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PERSONALITY PERSONALITY DISORDERSDISORDERS

Dept.ofDept.of PsychiatryPsychiatry andand PsychotherapyPsychotherapy, P, Péécscs

http://psychiatry.pote.huhttp://psychiatry.pote.hu

PERSONALITY DISORDERS:PERSONALITY DISORDERS:

EncompassEncompass impairmentsimpairments inin personalitypersonality ((i.e.characteri.e.character traitstraits) ) thatthat areare maladaptivemaladaptive, , pervasivepervasive, , inflexibleinflexible andand enduringenduring

TheseThese impairmentsimpairments start start inin earlyearly childchild-- hoodhood oror adolescenceadolescence andand notnot areare causedcaused byby otherother psychiatricpsychiatric oror medicalmedical disorderdisorder

The enduring pattern leads to clinically significant distress or impairment in social, occu- pational, or other important areas of functioning.

A behaviour or traits that are stable and of long duration, its onset can be traced back at least to adolescence or early adulthood

The enduring pattern is not due to the direct physiological effects of a substance ( a drug of abuse) another psychiatric disorder, or a general medical condition (e.g.head trauma)

As clinical diagnoses, they are coded in DSM system on axis II - to separate them from major mental disorders which are coded on axis I

GroupsGroups -- byby thethe similaritysimilarity ((clustersclusters) ) ofof symptomssymptoms

ClusterCluster AA -- paranoidparanoid, , schizoidschizoid, , schizotypalschizotypal areare characterizedcharacterized asas „„ oddodd andand excentricexcentric ”” groupgroup

ClusterCluster BB -- narcissisticnarcissistic, , borderlineborderline, , hystriohystrio-- nicnic andand antisocialantisocial areare characterizedcharacterized asas „„dramaticdramatic , , emotionalemotional , , erraticerratic ”” groupgroup

ClusterCluster CC -- obsessiveobsessive--compulsivecompulsive, , avoidantavoidant, , dependentdependent PDPD--s s areare characterizedcharacterized asas „„anxiousanxious andand fearfulfearful ”” groupgroup

DSM-IV-TR Personality Disorders

Cluster A personality disorders:

Paranoid personality disorder

Schizoid personality disorder

Schizotypal personality disorder

Cluster B personality disorders:

Antisocial personality disorder

Borderline personality disorder

Histrionic personality disorder

Narcissistic personality disorder

Cluster C personality disorders:

Avoidant personality disorder

Dependent personality disorder

Obsessive-compulsive personality disorder

Personality disorder not otherwise specified

Personality change due to a general medical condition

SomeSome epidemiologicalepidemiological datadata

PDPD’’ss lifetimelifetime prevalenceprevalence is is aboutabout 1010–– 15 % 15 % ((AndreasenAndreasen))

BorderlineBorderline PD is PD is foundfound inin approxapprox. 2.5% . 2.5% ofof gen.populationgen.population inin 10% 10% ofof psychpsych outpatientsoutpatients inin 1515--20% 20% ofof psychpsych inpatientsinpatients

BorderlinesBorderlines accountaccount forfor aboutabout 50% 50% ofof allall personspersons withwith PDsPDs

TipicallyTipically startsstarts inin adolescenceadolescence

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DSM IV DSM IV diagnosticdiagnostic criteriacriteria

AnAn enduringenduring patternpattern ofof innerinner experienceexperience andand behaviorbehavior thatthat deviatesdeviates markedlymarkedly fromfrom thethe expectationsexpectations ofof thethe individualindividual’’ss cultureculture

ThisThis patternpattern is is manifestedmanifested inin::

cognitioncognition ((waysways ofof perceivingperceiving andand interpretinginterpreting selfself, , otherother peoplepeople andand eventsevents

affectivityaffectivity ((rangerange, , intensityintensity, , labilitylability ofof emottionalemottional responerespone

impulseimpulse controlcontrol

interpersonalinterpersonal functioningfunctioning

EtiologicalEtiological FormulationsFormulations HistoricalHistorical considerationsconsiderations ::

The The termterm borderlineborderline reflectsreflects anan earlyearly categorizationcategorization ofof patientspatients whowho werewere felt felt toto be be onon thethe borderborder betweenbetween neurosisneurosis andand psychosispsychosis ((possiblypossibly schizophreniaschizophrenia).).

BiologicalBiological considerationsconsiderations ::

MoodMood disordersdisorders maymay playplay anan etiologicaletiological rolerole, , asas evidencedevidenced byby a a highhigh comorbiditycomorbidity withwith depressiondepression, , increasedincreased prevalenceprevalence ofof major (major (butbut notnot bipolarbipolar) ) depressiondepression inin relativesrelatives, EEG, EEG ((electroencephalographicelectroencephalographic) ) patternspatterns similarsimilar toto thosethose foundfound inin depresseddepressed individualsindividuals, , andand similarsimilar responseresponse patternspatterns toto somesome ((butbut notnot allall) ) antidepressantsantidepressants..

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ETIOLOGICAL FORMULATIONS IIETIOLOGICAL FORMULATIONS II

Genetic formulations:Genetic formulations: A genetic predisposition has been implicated. A genetic predisposition has been implicated. Some Some PDsPDs are more prevalent are more prevalent

in monozygotic twins than in in monozygotic twins than in dizygoticdizygotic twinstwins.. The The Cluster A grouping of Cluster A grouping of PDsPDs (paranoid, schizoid, (paranoid, schizoid, schizotypalschizotypal) may) may hhaveave aa

genetic link to schizophreniagenetic link to schizophrenia. Present as the . Present as the prodromalprodromal phase for phase for schizophrenia.schizophrenia.

Family members of schizophrenicFamily members of schizophrenic patients are more likely to present with patients are more likely to present with paranoid and paranoid and schizoid schizoid PDsPDs..

Childhood factors:Childhood factors: An increased prevalence of An increased prevalence of childhood CNS dysfunctionchildhood CNS dysfunction (e.g., head injury) is (e.g., head injury) is

found in persons with antisocial and borderline found in persons with antisocial and borderline PDsPDs.. Children with Children with attentionattention--deflcitdeflcit/hyperactivity/hyperactivity disorder are at greater risk of disorder are at greater risk of

developing antisocial PD.developing antisocial PD. Females with a Females with a history of sex abuse are at greater risk of developing history of sex abuse are at greater risk of developing

borderline PDborderline PD

EndocrinologicalEndocrinological formulations:formulations: Impulsive traitsImpulsive traits in persons with antisocial PD linked to higher levels of in persons with antisocial PD linked to higher levels of

testosterone. Thyroidtestosterone. Thyroid dysfunction is more common in individualsdysfunction is more common in individuals

OtherOther biologicalbiological andand psychosocialpsychosocial formulationsformulations ((especiallyespecially BPD)BPD)

Neurotransmitter formulations:Neurotransmitter formulations: ChangingChanging levelslevels ofof serotoninserotonin maymay influenceinfluence personalitypersonality traitstraits, , depressiondepression, , impulsivityimpulsivity, , aggressionaggression LowLow levellevel ofof serotoninserotonin maymay predisposepredispose toto borderlineborderline PDPD

Trauma Trauma hypothesishypothesis :: ThereThere areare pathologicalpathological similaritiessimilarities inin earlyearly childhoodchildhood traumastraumas thatthat lead lead toto thethe developmentdevelopment ofof borderlineborderline PD PD andand PTSDPTSD (e.g., (e.g., childhoodchildhood physicalphysical andand sexualsexual abuseabuse issuesissues ))

PatientsPatients withwith PDsPDs cancan be be characterizedcharacterized byby theirtheir most most dominantdominant defensedefense mechanismsmechanisms ((maturemature oror archaicarchaic ))

SplittingSplitting:: PeoplePeople areare seenseen asas eithereither allall goodgood oror allall badbad, , withwith frequentfrequent shiftsshifts betweenbetween thesethese twotwo idealizationsidealizations. . ThereThere is a is a diminisheddiminished abilityability toto viewview peoplepeople inin shadesshades ofof graygray (i.e., a (i.e., a mixturemixture ofof goodgood andand badbad qualitiesqualities). ). OftenOften, , thethe patientpatient withwith borderlineborderline PD PD likeslikes oror dislikesdislikes anan individualindividual basedbased onon thethe patient'spatient's assessmentassessment ofof hishis oror herher lastlast encounterencounter withwith thethe personperson..

ProjectiveProjective identificationidentification:: IntolerableIntolerable aspectsaspects oror feelingsfeelings ofof selfself areare projected projected ontoonto othersothers, , andand thethe otherother personperson is is inducedinduced toto fulfillfulfill thatthat rolerole. . IfIf suchsuch projection is projection is successfulsuccessful, , thethe patientpatient andand thethe otherother personperson ""feelfeel asas oneone."."

DeniaDeniall——denial of the existence of painful thoughts.denial of the existence of painful thoughts. MagicalMagical thinkingthinking::

The The beliefbelief thatthat thoughtsthoughts cancan causecause eventsevents toto occuroccur..

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DSMDSM--IV criteria for schizoid personality IV criteria for schizoid personality disordedisorder r „„AA”” clustercluster

A. A. A pervasive A pervasive pattern of detachment from social relationshipspattern of detachment from social relationships and a and a restricted range ofrestr