seminar 9am.pptx personality disorder dynp

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1. PERSONALITY DISORDERS (PART-2) DR ABHISHEK CHAUDHARY 2 ND YEAR PG RESIDENT DR M.K. SHAH MEDICAL COLLEGE AND RESEARCH CENTRE

2. Derived from Latin word ‘ Persona ’ meaning Mask . Personality refers to all the ways someone shapes and adapts in a unique way to an ever-changing internal and external environment. It reflects stable traits, temperament, attitudes, and behaviors that characterize an individual. Personality Disorders means “An enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture, is pervasive and inflexible, has onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment.” INTRODUCTION

3. Key DSM-5 features: Deviates from cultural expectations (in cognition, affectivity, interpersonal functioning, impulse control). Inflexible and pervasive across many situations. Onset in adolescence or early adulthood. Stable and enduring. Causes clinically significant distress or impairment. Not better explained by another mental disorder, medical condition, or substance

4. CLASSIFICATION OF PERSONALITY DISORDER DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDER (DSM-5) – CATEGORICAL/CLUSTER CLASSIFICATION (SECTION-II) DSM-5 – ALTERNATIVE MODEL FOR PERSONALITY DISORDERS(AMPD) ( SECTION – III ) INTERNATIONAL CLASSIFICATION OF DISEASES (ICD)-11 – WHO,2022 – DIMENSIONAL MODEL OF CLASSIFICATION ICD-10 – WHO.1992 RAYMOND CATELL’S OCEAN MODEL

5. CATEGORICAL/CLUSTER CLASSIFICATION ( DSM-5 SECTION-II) CLUSTER A ODD/ECCENTRIC CLUSTER B DRAMATIC/EMOTIONAL/ERRATIC CLUSTER C ANXIOUS/FEARFUL PARANOID PERSONALITY DISORDER SCHIZOID PERSONALITY DISORDER SCHIZOTYPAL PERSONALITY DISORDER AVOIDANT PERSONALITY DISORDER DEPENDENT PERSONALITY DISORDER OBSSESIVE-COMPULSIVE PERSONALITY DISORDER ANTISOCIAL PERSONALITY DISORDER BORDERLINE PERSONALITY DISORDER HISTRIONIC PERSONALITY DISORDER NARCISSISTIC PERSONALITY DISORDER

6. OTHER CATEGORIES : Personality change due to another medical condition Other specified personality disorder Unspecified personality disorder

7. DSM-5 SECTION-III ALTERNATIVE MODEL FOR PERSONALITY DISORDERS (AMPD) This hybrid dimensional-categorical model in Section III defines personality disorder in terms of impairments in personality functioning and pathological personality traits. In the approach in Section II, symptoms meeting criteria for a specific personality disorder frequently also meet criteria for other personality disorders, and other specified or unspecified personality disorder is often the correct (but mostly uninformative) diagnosis, in the sense that individuals do not tend to present with patterns of symptoms that correspond with one and only one personality disorder.

8. The specific personality disorder diagnoses that may be derived from this model include antisocial, avoidant, borderline, narcissistic, obsessive-compulsive, and schizotypal personality disorders. This approach also includes a diagnosis of personality disorder—trait specified (PD-TS) that can be made when a personality disorder is considered present but the criteria for a specific disorder are not met. Core Components/ Criterias of AMPD Criterion A – Level of Personality Functioning Captures the severity of impairment in personality functioning.

9. Two broad domains: Self Identity: experience of self as unique, boundaries, self-esteem, self-regulation. Self-direction: pursuit of coherent goals, self-reflective standards. Interpersonal Empathy: understanding/appreciating others’ experiences, tolerance of differing perspectives. Intimacy: depth and duration of connection with others, capacity for closeness. Impairments are rated on a 0–4 scale: 0 = No impairment 1 = Some impairment 2 = Moderate impairment 3 = Severe impairment 4 = Extreme impairment Diagnosis of a PD requires at least moderate impairment (Level ≥ 2) in self and interpersonal functioning.

10. Criterion B – Pathological Personality Traits Organized into 5 broad domains (like maladaptive Big Five): Negative Affectivity – frequent experience of negative emotions (emotional lability, anxiousness, separation insecurity, submissiveness). Detachment – withdrawal from people and experiences (anhedonia, depressivity , suspiciousness, withdrawal). Antagonism – behaviors that put one at odds with others (manipulativeness, deceitfulness, grandiosity, attention seeking). Disinhibition – impulsivity, risk taking, lack of planning (irresponsibility, distractibility). Psychoticism – odd, eccentric, unusual behaviors and thoughts (unusual beliefs/experiences, eccentricity, cognitive/perceptual dysregulation). NOTE : Each domain has facets (25 total traits) for detailed assessment.

11. Criterion C – Pervasiveness Impairments in functioning (Criterion A) and pathological traits (Criterion B) are relatively inflexible and pervasive across a range of personal and social situations. Criterion D – Stability Impairments in functioning and traits are stable over time.Onset can be traced back to adolescence or early adulthood. Criterion E – Not better explained by other mental disorder Personality disturbance is not better explained as a manifestation or consequence of another mental disorder (e.g., mood disorder, psychosis). Criterion F – Not due to substance/medical condition Impairments are not attributable to physiological effects of substances (drugs, medications) or another medical condition (e.g., head trauma, neurological disease). Criterion G – Not normative for development/culture Traits and impairments are not better understood as normative for an individual’s developmental stage (e.g., adolescence) or sociocultural environment.

12. INTERNATIONAL CLASSIFICATION OF DISEASES ( ICD)-11 – WHO,2022 Core Diagnostic Features : A Personality Disorder is diagnosed when there is a persistent disturbance in: Self-functioning Problems with identity, self-worth, accuracy of self-view, self-direction. Interpersonal functioning Difficulties in developing/maintaining close and mutually satisfying relationships. And: The pattern is pervasive and persistent, across situations/over time. It causes significant distress/impairment in personal, social, educational, occupational functioning. Onset in adolescence/early adulthood, stable across time. Not better explained by another mental/neurological disorder, substance, or medical condition.

13. Severity Levels of Personality Disorder ICD-11 classifies PD mainly by severity, not type. Mild Personality disorder Moderate personality disorder Severe personality disorder

14. Instead of categorical PD types, ICD-11 uses trait qualifiers to describe the style of personality disturbance: 1. Negative Affectivity -Frequent and intense experience of negative emotions (e.g., anxiety, anger, guilt). Emotional lability, poor regulation. 2. Detachment -Social withdrawal, intimacy avoidance, anhedonia, restricted affectivity. 3. Dissociality -Disregard for rights/feelings of others, self-centeredness, hostility, manipulativeness. 4. Disinhibition -Impulsivity, irresponsibility, distractibility, recklessness, lack of planning. 5. Anankastia (opposite of disinhibition) - Rigid perfectionism, orderliness, perseveration, over-control of emotions/behaviors. A person may have one or more traits, combined with severity, to describe their personality disorder.

15. Borderline Pattern Qualifier Although ICD-11 moved away from multiple types, it retained a "Borderline Pattern" qualifier (due to clinical/research importance and overlap with DSM). Borderline Pattern is diagnosed in addition to severity + trait domains, if: Unstable sense of self. Intense, unstable relationships. Marked emotional instability. Impulsivity, self-harm, chronic emptiness.

16. Feature ICD-10 ICD-11 Model Categorical Dimensional Core focus Distinct types of PDs Severity + trait domains Number of main PD categories 10 specific PDs (Paranoid, Schizoid, Dissocial, Emotionally unstable [impulsive/borderline], Histrionic, Anankastic, Anxious, Dependent, Others, Unspecified) One diagnosis: Personality Disorder (mild, moderate, severe) Additional codes Mixed PD, Enduring personality change, Habit & impulse disorders, Sexual/gender-related, Other adult personality/behavior disorders (F60–F69) Personality Difficulty (sub-threshold) Subtypes Emotionally Unstable PD split into Impulsive & Borderline types No subtypes – but Borderline Pattern Qualifier can be added Specification Based on symptom clusters (categorical types) Based on trait domains: 1. Negative Affectivity 2. Detachment 3. Dissociality 4. Disinhibition 5. Anankastia Severity levels Not specified Explicit: Mild, Moderate, Severe Flexibility Rigid, overlapping categories → high comorbidity Flexible, individualized → better clinical utility Clinical utility Often poor reliability, high overlap between PDs Better reliability, matches dimensional research evidence

17. Feature ICD-11 (2022, WHO) DSM-5 (2013, APA) Model Dimensional (primary) Categorical (Section II) + Alternative Dimensional Model (Section III: AMPD) Core Concept Personality disorder defined by disturbance in self and interpersonal functioning + severity Section II: 10 categorical PDs Section III (AMPD): Criterion A (self/interpersonal impairment) + Criterion B (maladaptive traits) Number of PD Types No multiple categories; only one PD diagnosis 10 categorical PDs (Paranoid, Schizoid, Schizotypal, Antisocial, Borderline, Histrionic, Narcissistic, Avoidant, Dependent, Obsessive-Compulsive) Severity levels Explicit: Mild, Moderate, Severe Section II: Not defined Section III: Dimensional ratings of impairment (0–4) Trait Qualifiers / Domains 5 trait domains: 1. Negative Affectivity 2. Detachment 3. Dissociality 4. Disinhibition 5. Anankastia 5 trait domains (AMPD): 1. Negative Affectivity 2. Detachment 3. Antagonism 4. Disinhibition 5. Psychoticism Borderline PD Borderline pattern qualifier retained (due to clinical utility) Borderline PD remains one of 10 types (Section II) + can also be diagnosed dimensionally (AMPD) Exclusions Must not be better explained by another mental/medical condition, substance, or cultural factors Same exclusions (general PD definition in DSM) Duration requirement Enduring pattern since adolescence/early adulthood Same – stable and long duration Psychosocial impact Explicitly rated via severity (impairment in functioning + risk of harm) Considered via impairment/distress but not rated dimensionally in Section II (only in AMPD) Clinical utility Flexible, reduces overlap, focuses on severity + traits Traditional DSM categories widely used clinically, but criticized for overlap. AMPD closer to ICD-11 but still optional (Section III).

18. ETIOLOGY GENETIC FACTORS - The best evidence that genetic factors contribute to personality disorders comes from investigations of more than 15,000 pairs of twins in the United States. The concordance for personality disorders among monozygotic twins was several times that among dizygotic twins. Moreover, according to one study, monozygotic twins reared apart are about as similar as monozygotic twins reared together. Similarities include multiple measures of personality and temperament, occupational and leisure-time interests, and social attitudes.

19. Cluster A personality disorders are more common in the biologic relatives of patients with schizophrenia. Adoption, family, and twin studies demonstrate an increased prevalence of schizotypal features in the families of schizophrenic patients. Less correlation exists between paranoid or schizoid personality disorder and schizophrenia. Cluster B personality disorders Antisocial personality disorder is associated with alcohol use disorders. Depression is common in the family backgrounds of patients with borderline personality disorder also often have a mood disorder as well. There is a strong association between histrionic personality disorder and somatic symptom disorder; patients with each disorder show an overlap of symptoms.

20. Cluster C personality disorders may also have a genetic base. Patients with avoidant personality disorder often have high anxiety levels. Obsessive compulsive traits are more common in monozygotic twins than in dizygotic twins. Patients with obsessive-compulsive personality disorder show some signs associated with depression—for example, shortened rapid eye movement (REM) latency period and abnormal dexamethasone-suppression test (DST) results.

21. BIOLOGIC FACTORS - Hormones. Persons who exhibit impulsive traits also often show high levels of testosterone, 17-estradiol, and estrone. In nonhuman primates, androgens increase the likelihood of aggression and sexual behavior, but the role of testosterone in human aggression is unclear. Platelet Monoamine Oxidase. Low platelet monoamine oxidase (MAO) levels are associated with activity and sociability. College students with low platelet MAO levels report spending more time in social activities than students with high platelet MAO levels. Low platelet MAO levels occur in some patients with schizotypal disorders. Electrophysiology. Changes in electrical conductance on the electroencephalogram (EEG) occur in some patients with personality disorders, most commonly antisocial and borderline types; these changes appear as slow-wave activity on EEGs.

22. Smooth Pursuit Eye Movements. Smooth pursuit eye movements are saccadic (i.e., jumpy) in persons who are introverted, who have low self esteem and tend to withdraw, and who have schizotypal personality disorder . These findings have no clinical application, but they do indicate the role of inheritance. Neurotransmitters. Studies of personality traits and the dopaminergic and serotonergic systems indicate an arousal-activating function for these neurotransmitters. Levels of 5-hydroxyindoleacetic acid (5-HIAA) , a metabolite of serotonin, are low in persons who attempt suicide and in patients who are impulsive and aggressive. Raising serotonin levels with serotonergic agents such as fluoxetine can produce dramatic changes in some character traits of personality. In many persons, serotonin reduces depression, impulsiveness, and rumination and can produce a sense of general wellbeing. Increased dopamine concentrations in the central nervous system produced by certain psychostimulants (e.g., amphetamines) can induce euphoria. The effects of neurotransmitters on personality traits have generated much interest and controversy about whether personality traits are inborn or acquired.

23. Other Biologic Factors. In the case of personality change due to another medical condition, structural damage to the brain is usually the cause, and head trauma is probably the most common cause. Cerebral neoplasms and vascular accidents, particularly of the temporal and frontal lobes, are also common causes. Medical Conditions Associated with Personality Change Head trauma Cerebrovascular diseases Cerebral tumors Epilepsy (particularly, complex partial epilepsy) Huntington disease Multiple sclerosis Endocrine disorders Heavy metal poisoning (manganese, mercury) Neurosyphilis Acquired immune deficiency syndrome (AIDS)

24. PSYCHOANALYTICAL FACTOR – Sigmund Freud suggested that personality traits are related to a fixation at one psychosexual stage of development. Wilhelm Reich subsequently coined the term character armor to describe individuals’ characteristic defensive styles for protecting themselves from internal impulses and interpersonal anxiety in significant relationships. When defenses work effectively, persons with personality disorders master feelings of anxiety, depression, anger, shame, guilt, and other affects. Their behavior is ego-syntonic; that is, it creates no distress for them even though it may adversely affect others. They may also be reluctant to engage in a treatment process; because their defenses are essential to controlling unpleasant affects, they are not interested in surrendering them.

25. Defense Mechanisms - To help those with personality disorders, psychiatrists must appreciate patients’ underlying defenses, the unconscious mental processes that the ego uses to resolve conflicts among the four lodestars of the inner life: instinct (wish or need), reality, important persons, and conscience. Fantasy Seen in schizoid PD. Retreat into imaginary life/friends → aloof, fear of intimacy. Management: Quiet, reassuring interest; don’t push closeness. Dissociation Separation of thought/feeling from rest of psyche. Seen in borderline PD → derealization, depersonalization. Isolation of Affect Memory/idea separated from emotion. Seen in obsessive-compulsive PD. Detailed recall without affect, rigid control. Management: Allow control, give rational/systematic explanations.

26. Projection Attributing one’s own unacceptable feelings to others. Seen in paranoid traits → faultfinding, sensitive to criticism. Management: Acknowledge minor errors, be honest, formal distance. Avoid confrontation. Use counter projection. Splitting Dividing people as 'all good' or 'all bad'. Common in borderline PD, esp. inpatient. Management: Anticipate, discuss in staff meetings, gently confront 'no one is all good/bad’. Acting Out Direct expression of unconscious wish via action (tantrums, assaults, promiscuity). Appears guiltless. Management: Regain attention, set limits, ensure safety.

27. Projective Identification When a person puts their own feelings into someone else and makes that person feel and act the same way. Seen in borderline PD. Steps: ( i ) Project part of self → (ii) induce other to feel it → (iii) shared identification. Example A patient feels intense anger toward their therapist but cannot tolerate acknowledging it. Projection → The patient accuses the therapist of being angry or hostile. Induction → The patient behaves in such a provocative, hostile way that the therapist actually begins to feel irritated or angry. Identification → The therapist now feels the anger the patient projected, and both “share” the emotional state.

28. Cattell's Contribution: 16 Personality Factors (16PF) Raymond Cattell used factor analysis to identify 16 core personality traits , which he considered to be the building blocks of personality. These traits were measured using the 16 Personality Factor Questionnaire (16PF) . Cattell’s work was one of the first systematic efforts to quantify personality traits empirically . From Cattell to the Big Five (OCEAN) Later researchers (notably Costa & McCrae ) simplified and refined personality trait research. They found that many of Cattell's 16 traits could be The OCEAN model represents five broad dimensions of personality , each encompassing a range of specific traits : Openness to Experience Conscientiousness Extraversion Agreeableness Neuroticism

29. Role of the OCEAN Model in Classifying Personality Disorders While Cattell's theory itself isn't directly used in diagnosing personality disorders, the OCEAN model has become highly influential in understanding and conceptualizing them: How OCEAN Helps: Provides a dimensional (spectrum-based) understanding of personality, unlike the categorical approach used in the DSM (Diagnostic and Statistical Manual of Mental Disorders). Helps in identifying personality pathology as extreme manifestations of normal traits. Openness to Experience : Openness refers to a person's willingness to engage with new experiences , imaginative thinking , and intellectual curiosity . • High openness is linked to creativity and innovation. • Low openness may contribute to rigidity in thinking (relevant in obsessive-compulsive or schizoid personality traits).

30. Conscientiousness : This trait reflects how organized, responsible, and goal-directed a person is. It involves self-discipline, planning, and dependability . • High levels are associated with success in work and academic settings. • Extremely low levels are associated with impulsivity and irresponsibility — common in antisocial and borderline personality disorders. Extraversion Extraversion reflects the extent to which a person is sociable, energetic, and assertive . • Low extraversion is linked with social withdrawal , seen in avoidant , schizoid , or depressive personality traits. • High extraversion may be linked with histrionic or narcissistic traits in extreme forms.

31. Agreeableness Agreeableness reflects interpersonal tendencies , such as kindness, trust, and cooperation. • Low agreeableness is associated with antagonism , often seen in narcissistic , paranoid , and antisocial personality disorders. • High agreeableness is generally positive but may lead to people-pleasing behaviors. Neuroticism Neuroticism refers to emotional stability vs. emotional reactivity . High neuroticism indicates frequent and intense negative emotions . • High neuroticism is linked to borderline , avoidant , and dependent personality disorders. • Low neuroticism may be a protective factor against many mental health issues.

32. Development and Course of Personality Disorders Personality disorders usually appear in adolescence or early adulthood and show enduring, stable patterns of thinking, feeling, and behaving. Some (e.g., antisocial, borderline) may improve or remit with age; others (e.g., obsessive-compulsive, schizotypal) tend to persist. Can be diagnosed in children/adolescents only if traits are pervasive, persistent, and not stage-related; must be present ≥1 year. Exception: Antisocial PD cannot be diagnosed before 18 yrs. Symptoms may worsen with loss of support (e.g., spouse, job). New onset in middle/later life → always evaluate for medical condition or substance use disorder.

33. THANK YOU References : American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.; DSM-5-TR). American Psychiatric Publishing. Kaplan & Sadock’s Synopsis of Psychiatry (12th Edition, 2021)