Personality disorders Pavel Theiner, MD, PhD Departement of Psychiatry Personality •Personality–individual differences among people in behaviour patterns, cognition and emotions (different personality theorists present their own definitions of the word based on their theoretical positions) •The term "personality trait" refers to enduring personal characteristics that are revealed in a particular pattern of behaviour in a variety of situations. •Individual differences in personality have many real life consequences. •Under normal conditions personality is an integrated complex •Personality is quite stable (thus differing from mental disorders) Personality •The personality structure is characteristic and individual for every individual • •Inborn part = temperament •Acquired part = character Personality types and mental disorders •Different personality types predispose in a different way to psychiatric diseases – there is a link with individual’s usual reactions to stress stimuli. •The type of personality in the same time influences and changes the ‘textbook picture’ of a particular mental disorder – pathoplastic factor. •The type of personality determines the acceptance of the disorder and treatment adherence. Biological basis of personality • • •Genetic influence •The personality of a child is often similar to that of parent(s) •The heritability of different personality traits is 30 – 50% •Some personality traits have been proven to be linked to known genes variability •Ex.: ‘novelty seeking’ and a variability of the D4-receptor gene was found in 1996 (Benjamin et al., Ebstein et al.), the result however was not replicated (Jönson, 1997). •‘harm avoidance’ and ‘neuroticism’ and a variability of the serotonin transporter gene • •The differences in temperament in childhood influence the experiences that children acquire and these further influence their personality development. • • Psychological basis of personality •Childhood experiences influence forming of personality •It is a common clinical experience •A scientific proof is however difficult •How can be those experiences measured and quantified? •Are there more factors between early childhood and adulthood that form personality? •Are the childhood memories of adults accurate enough? • •The result of these inconsistencies is an amount of psychological theories, some of which are more and some less influential. •Psychodynamic theories (Freud, Jung, Adler, Horney, Sullivan, Fromm et al.) • • • Psychoanalytic theory of personality •Postulated by Sigmund Freud, Austrian neurologist and psychiatrist, in 1923 •The most important factors that influence the development of personality occur in the first 5 years of life •The developing child has to successfully pass through the key stages of libido development (oral, anal and genital) in order to develop a healthy personality •The parent – child relationship is a fundamental factor Psychoanalytic theory of personality Other personality theories •Jung model •Adler model •Attachment theory •Behavioral theory of personality •Cognitive theory of personality •Evolutional theory of personality •Cloninger model of personality • Cloninger model of personality •Temperament •Novelty seeking •Harm avoidance •Reward dependence •Persistence • •Character •Self-directedness •Cooperativeness •Self-transcendence Assessment of personality •History: •relationships •leisure time activities and hobbies •prevailing mood •character •attitudes and opinions (moral, religious, towards health, towards body etc.) •vices and virtues •misuse and abuse •The history taken from patients and their families •Observation of hospitalized patients •The evaluation made by patients theirselves is often inaccurate Assessment of personality •In everyday life the personality of an individual is estimated according to their behaviour in specific situations. •In psychiatric patients is however the behaviour significantly influenced by the mental disorder and thus it’s not possible to estimate the personality and other ways are required, mainly the facts from the history of the patient. •There are standardized psychological tests evaluating the personality – these are however also inaccurate in the presence of acute mental disorder Why is worth evaluating of the patient’s personality? •While thinking about the aetiology of the disorder in particular patient it’s important to know how he/she deals with particular stress situations. •The personality can clarify atypical symptoms •During treatment the knowledge helps anticipate the patient’s reactions and potential problems in treatment Personality can be also ill... •Some personality types are abnormal insofar as they significantly impair daily life of their carriers in many aspects •Impossible to find a sharp border between normal and abnormal •Social criteria of impairment are used (stressful to the patient or other people) Personality can be also ill... •Markedly disharmonious attitudes and behavior, generally involving several areas of functioning; e.g. affectivity, arousal, impulse control, ways of perceiving and thinking, and style of relating to others; •The abnormal behavior pattern is enduring, of long standing, and not limited to episodes of mental illness; •The abnormal behavior pattern is pervasive and clearly maladaptive to a broad range of personal and social situations; •The above manifestations always appear during childhood or adolescence and continue into adulthood; •The disorder leads to considerable personal distress but this may only become apparent late in its course; •The disorder is usually, but not invariably, associated with significant problems in occupational and social performance. Diagnosis of abnormal personality •In the past the terms ‘psychopathy’ and ‘psychopath’ were used • •These terms have become commonly used and offensive and therefore deleted from the official terminology • •The current term is PERSONALITY DISORDER (PD) Personality disorders - overview •3 clusters •Cluster A: odd, eccentric •Paranoid PD •Schizoid PD •(Schizotypal PD) •Cluster B: dramatic, emotional or erratic •Dissocial (antisocial) PD •Borderline PD •Histrionic PD •Narcissistic PD •Cluster C: anxious and fearful •Avoidant PD •Dependent PD •Obsessive-compulsive PD • Paranoid personality disorder •Also querulant or fanatic: •excessive sensitivity to setbacks and rebuffs; •tendency to bear grudges persistently, i.e. refusal to forgive insults and injuries or slights; •suspiciousness and a pervasive tendency to distort experience by misconstruing the neutral or friendly actions of others as hostile or contemptuous; •a combative and tenacious sense of personal rights out of keeping with the actual situation; •recurrent suspicions, without justification, regarding sexual fidelity of spouse or sexual partner; •tendency to experience excessive self-importance, manifest in a persistent self-referential attitude; •preoccupation with unsubstantiated "conspiratorial" explanations of events both immediate to the patient and in the world at large. • Schizoid personality disorder • •Emotional coldness, detachment or reduced affect. •Limited capacity to express either positive or negative emotions towards others. •Consistent preference for solitary activities. •Very few, if any, close friends or relationships, and a lack of desire for such. •Indifference to either praise or criticism. •Little interest in having sexual experiences with another person (taking age into account). •Taking pleasure in few, if any, activities. •Indifference to social norms and conventions. •Preoccupation with fantasy and introspection. • • Antisocial personality disorder •Callous unconcern for the feelings of others; •Gross and persistent attitude of irresponsibility and disregard for social norms, rules, and obligations; •Incapacity to maintain enduring relationships, though having no difficulty in establishing them; •Very low tolerance to frustration and a low threshold for discharge of aggression, including violence; •Incapacity to experience guilt or to profit from experience, particularly punishment; •Marked readiness to blame others or to offer plausible rationalizations for the behavior that has brought the person into conflict with society. Borderline personality disorder •The most distinguishing symptoms of BPD are marked sensitivity to rejection, and thoughts and fears of possible abandonment. •the features of BPD include: •unusually intense sensitivity in relationships with others •difficulty regulating emotions and impulsivity •feeling unsure of one's personal identity and values •strong emotions and (unsuccessful) efforts to manage them •feelings of emptiness and repeated self-harm Borderline personality disorder •These patients are often hospitalized in psychiatric wards for different symptoms – depression, anxiety, self-harm, suicidal risk or attempt. •The psychiatric comorbidity is high • •Etiology: •Importance of the adverse childhood experiences • •The prevalence is 2-3% and this disorder is more frequent in females •In psychiatric patients, regardless the basic diagnosis, exists in about 25% as co-morbidity •The course of the disorder is stable from adolescence till adulthood, but later (usually after 40’s) the symptoms diminish •The differential diagnosis is usually complex • Histrionic personality disorder •Exhibitionist behavior •Constant seeking of reassurance or approval •Excessive sensitivity to criticism or disapproval •Inappropriately seductive appearance or behavior of a sexual nature •Using somatic symptoms (of physical illness) to garner attention •A need to be the center of attention •Low tolerance for frustration or delayed gratification •Rapidly shifting emotional states that may appear superficial or exaggerated to others •Tendency to believe that relationships are more intimate than they actually are •Blaming personal failures or disappointments on others •Being easily influenced by others, especially those who treat them approvingly •Being overly dramatic and emotional Narcissistic personality disorder •People who are diagnosed with a narcissistic personality disorder are characterized by exaggerated feelings of self-importance. •They have a sense of entitlement and demonstrate grandiosity in their beliefs and behavior. •They have a strong need for admiration, but lack feelings of empathy •In addition to these symptoms, the person may display arrogance, show superiority, and seek power. • The symptoms of narcissistic personality disorder can be similar to the traits of individuals with strong self-esteem and confidence; differentiation occurs when the underlying psychological structures of these traits are considered pathological. Narcissists have such an elevated sense of self-worth that they value themselves as inherently better than others, when in reality they have a fragile self-esteem, cannot handle criticism, and often try to compensate for this inner fragility by belittling or disparaging others in an attempt to validate their own self-worth. •They are unable to relate, understand, and rationalize the feelings of others. Instead of behaving in a way that shows how they are feeling in the moment, they behave in the way that they feel they are expected to behave or that gives them the most attention. • Obsessive-compulsive PD •The main symptoms of OCPD are preoccupation with remembering and paying attention to minute details and facts, following rules and regulations, compulsion to make lists and schedules, and rigidity/inflexibility of beliefs or showing perfectionism that interferes with task completion. • •These symptoms are ego-syntonic (unlike OCD) • • Avoidant personality disorder •Hypersensitivity to rejection/criticism •Extreme shyness or anxiety in social situations, though the person feels a strong desire for close relationships •Self-imposed social isolation •Severe low self-esteem •Self-loathing •Self-critical about their problems relating to others •Problems in occupational functioning •Feeling inferior to others • •Similar symptoms in social phobia •The risk of developing alcohol abuse/deprendence • Dependent personality disorder •encouraging or allowing others to make most of one's important life decisions; •subordination of one's own needs to those of others on whom one is dependent, and undue compliance with their wishes; •unwillingness to make even reasonable demands on the people one depends on; •feeling uncomfortable or helpless when alone, because of exaggerated fears of inability to care for oneself; •preoccupation with fears of being abandoned by a person with whom one has a close relationship, and of being left to care for oneself; •limited capacity to make everyday decisions without an excessive amount of advice and reassurance from others. •Associated features may include perceiving oneself as helpless, incompetent, and lacking stamina. • Other personality disorders •Mixed personality disorders •Enduring personality changes after catastrophic experience •Enduring personality changes after psychiatric illness •Organic personality disorder • Děkuji za pozornost