulsive personality disorder as an inhibiting perfectionism that makes ordinary work a burden and leaves the person immersed in trivial detail. High moral standards are exaggerated to become painful guilty preoccupation with wrongdoing, which stifles enjoyment. People with this disorder seem without humour, ill at ease when others are enjoying themselves, moralistic in their opinions, and judgemental in their attitudes. They are often mean to the point of being miserly and do not enjoy giving or receiving gifts.

59. Indecision is another prominent feature of such people. They find it hard to weigh up the advantages and disadvantages of new situations; they delay decisions, and often ask for more and more advice. They fear making mistakes, and after deciding they worry lest the choice was wrong.   Sensitivity to criticism is a related feature of this personality. There is an undue concern about other people�s opinions, and an expectation of being judged as harshly as they judge themselves.

60. Outwardly, such people often show little emotion. However, they are given to smouldering and unexpressed feelings of anger and resentment, often provoked by other people who have interfered with their routine of life. Such angry feelings may be accompanied by obsessional thought and images of an aggressive kind, even in those who do not develop the full syndrome of an obsessional disorder.   According to ICD-10, the diagnostic guidelines for paranoid personality disorder include the following features (in addition to features of personality disorders in general, described above). A clear evidence is usually required of the presence of at least three of the traits or behaviours given in the clinical description.

61. 1.Feelings of excessive doubt and caution.2.Preoccuption with details, rules, lists, order, organization or schedule.3.Perfectionism that interferes with task completion.4.Excessive conscientiousness, scrupulousness, and undue preoccupation with productivity to the exclusion of pleasure and interpersonal relationships.5.Excessive pedantry and adherence to social conventions.6.Rigidity and stubbornness.7.Unreasonable insistence by the patient that others submit to exactly his or her way of doing things, or unreasonable reluctance to allow others to do things.8.Intrusion of insistent and unwelcome thoughts or impulses.

62. This disorder is more often diagnosed in males, and is common in the premorbid personality of patients with obsessive compulsive disorder. Major depressive episodes are frequent. Psychodynamically, this disorder is believed to result from fixation at the anal sadistic phase, with the employment of reaction formation as a defense mechanism.  Treatment  1.Psychoanalysis or Psychoanalytical psychotherapy.  2.Group psychotherapy.

63. PASSIVE-AGGRESSIVE PERSONALITY DISORDER It is characterized by the following clinical features:  - Significant and persistent passive resistance to demands for adequate social and occupational performance.  - Stubbornness, intentional inefficiency, procrastination, unjustified protests, �forgetfulness� and/or dawdling are used to achieve the purpose. Passive resistance is viewed as an expression of �covert anger� or �retroflexed anger�. This behaviour is often �chosen� in spite of the fact that a more direct and active way of showing an opinion and/or resisting was possible. An overlap with dependent personality disorder is common. Secondary depression may develop.

64. Treatment 1.Supportive psychotherapy.  2.Behaviour therapy: Social skills training and assertiveness training are helpful.  3.Group therapy.  4.Drug therapy: Antidepressants may be needed for secondary depression.

65. ENDURING PERSONALITY CHANGES, NOT ATTRIBUTABLE TO BRAIN DAMAGE AND DISEASE  This category includes disorders of adult personality and behaviour which develop following catastrophic or excessive prolonged stress, or following a severe psychiatric illness, in people with no personality disorder. The presence of brain damage or disease which may cause similar clinical features should be ruled out.

66. GENERAL CAUSES OF PERSONALITY DISORDER Genetic causes Although there is some evidence that normal personality is partly inherited, there is little evidence about the genetic contribution to personality disorders. On personality tests, the scores of pairs of twins brought up apart were as similar as those of pairs of twins reared together, suggesting a substantial genetic influence. It has been suggested that personality disorders are merely extremes of genetic variation. However, there is no direct evidence to test this hypothesis.

67. Body build The idea that body build is related to temperament is illustrated by the common belief that fat men are jolly. Kretschmer (1936) attempted to study the association scientifically. He described three types of body build: pyknic (stocky and rounded), atchletic (with strong development of muscles and bones), and asthenic or leptosomatic (lean and narrow). Kretschmer suggested that pyknic build was related to the cyclothymic type of normal personality, and to the cycloid type of abnormal personality (cyclothymes are variable in mood). Asthenic build was thought to be related to the schizothymic type of normal personality and the schizoid type of abnormal personality (schizothymes are cold, aloof. And self-sufficient). Kretschmer�s findings must be viewed cautiously because he made subjective judgements of personality and did not use statistics.

68. Sheldon et al. (1940) repeated these studies using more quantitative methods. Instead of assigning physique to one of three types, he rated it along three dimensions. Endomorphy signified �predominance of soft roundness�; mesomorphy �predominance of muscle, bone, and connective tissue�, and ectomorphy �predominance of linearity and fragility�.   Sheldon�s efforts at more precise measurement did not reveal any simple relationship between body build and personality. Interest in the subject has declined in recent years. In any case, even if such an association were to be proved, its significance would be difficult to explain. The most likely link would presumably be through genetic causes of both variables.

69. Psychological theories Although it is generally agreed that upbringing must affect the development of normal personality, little is known about the extent and nature of its influence in shaping abnormal personalities. This lack on information has allowed many rival theories of psychological development to flourish. Because none of these offers a satisfactory explanation of disorders of personality, only a brief account will be given of the two widely adopted schemes and reference made to some other theories.

70. Freud�s theories: In this scheme, emphasis is placed on events in the first five years of life. Certain predictions are made about the effects of failure at particular stages; for example, that serious difficulties at the anal stage will result in an obsessional personality disorder. The scheme allows for some modifications of personality at a later age through identification with people other than the parents, but these are thought to be less important than the earlier influences.

71. Jung�s theory is difficult to grasp because he chose to explain it in a particularly abstruse kind of metaphor. Unlike Freud, Jung thought of personality development as a life-long process. Indeed he referred to events in the first part of life as merely �fulfilling one�s obligations�, and applied this term to severing ties with parents, finding a spouse, and starting a family. Jung was more concerned with changes that occur later and reach completion only when a person is ready to face death.

72. Studies of childhood influences on personality development  Even in young infants, marked differences can be seen in such characteristic activities as patterns of sleeping and waking, approach and withdrawal from new situations, the intensity of emotional responses, and span of attention. Although these differences have been shown to persist into the childhood years, they do not seem to be closely related to adult personality traits. Considerable attention has been given to the effects on personality development of disturbances in parent-child relationships, particularly maternal deprivation. However, although such deprivation has been proposed as a cause of antisocial personality, there is no convincing evidence that it leads to other kinds of personality disorder.