Personality Disorders

Dr. Hassan Sarsak, PhD, OT

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Personality The OTR should understand normal personality

development before learning what is considered dysfunctional.

Personality is an abstract word. Personality: enduring(stable) and pervasive (consistent)

patterns of perceiving, relating to, and thinking about the environment and oneself that are exhibited in a wide range of social and personal contexts. It represents the repertoire of coping skills and adaptive flexibilities, that will determine the level of individuals mastery of his or her psychosocial environment.

It comprises a person’s lifelong style of relating, coping, behaving, thinking, and feeling

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Personality

It represents a network of traits that emerge from a matrix of biological disposition and experiential learning, persist over a periods of time, and characterize the individual’s distinctive manner of relating in the environment”(Millon, 1996 in Cara & MacRae 2005, pg.,238)

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Personality According to Millon 1996, Personality is

composed of three polarities: Positive vs. negative Self vs. others Active vs. passive

“That is, people will be motivated by the type of reinforcement they seek, whether the pursuit of pleasure or the avoidance of pain, relying on self or others for support and nurturing, and behaving in an active and controlling, or more accomodating and reactive way” (Cara & MacRae, 2005, pg.,238)

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So what is Personality? Internal perspective: Processes within an

individual that explain why he or she behaves in characteristic ways.

Attitudes, emotions, ways of thinking Fairly stable across time and situations Partly inherited

External perspective: How the individual is perceived by others that he or she interacts with (reputation).

“She has a great personality!” Shaped by two fundamental motives related to

social interaction Getting along with others (cooperation) Getting ahead of others (competition)

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Maladaptive Personality Maladaptive personality pattern

occurs When 1- personality traits are inflexible

and poor choices of behavior present:

Limited interpersonal strategies Limited ability to cope with stress Limited goals Choices of behavior often do not match the

situation in which they are used

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Maladaptive Personality2- There is a tendency to foster

vicious circle: Personal choices elicit similar rigid or

extreme responses Little understanding of poor choices and how

other wrong behaviors have pulled for the other’s responses.

Consequently there is little awareness of responsibility for interactions and inability to change behavior. This sets into motion additional poor choices of behavior and self-defeating sequences with other, which cause already-established difficulties not only to persist but to be aggravated further.

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Maladaptive Personality3- Tenuous ضعيفstability under stressful

situation: Lack of resilience in conditions perceived as stressful,

causing extreme susceptibility to new difficulties and disruptions and reversion to familiar, maladaptive ways of coping.

There is lessened control over emotions and tendency toward developing increasingly distorted perceptions of reality??? (Derealization: feeling of unreality)

Those can cause significant functional impairment or subjective distress, which constitute a personality disorder.

Ego- syntonic feeling:”it feels right”

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Personality disorders have been present throughout the history of medicine.

Hippocrates, personality styles result from excess in the four humors…?.

Psychiatrist in the 19th century referred to personality disorders as moral insanity.

Theories of PD.

Theories of P.D. Table 9-1 in Cara & MacRae 2005, pg., 237

Biophysical Neuropsychiatric Psychodynamic Behavioral Cognitive Interpersonal Biopsychosocial/Evolutionary Neurobiological/Temperament

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DSMIV-TRA. DSM-IV diagnostic criteria: P.D. is an enduring pattern of inner experience & behavior that deviates markedly from the expectations of the individual’s culture. This pattern is manifested in two (or more) of the following:

Cognition (i.e., ways of perceiving and interpreting self, other people, and events)

Affectivity (i.e., the range, intensity, lability, and appropriateness of emotional response).

Interpersonal functioning Impulse control

B. Behavior must be inflexible and maladaptive across a broad range personal and social situationsC. There must be an evidence of onset in late childhood or adolescence. See Box 11-1 for the rest of the criteria pg. 144 (Brown)

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DSMIV-TR DSM-IV_TR groups the 10 PDs into three

categories:1. Cluster A: odd or eccentric behavior

(experience cognitive, perceptual or thought disorder).

Includes Paranoid, Schizoid, & Schizotypal

2. Cluster B: dramatic, emotional behavior (symptoms of mood lability, depression or interpersonal sensitivity)

Includes Antisocial, Borderline, Histrionic & Narcissistic

3. Cluster C: anxious and fearful behavior (experience anxiety in some form, obsessive thinking, and inhibited behaviors).

Avoidant, Dependent & Obsessive-Compulsive

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Types of P.D – Cluster A (1- Paranoid) Paranoid PD: pervasive distrust and

suspiciousness of others such that their motives are interpreted as malevolent, beginning by early adulthood and present in a variety of contexts (doubtful, suspicious without justification…).

Ch.ch: long-standing suspiciousness and mistrust of people, consistently on guard, hyper vigilant, and ready for any threat. They appear tense and irritable, insensitive to the feelings of others, oversensitive and misinterpret events, envious and hostile to others who are successful. They consistently testing the honesty of others. They perceive the world as harsh and unkind.

Cause: hereditary, parental antagonism and harassment.

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Types of P.D.- Cluster A (2- Schizoid P. D.) Schizoid PD: profound defect in the ability to perform

personal/social relationships or to respond to others in any meaningful, emotional way.

Ch.ch: social withdrawal (lack close friends), discomfort with human interaction, cold and aloof, indifferent to others, prefer to work in isolation (usually chooses solitary activities), unsociable, little need for emotional tie or desire (neither desires nor enjoys close relationships including being part of family), shy, anxious, uneasy, inappropriately serious about everything, unable to experience pleasure. They are cold and bleak, and unempathetic (emotional coldness).

Cause: hereditary, early pattern of object relations (early interpersonal relationships primarily in the family), familial style, and culture.

15Types of P.D.- Cluster A (3- Schizotypal) Schizotypal PD: latent schizophrenics. Their behavior

is odd (odd and vague beliefs, odd appearance…) and eccentric, but not to the level of schizophrenia.

Ch.ch: aloof and isolated, have bland and apathetic affectا, magical thinking (bizarre fantasies, sixth sense, telepathy), idea of reference (to believe that everything around relates to one’s, such as 'the feeling that strangers are talking about him/her, that man crossing his legs, it can't just be accidental; It has a particular meaning!!), illusions (unusual perceptual experiences such as bodily illusions*), depersonalizations, bizarre speech pattern (stereotyped speech; disrespectful way of speech; e.g., all men are cheaters, all women are suspicious..). They are indifferent, have impassivity. They are shunned, overlooked, rejected, and humiliated by others. Low self-esteem, excessive social anxiety.

Causes: common among the first degree biological relatives of people with schizophrenia. Impaired cognitive function,

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Types of P.D.– Cluster B (1-Antisocial personality)

Is a pattern of socially irreversible, exploitative, and guiltiness behavior that reflects a disregard for the rights of others (violation of others rights).

Ch.Ch: tendency to fail to conform to the law, sustain consistent employment, and develop stable relationship. Exploit and manipulate others for personal gains, deceitful, cold and callous (lack of remorse), argumentative, low tolerance for frustration (irritable, aggressive), they are restless and easily bored, unable to delay gratification, taking chances and seeking thrills (irresponsible). When things go their ways they are cheerful and gracious if not they become furious and vindictive.

Etiology : biological influences, family dynamics.

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Types of P.D. – Cluster B(2- Borderline personality)

Characterized by pattern of intense and chaotic relationships with affective instability and fluctuating attitudes toward other people, unstable self image and impulsivity.

Ch.Ch: impulsive, lack of clear sense of identity. Chronic depression, inability/fearful to be alone, clinging and distancing, splitting*, manipulation, self-destructive behavior, impulsivity, recurrent suicidal behavior, chronic feelings of emptiness, inability to control intense anger.

Etiological implication: fixation in the rapprochement phase of the development.

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Types of P.D. – Cluster B (3- Histrionic) مسرحي تمثيلي

Histrionic PD: this disorder characterized by colorful, dramatic, and extroverted behavior in excitable, emotional people (excessive emotionality). They have difficulty maintaining long-life relationships.

Ch.Ch.: self-dramatizing, attention-seeking (uncomfortable in situations in which he/she is not the center of attention, uses physical appearance to draw attention), overly gregariousا, and seductive. Highly suggestible, impressionable, strongly dependent. They might have somatic complains.

Causes: sympathetic arousal, adrenal hyperactivity, and neurochemical imbalance. Hereditary.

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Types of P.D. - Cluster B (4- Narcissistic)

Narcissistic PD: exaggerated sense of self-worth. They lack empathy and are hypersensitive to the evaluation of others. They believe that they have the inalienable right to receive special consideration.

Ch.Ch: lack of humility (arrogant, think they are special), overly self-centered and exploiting others to fulfill their own desires (exploitative(. Impaired interpersonal relationships, grandiose mood, optimistic, relaxed, cheerful, carefree. Mood easily change, envious.

Cause: family dynamics,

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Types of P.D. - Cluster C (1- Avoidant)

Avoidant PD: those are extremely sensitive to rejection, and have socially withdrawn life.

Ch.Ch: lack of confidence, uncertain, timid, withdrawn, cold, strange. They view others as critical, betraying, and humiliating (hypersensitive to negative evaluation and/or criticism), avoid activities that involve significant interpersonal contact because of fears of criticism/disapproval/rejection, feel inferior to others, etc.

Types of P.D. - Cluster C (2- Dependent)

Dependent PD: pervasive and excessive need to be taken care of that leads to submissive and clinging behavior and fears of separation.

Ch.Ch: lack of self-confidence, passive, acquiescent to desires of others (difficulty expressing disagreement with others because fear of loss of support), they may hastily and easily hurt by criticism, avoid responsibilities, easier to initiate tasks for someone else than themselves, have difficulty making decisions without excessive amount of advice, feels helpless when alone, urgently seeks for another source of care when a close relationship ends….

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Types of P.D. – Cluster C (3- Obsessive-compulsive)

Obsessive-compulsive PD: those are serious and formal and have difficulty expressing emotions. They are overly disciplined, perfectionist (e.g., unable to complete a project if his personal standards are not met), and preoccupied with rules, details, and organization. Ch.Ch: inflexible and lack of spontaneity (inflexible about matters of morality, ethics, or values; rigid, stubborn), tend to be polite and formal, typifying the bureaucratic personality. Immature and irresponsible emotional behavior. Ambivalent, conflict, and hostility.

Types of P.D. – not otherwise specified

1- Passive aggressive: pervasive pattern of negativistic attitudes and passive resistance to demands for adequate performance in social and occupational situations.

Ch.Ch: they feel cheated and unappreciated, life unkind

2- Depressive (pessimistic, guilt, blaming self, critical, low self esteem, unhappiness, etc)*

3- Sadomasochisitic* 4- Sadistic

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Onset, prevalence & Prognosis of P.D.

Symptoms start in childhood or early adolescence

The prevalence varies with the specific disorder from rare to 3%

The prognosis also varies with condition often remains unchanged (chronic conditions)

There is an increased risk of the development of depressive disorder with several of P.D.

There is some evidence that the symptoms of avoidant, borderline, and antisocial P.D may decrease with age

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