Description of personality disorders - summary of chapter 1 of Personality disorders

Personality disorders
Chapter 1
Description of personality disorders

Clinical picture

Personality is the individual differences in usual tendencies to think, feel and behave. Abnormal personality or pathology refers to maladaptive traits that are overly rigid and/or extreme. Constellations of such pathologically amplified personality traits may constitute personality disorders.

A personality disorder is a chronic psychiatric disorder with onset in adolescence continuing into adulthood, characterized by pathological personality traits that lead to a disruption in the development and maintenance of mutual interpersonal relationships. This is to an extent that leads to prolonged subjective distress of self and/or others.

Personality disorders concern how people matured into adult personalities, and the building blocks are often referred to as traits. Associated problems don’t typically fall into circumscribed specific categories. They involve personal identity and dissatisfaction and dysfunction in interpersonal relationships. It is about difficulties related to how people typically experience and respond to themselves, others, and the world around them (ego-syntonic pathology).

The hallmark of personality disorders is disturbed relationships.

The DSM defines personality disorder as an enduring pattern of inner experience and behaviour that deviates markedly from the expectations of the individual’s culture. This pattern is manifested in two or more of the following areas: cognition, affectivity, interpersonal functioning and impulse control. This is inflexible and pervasive across a broad range of personal and social situations and present for a long duration.

Personality disorder is a longstanding, pervasive and persistent pattern of experience and behaviour. This is different from cultural expectation and problematic in terms of personal suffering and/or impairment in functioning.

Phenomenology of the personality disorders

Most patients manifest personality pathology that is a combination or mix of the various personality disorders identified in the DSM.

Cluser A

Cluster A consists of: paranoid, schizoid and schizotypical disorders.

This is the odd or eccentric cluster.

Paranoid personality disorder

The criteria are variations of profound mistrust and suspiciousness regarding the motives of other persons. Patients are hypervigilant to hidden meanings and threats, but in a contentious hostile way.

DSM-IV criteria:

• A pervasive mistrust and suspiciousness of others such that their motives are interpreted as malevolent, beginning by early adulthood and present in a variety of contexts
  • 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 and 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
  • 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 another disorder or medical condition.

Schizoid personality disorder

Patients with schizoid personality disorder tend to lead a withdrawn, isolated life. They are quietly distant, and prefer to be on their own, with minimal needs for relatedness. Typically, they tend to be somewhat low in energy and their emotional life is rather flat.

DSM-IV criteria:

• A pervasive pattern of detachment from social relationships and a restricted range of expression of emotions in interpersonal settings, beginning in early adulthood and present in a variety of contexts
  • 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 confidants other than first-degree relatives
  • Appears indifferent to the praise or criticism of others
  • Shows emotional coldness, detachment, or flattened affectivity
• Does not occur exclusively during the course of another disorder or medical condition

Schizotypal personality disorder

Persons with schizotypal personality disorder hold unusual beliefs. What has no meaning to most persons may have very special meaning to an individual with schizotypal personality disorder.

DSM-IV criteria:

•  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 behaviour, beginning by early adulthood and present in a variety of contexts
  • Ideas of reference
  • Odd beliefs or magical thinking that influences behaviour and is inconsistent with subcultural norms
  • Unusual perceptual experiences, including bodily illusions
  • Odd thinking and speech
  • Suspiciousness or paranoid ideation
  • Inappropriate or constricted affect
  • Behaviour or appearance that is odd, eccentric, or peculiar
  • 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
• Does not occur exclusively during the course of another disorder or medical condition

Cluster B

Cluster B contains: antisocial, borderline, histrionic and narcissistic personality disorder.

This is the emotional or dramatic cluster.

Antisocial personality disorder

Patients with antisocial personality disorder tend to disregard the rights of others and are prone to unethical behaviour. They tend to be irresponsible, and do not learn from previous mistakes.

DSM-IV criteria

• A pervasive pattern of disregard for and violation of the rights of others occurring since age 15 years
  • Failure to conform to social norms with respect to lawful behaviours as indicated by repeatedly performing acts that are grounds for arrest
  • Deceitfulness
  • Impulsivity or failure to plan ahead
  • Irritability and aggressiveness
  • Reckless disregard for safety of self or others
  • Consistent irresponsibility
  • Lack of remorse
• The individual is at least 18
• There is evidence of conduct disorder with onset before age 15
• Does not occur exclusively during the course of another disorder or medical condition

Borderline personality disorder

Central to borderline is a pervasive pattern of instability across multiple domains, including affect, interpersonal relationships, and self-image.

DSM-IV criteria

• A vervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts
  • 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
  • Impulsivity in at least two areas that re potentially self-damaging
  • Recurrent suicidal behaviour, gestures, threats, or self-mutilating behaviour.
  • Affective instability due to a marked reactivity of mood
  • Chronic feelings of emptiness
  • Inappropriate intense anger or difficulty controlling anger
  • Transient, stress-related paranoid ideation or severe dissociative symptoms

Histrionic personality disorder

A key feature of persons with histrionic personality disorder is the lability and shallowness of their affect. They seek to be the centre of attention, and are unhappy when they are not.

DSM-IV criteria

• A pervasive pattern of excessive emotionality and attention seeking, beginning by early adulthood and present in a variety of contexts
  • Is uncomfortable in situations in which (s)he is not the centre of attention
  • Interaction with others is often characterized by inappropriate sexually seductive or provocative behaviour
  • Displays rapidly shifting and shallow expression of emotions
  • Consistenly uses physical appearance to draw attention to self
  • Has a style of speech that is excessively impressionistic and lacking in detail
  • Shows self-dramatization, theatricality, and exaggerated expression of emotion
  • Is suggestible
  • Considers relationships as more intimate as they actually are

Narcissistic personality disorder

People with narcissistic personality disorder are characterized by their self-centredness and preoccupation with success, achievement, and greatness. They believe they deserve special attention and privileges and have little empathy for others.

DSM-IV criteria

• A pervasive pattern of grandiosity, need for admiration, and lack of empathy, beginning by early adulthood and present in a variety of contexts
  • Has a grandiose sense of self-importance
  • Is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love
  • Believes that (s)he is ‘special’ and unique and can only be understood by, or should associate with, other special or high status people
  • Requires excessive admiration
  • Has a sense of entitlement
  • Is interpersonally exploitative
  • Lacks empathy
  • Is often envious of others or believes that others are envious or him or her
  • Shows arrogant, haughty behaviours or attitudes

Cluster C

Cluster C includes: avoidant, dependent and obsessive-compulsive personality disorders. This is the anxious cluster.

Avoidant personality disorder

Patients with avoidant personality disorder are sensitive to criticism, disapproval, and ejection. They tend to avoid interpersonal contact. Their mood is generally anxious.

DSM-IV criteria

• A pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluations, beginning by early adulthood and present in a variety of contexts
  • Avoids occupational activities that involve significant interpersonal contact, because of fears of criticism, disapproval, or rejection
  • Is unwilling to get involved with other people unless certain of being liked
  • Shows restraint with 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
  • 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

Dependent personality disorder

Patients with dependent personality disorder have excessive needs for guidance, reassurance, and assistance. They tend to feel incompetent.

DSM-IV criteira

• A pervasive and excessive need to be taken care of that leads to submissive and clinging behaviour and fears of separation, beginning In early adulthood and present in a variety of contexts
  • 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 or her life
  • Has difficulty expressing disagreement with others because of fear of loss of support or approval
  • Has difficulty initiating projects of doing things on his or her own
  • Goes to excessive lengths to obtain nurturance and support from others, to the point of volunteering to do things that are unpleasant
  • Feels uncomfortable or helpless when alone because of exaggerated fears of being unable to care for him or 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 him or herself

Obsessive-compulsive personality disorder

Patients with obsessive-compulsive personality disorder have as most prominent feature behavioural discipline, a counterproductive preoccupation with details, and deep-felt obedience to rules and regulations.

DSM-IV criteria

• 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
  • Is preoccupied with details, rules, lists, order, organization, or schedules to the extent that the major point of the activity is lost
  • Shows perfectionism that interferes with task completion
  • Is excessively devoted to work and productivity to the exclusion of leisure activities and friendships
  • Is overconscientious, scrupulous, and inflexible about matters of morality, ethics, or values
  • Is unable to discard worn-out or worthless objects even when they have no sentimental value
  • Is reluctant to delegate task or to work with others unless they submit exactly to his or her way of doing things
  • Adopts a miserly spending style towards both self and others
  • Shows rigidity and stubbornness

Personality disorder not otherwise specified

This label should be assigned when the patient meets the general criteria for a personality disorder and this does not reach the threshold for any personality disorder in particular.