An approach to personality disorders 2.pptx

An approach to personality disorder

1. An approach to personality disorders Presented by : Dr Prabidhi Adhikari Moderator: Lect. Dr Md Ainuddin Bagban

2. Contents Introduction History Epidemiology and etiology Classification Description of each personality disorder Approach/management References

3. Introduction The word  personality  comes from the Latin word  persona . Persona- “ A mask worn by an actor” Gordon Alport defined personality as the; “ Dynamic organization within the individual of those psychophysical systems that determine his or her unique adjustment to the environment”

4. Introduction Personality traits are enduring patterns of perceiving, relating to, and thinking about the environment and oneself that are exhibited in a wide range of social and personal contexts. (DSM-5) Personality refers to  an individual's characteristic way of behaving, experiencing life, and of perceiving and interpreting themselves, other people, events, and situations .(ICD 11)

5. Introduction P ersonality disorders: when personality traits are inflexible and maladaptive and cause significant functional impairment or subjective distress. Diagnosis is warranted only if personality traits are: Inflexible, maladaptive, and enduring. Cause functional impairment/subjective distress Ego syntonic: Don’t believe that there is anything wrong with them . Alloplastic thinking: believe society (not them) should change As a result, maladaptive behavior is repeated.

6. Manifested in two (or more) of the following areas: Cognition (i.e. ways of perceiving and interpreting self, other people, and events) Affectivity ( i.e.the range, intensity, liability and appropriateness of emotional response) Interpersonal functioning Impulse control

7. History Can be traced back to 400BC , when H ippocrates described four personality patterns. Choleric (meaning irritable) Melancholic (meaning sad) Sanguine (meaning optimistic) Phlegmatic (meaning apathetic) Theories can also be traced back to ancient C hinese and G reek philosophy. Theophrastus (c 371 - c 287 bc ) described 30-character types. For e.g , ‘the suspicious man’ - paranoid personality disorder.

8. History In 1780, Franz Gall, a German physician, proposed that the distances between bumps on the skull reveal a person’s personality traits, character, and mental abilities Measuring these distances revealed the sizes of the brain areas underneath, providing information on personality . (Fancher, 1979)

9. History In 18th Century Pinel described personality disorder for the - 1 st time . articulated the concept “ Manie sans delire ” (meaning ‘mania without delusion’) to describe outbursts of aggression in the absence of mental illness He suggested that this was caused by a “deficient upbringing” or a “weak and permissive mother”.

10. History Ribot (1839 - 1916) discussed “ normal and abnormal characters ”, believing these could not be changed. Kraepelin (1856 - 1926) classified “ psychopathic personalities ” into four types: Born criminal, Irresolute or weak-willed Pathological liar and Pseudo querulants (meaning paranoid personality) This developed into seven types, including emotionally unstable types.

11. History Freud (1856 - 1939) gave the psychoanalytic approach. He linked it to childhood experiences. He believed that difficulties in the psychosexual stages such as the oral-biting stage led to distinctive personality traits.

12. History Schneider (1923) – considered PDs as socially deviant extreme variant of normally occurring personality; Categorized personality disorder (First comprehensive system-1958) Described psychopathic personalities in his book Hyperthymic Depressive Insecure Fanatical Lacking in self-esteem Labile Affect Explosive Abulic Asthenic Wicked ICD and DSM relies exclusively on Kurt Schneider’s Work on 10 personalities

13. Nosology DSM I (1952 ) - “ patterns of behavior; resistant to change, but not connected to a lot of anxiety or personal distress on the part of the patient ”. DSM II (1968) - “ characterized by deeply ingrained, maladaptive patterns of behavior that are perceptibly different in quality from psychotic and neurotic symptoms .” specified 10 personality disorders - paranoid, cyclothymic, schizoid, explosive, obsessive compulsive, hysterical, asthenic, antisocial and passive-aggressive personality disorder. DSM III (1980) – “inflexible, maladaptive and causing significant impairment in functioning or subjective distress.” Included in AXIS II Specific Diagnostic criteria were added Five new personality disorders were added - schizotypal, narcissistic, borderline, avoidant and dependent, as well as mixed personality disorder.

14. Epidemiology Lifetime prevalence in the general population : 10 to 13 percent . Primary care outpatient settings : 20 to 30 percent Greater in psychiatric samples : up to 30-50% percent Are at high risk of early death from suicide or accident (suicide rate is as high as that seen for major depression) 9-28% of persons who complete suicide are diagnosed with PD. About 1/3 of adolescents and young adults who complete suicide have PD. ( Dr.Hafidh M.Farhan )

15. Epidemiology Associated with impaired social, personal, and occupational adjustment. Increased rates of unemployment, homelessness, divorce and separation, domestic violence and substance misuse. Increased rates of healthcare utilization. Associated with poorer response to treatment, particularly antidepressant medication and electroconvulsive therapy.

16. Etiology Genetic Concordance with monozygotic twins Cluster A – Schizophrenia (especially Schizotypal) Cluster B – ETOH, Depression, Somatization Cluster C – Anxiety Cluster B PD has a higher incidence in identical twins.

17. Etiology Psychoanalytical view : Failed to progress through appropriate psychosexual stage of development. Clients who developed PS encounter difficulties at the individual’s separation stage of development (18 month to 2 years) Defense mechanisms, object relations Underdeveloped Ego and Superego

18. Etiology Social Learning : Failure to develop normal social skills, (such as avoidant personality disorder) ( kantor , 2010). Cognitive theories: maladaptive thought patterns and cognitive distortions are displayed lead to develop inaccurate perceptions of others (Beck, 2015).  Are strengthened during aversive life events as a protective mechanism and ultimately come together to form patterns of behavior displayed in personality disorders (Beck, 2015).

19. Etiology Behavioral Theories : Research supports an additive modeling or imitating component to the development of personality disorders, especially antisocial personality disorder (APA, 2022). Reinforcement, or rewarding of maladaptive behaviors is also observed in the development of many personality disorders. Excessive reinforcement or praise during childhood may contribute to the grandiose sense of self observed in individuals with narcissistic personality disorder ( millon , 2011).

20. Etiology Autonomic Nervous System: Hypothalamus hypometabolism. Excessive aggression that powers the development of borderline, passive-aggressive, histrionic and narcissistic personality disorders Brain Chemistry: Disturbance or imbalance of dopamine and serotonin neurotransmitter. Neurobiological correlates – eg. low levels of 5-HIAA a metabolite of serotonin – linked to impulsivity and aggression (ASPD and BPD) Chronic nervous system under-arousal is thought to contribute to thrill seeking, impulsivity and dangerousness in ASPD. Hormonal : Increase level of estrone, estradiol and testosterone (seen in people with impulsive behavior) Increase noradrenergic metabolites (seen in gamblers and people demonstrating sensation seeking behavior).

21. Etiology ( Social ) Family dysfunction.  High levels of psychological and social dysfunction within families High levels of poverty, unemployment, family separation, and witnessing domestic violence are routinely observed (Paris, 1996). Childhood maltreatment.   Individuals with PD are at-risk for an underdeveloped or absent sense of self. ( developed during the first four to six years of a child’s life; affected by the raised emotional environment )

22. Etiology A ttachments   with primary caregivers Securely attached children – less likely to develop personality disorders Anxious attachment- at risk for developing internalizing disorders, Ambivalent – at risk for developing externalizing disorders, Disorganized- at risk for dissociative symptoms and personality-related disorders ( alwin , 2006).

23. Temperament Derived from the Latin  “ temperare ”, which means “ to mix ,” suggests a relation between behavioral predispositions and biological substrates. Temperament is part of the overall expression of personality Conceptualized as a foundational substrate for the subsequent development of personality (heritable biases in emotionality ) Genetic difference account for 50% variance; 25-30% non-shared environment Has stronger biological basis than personality traits, are developmentally evident earlier, less mediated by environmental influences (epigenetic mechanisms-have role)

24. Temperament Temperament traits: Harm avoidance, novelty seeking, reward dependence, and persistence. Temperament types: Easy going, slow to warm up, difficult

25. Harm avoidance Novelty seeking  Reward dependence Persistence Involves a bias towards inhibiting behavior that would result in punishment or non-reward. Results in fear of uncertainty, social inhibition, shy behavior, and avoidance of danger or the unknown, all of which are characteristics of schizoid personality disorder. Describes an inherent desire to initiate novel activities that are likely to produce a reward signal.  Schizoid personality disorder presents with low novelty seeking, resulting in slow-tempered, uninquiring, isolative, and stoical behaviors. Describes the amount of desire to alter behaviors in response to social reward cues.  Individuals with schizoid personality typically have low reward dependence and, as a result, spend most of their time in isolation, with little need for social reward compared to others.  Describes the ability to maintain behaviors despite frustration, fatigue, and limited reinforcement. Low persistence is associated with indolence, inactivity, and ease of frustration. These individuals rarely strive for higher accomplishments. Low persistence is consistent with schizoid personality disorder.

26. Temperaments Novelty Seeking High Low (choleric) Exploratory Reserved Impulsive Deliberate Extravagant Thrifty Irritable Stoical Harm Avoidance Pessimistic Optimistic (Melancholic) Fearful Daring Shy Outgoing Fatigable Energetic Reward Dependence Sentimental Detached (Sanguine) Open Aloof Persistence Industrious Lazy (Phlegmatic) Determined Spoiled Cluster A is determined by low reward dependence Cluster B is determined by high novelty seeking Cluster C is determined by high harm avoidance Persistence predicts obsessive-compulsive traits

27. Character Self-Directedness High Low Responsible Blaming Self-accepting Wishful Disciplined Undisciplined Resourceful Passive Cooperativeness Tender hearted Intolerant Empathic Selfish Principled Opportunistic Self Transcendent Imaginative Conventional Spiritual Materialistic Intuitive Logical Idealistic Relativistic The social and cultural contributions to personality. Poorly developed character traits, especially self-directedness and cooperativeness, are a common in all subtypes of personality disorder High self-transcendence correlates with schizotypal and paranoid symptoms and with borderline, histrionic, and narcissistic symptoms (depicting proneness to dissociation) High self-transcendence might be an important component in one's susceptibility to psychosis (when other two character traits are low)

28. Personality disorder Impairments in self-functioning and/or interpersonal functioning are manifested in maladaptive patterns of cognition, emotional experience, emotional expression, and behavior.(ICD-11)

29. Personality disorder

30. A B C Detachment,  reward dependence Impulsivity,  novelty seeking Fearfulness,  harm avoidance

31. Dimensions and disorders

32. Prevalence Epidemiology of personality disorder, new oxford textbook of psychiatry

33. Paranoid A genetic predisposition; Higher incidence in relatives of schizophrenia early childhood deprivation or abuse may cause patient to develop a sense of mistrust. Referred to treatment by spouse or employer More common in male High among minority groups, immigrants, persons who are deaf Racial variation May experience very brief psychotic episodes

34. Paranoid use the defense mechanism of projection, which is blaming other people, institutions, or events for their own difficulties. patients with PPD suffer from low self-esteem seeing themselves as lacking efficacy and others as malicious and deceitful. This distorted view of others leads to excessive guardedness, emotional instability, and fear of being vulnerable. Cognitive theories argue self-deficiency is the core of PPD.(Aaron Beck)

35. Paranoid A pervasive pattern of distrust or suspiciousness on others such as their motives are interpreted as malevolent, beginning by early adulthood ;present in variety of contexts. 4 or more: Suspects without basis that others are harming/exploiting/deceiving Preoccupation with doubts about loyalty Reluctant to confide in others Hidden meanings to benign remarks Persistently bears grudges Reacts angrily to perceived attacks not apparent to others Recurrent suspicions, Suspects infidelity Not due to other disorder

36. 36 Points on Continuum Gullible Delusional Disorder Paranoid P. D. Paranoid Traits Paranoid Schizophrenic Normal Paranoia is a common characteristic among other disorders such as borderline personality disorder (BPD), post-traumatic stress disorder (PTSD), and schizophrenia.

37. Schizoid M:F = 2:1 Heritability rates about 30% Some of the features of  autism spectrum disorder  resemble schizoid personality disorder, probable genetic relationship between the two Having caregivers who were emotionally cold, neglectful and detached during childhood  Due to attachment issues during infancy, there is a hypothesized intense fear of intimacy in schizoid behaviors Early childhood, a stable pattern Those with schizoid tendencies have withdrawal defense mechanisms

38. Schizoid Detached from social relations and restricted range of emotion in interpersonal settings . 4 or more of the following: No desire nor enjoys any close relationships Chooses solitary activities No/little interest in sexual experiences with others Anhedonia lack of close friends Indifferent to praise or criticism Shows coldness, detachment, flattened affectivity

39. Schizoid Appearance: may be disheveled. Behavior: difficulty making eye contact, may be reluctant to cooperate, aloof, and difficult to engage.  Speech: decreased amount of speech with short answers. No difficulties with speech initiation, volume, or vocabulary. Affect: affective flattening (blunting) is common Thought content: no hallucinations or delusions should be present.  Thought process: usually linear, albeit limited in range and logic. Some disorganization may be present (such as looseness of associations); Cognition: not impaired Schizoid personality disorder is unlikely to resolve either on its own or with treatment. Focus on improving quality of life.

40. Schizotypal Relatives of schizophrenia patients – higher incidence Monozygotic twins 33%; dizygotic twins 4% Females w/ fragile X syndrome (FMR1 CGG triplet 200x) Hereditability of  schizotypy has been estimated between 30% and 50%. Childhood history of institutional care Can decompensate to brief psychotic periods with extreme stressors. Schizotypal individuals have family dynamics characterized by parental indifference, impassivity or formality, closeness feels neither natural nor comfortable and social skills are not developed World health organization reclassified schizotypal personality disorder as a form of schizophrenia in the international classification of diseases, 11th revision (ICD-11)

41. Schizotypal Platelet monoamine oxidase levels are associated with sociability levels, with low levels occurring in schizotypal personality disorder Individuals with schizotypal tendencies have withdrawal defense mechanisms. S chizotypal personality disorder has identified similar biological causes to that of schizophrenia—high activity of dopamine and enlarged brain ventricles ( Lener et al., 2015)

42. Schizotypal A pervasive pattern of social and interpersonal deficits characterized by acute discomfort with, and reduced capacity for, close relationships, as well as cognitive or perceptual distortions and eccentricities of behavior, typically beginning in early adulthood and present in a variety of contexts, as indicated by 5 (or more) of the following: Ideas of reference (not delusional) Strange, odd, magical beliefs Unusual perceptions and illusions Odd thinking and speech Suspicious or paranoid ideation Inappropriate or constricted affect Odd, eccentric or peculiar behavior No friends ;social anxiety Social anxiety = persistent paranoia

43. Schizotypal Appearance: May appear unkempt, disheveled, or eccentric with odd attire. Behavior: May be inappropriate, stiff, peculiar, socially detached, hypervigilant, suspicious, or overtly paranoid. Speech: Include odd, vague, metaphorical, or stereotyped speech may tend to have more pauses, slower speech, and less pitch variability. Affect: constricted to expansive ; may be inappropriate to the circumstances. Thought Content: May be suspicious or have paranoid ideation with magical thinking, fixation on the supernatural or paranormal, odd beliefs, overvalued ideas, or ideas of reference. Thought Process: Ranges from logical and goal-directed to vague and rambling, without actual derailment. Perceptions: may describe unusual perceptual experiences, including bodily illusions or sensing that another person is present, generally not at the level of overt hallucinations. Cognition: General cognition and orientation are not impaired

44. Schizotypal Course of schizotypal personality disorder is relatively stable, with few individuals developing schizophrenia or another psychotic disorder studies have reported 25%–35% transition rates from schizotypal disorder to schizophrenia-spectrum psychosis

45. Anti social Common in poor urban areas and mobile residents Boys with disorder come from large families Onset before 15yrs of age;  3 times greater in males than females In prison 75% prevalence Familial pattern: 5 times more common in 1 st degree relatives an increased incidence of sociopathy and alcoholism in fathers of these patients. Psychological - maternal deprivation, lack of discipline, impulsiveness Can present as charming and “normal” Need for stimulation and risky stimulus-seeking behaviors Substance abuse – medication abuse can be an issue Some research has shown that treatment of impulsivity early in adolescence may help prevent later development of antisocial personality disorder. 25% of girls and 40% of boys diagnosed with conduct disorder eventually develop ASPD.

46. Anti social Twin studies find a monozygotic concordance rate of 67% compared to a 31% concordance rate in dizygotic twins. Family studies estimate that 20% of individuals with ASPD have a first-degree relative with ASPD.  A twin study involving 1048 subjects investigating substance use disorder, ASPD, and disinhibition found a shared common heritability factor of 0.81. A large sample of male children who experienced childhood abuse reveals a functional polymorphism in the gene encoding monoamine oxidase A (MAO-A) that moderately predicts the development of ASPD, with low levels of MAO-A expression more likely to lead to the development of ASPD Low cerebrospinal fluid levels of the major metabolite of serotonin, 5-HIAA, are associated with violent, suicidal, and impulsive behaviors Subclinical injury to the brain in utero due to maternal tobacco smoke exposure or drug use and maternal starvation has been proposed as a predisposing factor for antisocial behavior.  Chemicals generated from tobacco and lower oxygen levels may contribute to neuronal injury in the developing fetus. defense mechanisms of displacement, denial, projection, rationalization, and regression

47. Anti social Under arousal of the autonomic nervous system is the suggested underlying pathophysiology for some individuals with ASPD. This hypothesis proposes that individuals with ASPD require higher sensory input to produce normal brain functioning than normal subjects, causing affected individuals to seek higher sensory input to raise their arousal levels to more tolerable amounts. The result may be a higher risk tolerance for situations with higher arousal.  Findings to support this suggestion are lower pulse rates, lower skin conductance, and increased amplitude on event-related potentials in patients with A SPD 50% of individuals with ASPD exhibit various electroencephalogram (EEG) abnormalities, including more slow-wave activity. Individuals with ASPD have a higher occurrence of minor facial abnormalities and, in childhood, have a higher occurrence of learning disorders, attention deficit and hyperactivity disorder, and persistent enuresis. [

48. Anti social Continuing pattern of disregard for and violates rights of others since 15 3 or more of the following: Breaking laws repeatedly Lying, conning Impulsivity, poor planning Aggressive, fights Reckless disregard for others’ safety Irresponsible with work, money Lack of remorse In addition, individual must be at least 18 and there must be evidence of conduct disorder before 15

49. Anti social peak crime rates / highest severity of crimes at younger ages. Psychopath Subset of Antisocial population See humans as objects Treatments have little effect Can be excessively cruel Remorseless Can be very intelligent

50. Anti social Appearance: general grooming and appearance Behavior: can be manipulative, disinhibited, aggressive, or deceitful.   Speech: generally, no problems with speech initiation or vocabulary. Affect: Frustration tolerance is generally low, allowing a higher propensity for anger. Thought content: Assessing suicide and homicide risk is essential. Thought process: generally, linear thought process but are limited in range and logic; consistently fail to plan or to learn from previous mistakes.  Cognition: General cognition and orientation are typically unimpaired.  Insight: poor understanding for how their actions impact their social and occupational functioning. Judgment and impulse control:poor judgment and impulse control. 

51. Prognosis and course Remission rates of 12% to 27%; mean age is 35., but many remain symptomatic, and some never improve - pts begin to look hypochondriacal or have depressive disorders afterwards. Substantial numbers of individuals with ASPD ‘‘mature’’ in character, ‘‘burn out’’ or stop their criminal behavior by middle age, mostly between the ages of 30 and 40 years Robins found that in 82 individuals with ASPD followed from childhood into adulthood (mostly in their mid-40s), 12% were completely in remission, 27% had ‘‘burned out’’ with greatly reduced range and severity of antisocial behaviour , and 61% showed little improvement .

52. Prognosis and course Those with less baseline symptomatology show better remission rates; those imprisoned for more extended periods displayed greater remission rates than those detained for shorter periods.  Factors that predict improved outcomes are older age at presentation, improved community ties, job stability, and marital attachment increased incidence of death resulting from accidental incidents, suicides, or homicides

53. Borderline M:F= 1:2 MDD ,alcohol use and substance use – in 1 st degree relatives Often confused with Bipolar I or II High degree of overlap with both Axis I and Axis II disorders 24%-74% also diagnosed with major depression; 4% to 20% bipolar 25% of bulimics also diagnosed with BPD 67% also diagnosed with substance use disorder Psychosis may be seen transiently - usually last less then 24 hours Suicide attempts are common in BPD, with 60–70% attempting suicide at some point and rates of completed suicide of 10% (Oldham  Reference Oldham2006) chronically unstable with suicidal ideation extremely common.

54. Borderline Low levels of serotonin activity in combination with deficient functioning of the frontal lobes—particularly the prefrontal cortex ;as well as an overly reactive amygdala, may explain the impulsive and aggressive nature (stone, 2014) Show deficits in serotonin activity ( thompson , ramos , & willett , 2014) Fonagy ( Reference Fonagy and Bateman2008 ) proposes that deficits in mentalising capacity are a core aspect of the psychopathology of BPD. Mentalising is the capacity to make sense of ourselves and of others in terms of mental states Electrophysiology – slow wave activity 10% suicide rate

55. Borderline Characterized by pervasive pattern of instability in interpersonal relationships, self-image and affects and marked impulsivity, beginning by early adulthood and present in variety of contexts.

56. Histrionic F>M Association with somatization and alcohol use disorder Lessens with age sensation-seeking but less likely to be dangerous A history of a disturbance early in life in attachments and separation or unresolved oedipal problems (the latter results in better functioning than the former.) Strong association is found between histrionic personality disorder and somatization disorder (briquet's syndrome)

57. Histrionic Pervasive pattern of excessively emotional and attention-seeking 5 of the following: Must be center of attention Sexually seductive Rapid and shallow shifting emotions Attention via appearance Speech lacks detail Exaggerated expression of emotions Easily influenced by others Thinks relationships are more intimate than they are

58. Narcissistic Offsprings have high risk *PSYCHOIS* may appear under acute stress. Depression is common as is intense envy

59. Narcissistic Pervasive pattern of grandiosity , need for admiration, and lacks empathy 5 of the following: Grandiose Preoccupation with fantasies of success Believes is special/can only associate with special people Requires admiration Entitled Exploitive of others Lacks empathy Mind ruled by thoughts of envy Arrogant

60. Avoidant Infant with timid temperament is associated Anxious when relationships get more intimate = fear of rejection Tends to avoid new relationships after losing one Often associated, or confused with, social anxiety Social anxiety is a fear of being embarrassed or humiliated when being the center of attention in groups Comorbid depression and anxiety is common Discounting the positive:   I ndividuals who have been routinely criticized or rejected during childhood may have difficulty accepting positive feedback from others, expecting only to receive rejection and harsh criticism. ( Weishaar & Beck, 2006).

61. Avoidant Social inhibition, inadequacy, hypersensitivity to criticism 4 or more of the following: Avoids job activities due to fear of criticism Only relates with those who like them Can’t develop intimacy due to fear Preoccupied with being ridiculed Inhibited in new relationships due to inadequacy Views self as inferior to others Avoids activities that could be embarrassing

62. Dependent F>M More in younger children Attachment Styles: Early attachment patterns with primary caregivers play a crucial role in how individuals form adult relationships. Disruptions or inconsistencies in early bonding might contribute to dependent behaviours later in life. Childhood Experiences: Children who experienced chronic physical illness or separation from parents during critical developmental stages might develop dependency traits as coping mechanisms

63. Dependent Environmental Factors: Parenting Styles: Overprotective or authoritarian parenting . Traumatic Events: Experiencing trauma, especially during formative years. The trauma could range from abandonment, prolonged hospitalization, or any significant life disruption during childhood. Psychological Factors: Personality and Temperament: naturally anxious or neurotic individuals might develop stronger dependent behaviors in response to stressors. Cognitive Patterns: Individuals with DPD often have a cognitive bias that emphasizes their weakness or incompetence and underscores the strength or capabilities of others. This skewed perception reinforces their dependent behaviours .

64. Features Pervasive and excessive need to be taken care of that leads to submissive and clinging behavior and fear of separation. 5 or more of the following: Must get lots of advice for decisions Can’t be responsible for big things Can’t disagree due to fear of losing support Can’t initiate projects due to self-confidence problems Goes to extremes to be accepted Can’t be alone Must immediately replace broken relationship Preoccupation with being left alone

65. OCPD M>F More common in 1 st degree relatives Backgrounds of harsh discipline; Parents expected their children to live up impossible standards and then condemned them when they failed. cognitive distortions such as  dichotomous thinking , also known as all-or-nothing thinking, are observed in several personality disorders. More specifically, dichotomous thinking explains rigidity and perfectionism in OCPD, and the lack of self-sufficiency among individuals with dependent and borderline personality disorders ( Weishaar & Beck, 2006)

66. OCPD Pervasive pattern of preoccupation with order, perfection, and interpersonal control at the expense of flexibility, openness and efficiency 4 or more of the following: So focused on rules, loses the point So perfectionistic, can’t complete task All work, no play Inflexible with morals, ethics or values Unable to discard worn-out, useless objects Hoards everything, including money Can’t delegate Rigid and stubborn

67. Diagnosis of PD Depends on longitudinal observation of a patient's behaviors to understand the patient's long-term functioning. Many features of pd overlap with symptoms of acute psychiatric illness.  Therefore, should generally be diagnosed when there is not a concurrent acute psychiatric condition.  May take several encounters to firmly establish the diagnosis .

68. Personality Disorders-Assessment Clinical interview Self report Inventories e.g., Minnesota Multiphasic Personality Inventory, Millon Multiaxial Clinical Inventory, Personality Diagnostic Questionnaire Semi structured interview Projective tests : Rorschach's inkblot test Illustrative anecdotes and detailed statements should be given in order to aim at a picture of an individual, rather than a type Assessment should be detail especially in cases of neurosis or affective disorder

69. Clinical assessment Assess in following dimensions Social relations Intellectual activities and leisure activities Prevailing mood Character

70. Character Attitude towards work/ responsibility, ability to take decisions, methodological, meticulous or haphazard, rigid or flexible… Interpersonal relationships: confident or shy/timid, insensitive or touchy, trusting or suspicious or jealous, irritable or emotionally controlled, tactful or outspoken, tolerant or intolerant, adaptable or unadaptable… Moral, religion, social and health related standards Energy and initiative Fantasy life

71. Temperament assessment

72. Temperament .

73. Projective tests Inkblots as projective stimuli The Rorschach test Picture as projective stimuli Thematic apperception test Word as projective stimuli Word association test Sentence completion test Sound as projective stimuli Like auditory inkblots ( skinner ,1979 ) rarely used and little supporting evidence

74. Personality disorder and other disorder Personality affects the prognosis, management and risk of developing many physical and mental disorders by its effect on: Help-seeking behaviours Compliance with treatment Coping styles Risk-taking Lifestyle Social support networks Therapeutic alliance Eating and drinking habits Smoking habits Sexual habits High rates of Axis I psychiatric disorders More severe Axis I symptoms Worse prognosis of Axis I disorders Longer and costlier treatments for Axis I disorders Excess mortality from suicide, accidents and violence

75. Management Establishing and strengthening the therapeutic alliance Consider the primary symptom complex Set clear boundaries Consider transference and countertransference Educate the patient about reasons for medication, possible side-effects and expected positive effects Long term treatment plan ;involve patient Develop plan for handling emergencies; self harm; harm to others Psychotherapy is first line No FDA approved medication Therapeutic communities (TCs): are structured environments where people with a range of complex psychological conditions and needs come together to interact and take part in therapy.

76. Disorder Psychotherapy Anti social cognitive-behavioral approaches aimed at addressing maladaptive behaviors and thought patterns. Histrionic clarification-oriented psychotherapy Narcissistic psychotherapy (talk therapy); may be done individually or with your partner or family Trans focus therapy Borderline cognitive- behavioural , and psychoanalytically oriented psychotherapy; DBT MBT is based on the concept that people with BPD have a poor capacity to mentalize. The goal of MBT is to improve your ability to recognize your own and others' mental states, learn to "step back" from your thoughts about yourself and others and examine them to see if they're valid. Dependent Parenting Techniques: Balanced parenting that encourages independence, while also providing emotional support, can be beneficial. Overprotective or overly authoritarian styles might contribute to dependency traits in children Avoidant Social skills training and behavioral techniques OCPD CBT: Cognitive therapy aims to identify and change patients’ maladaptive interpretations and meanings that they associate with experience Behavioural therapy aims to increase adaptive and decrease maladaptive behaviour patterns, by using behavioural techniques such as graded exposure to increase the patient’s rewards and tolerance for novelty, increase emotional awareness and expression, and decrease avoidance tendencies

77. Management Symptom complex Medication Cognitive/perceptual disturbance: Suspiciousness, paranoid ideation, ideas of reference, magical thinking, derealisation , depersonalisation Antipsychotics :low doses (1–2mg per day of haloperidol equivalent) Impulsivity: Risky or reckless behaviour , aggression,, threats, recurrent suicidal threats and behaviour , self-mutilation Mood stabilizers, (lithium, valproic acid or lamotrigine); SSRIs Affect dysregulation: Lability of mood, ‘rejection sensitivity Anhedonia, social anxiety and avoidance SSRIs, MAOI

78. Management

79. Comorbidities

80. References CTP 10 th edition Oxford Textbook of Psychiatry, 6th Ed DSM-5 ICD-11 Drug treatment for personality disorders; Advances in Psychiatric Treatment (2004), Personality Disorder From Evidence to Understanding, Cambridge press,2022