Personality

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Personality Disorders
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• Common
• Chronic
• 10-20 of general population
• aggravating,de-manding,or parasitic
• Poor prognosis
• 50 of psychiatric patients have a personality
  disorder

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• apredisposingfac-torforotherpsychiatricdisorders
• (e.g.,substanceuse,
• suicide,
• affectivedisorders,
• impulse-controldisorders,
• eatingdisorders,
• anxietydisorders)i

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• interferes with treatment out-comes of AxisI
  syndromes
• Increases
• personal incapacita-tion,
• morbidity,
• mortality of these patients

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• Persons with personality disorders are far more
  likely to refuse psychiatric help and to deny
  their problems
• Personality disorder symptoms are allo-plastic
  (i.e.,able to adapt to,and alter,the external
  environment) and egosyntonic (i.e.,acceptable to
  the ego)

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• Persons with personality disorders do not feel
  anxiety about their maladaptive behavior
• Enduring subjective experiences and
• behavior that deviate from cultural standards,
  are rigidly pervasive, have an onset in
  adolescence or early adulthood, are stable
  through time, and lead to unhappiness and
  impairment.

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• When personality traits are rigid and maladaptive
  and produce Functional impairment or subjective
  distress, a personality disorder may be diagnosed

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• Personality disorder subtypes classi?ed in
  DSM-IV-schizotypal,schizoid,andparanoid(ClusterA)
  odd,aloof
• narcissistic,borderline,antisocial,andhistrionic(C
  lusterB) dramatic, impulsive,and erratic
  features,
• obsessive-compulsive,dependent,andavoidant(Cluster
  C). anxiousandfearfulf

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• Personality disorders are coded on AxisII of
  DSM-IV-TR.
• GeneticFactors
• Twin studies
• Cluster A Schizophrenia
• Cluster B
• Alcohol and ASPD
• Borderline and depression mood diisorders
• Histrionic and Somatization
• Cluster C
• Avoidant PD anxious
• OCPD-depressive features

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Biological factors

• Impulsive traits-High testorsterione, 17
  estradiol, estrone levels
• Androgens increase the like lihood of aggression
  and sexual behavior,
• Boderline personality abnormal DST test

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Lowplateletmonoamineoxidase(MAO)levels

• Activity and sociability in monkeys.
• Collegestudents- lowplatelet MAO levels report
  spending more time in social activities
• Schizotypal disorders.

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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.

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Neuro tranmsitters

• High endogenous endorphin levels maybe associated
  with persons who are phlegmatic.
• Levels of 5-HIAA,a metabolite of serotonin, are
  low in persons who attempt suicide and in
  patients who are impulsive and aggressive

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• In many persons, serotonin reduces
  depression,impulsiveness,and rumination,and can
  produce a sense of general well-being.
• Increased dopamine concentrations in the central
  nervous system, produced by certain
  psychostimulants (e.g.,amphetamines) can induce
  euphoria.

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• antisocial and borderline types slow-wave
  activity on EEG

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• Sigmund Freud suggested that personality traits
  are related to a ?xation at one psychosexual
  stage of development
• Those with an oral character are passive and
  dependent because they are ?xated at the oral
  stage,when the dependence on others for food is
  prominent.

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• Those with an anal character are
  stubborn,parsimonious, and highly conscientious
  because of struggles over toilet training during
  the anal period.

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• Wilhelm Reich subsequently coined the term
  character ar-mor to describe persons
  characteristic defensive styles for protecting
  themselves from internal impulses and from
  interpersonal anxiety in signi?cant
  relationships.Reichs theory has had a broad
  in?uence on contemporary concepts of personality
  and personality disorders.For example, each human
  beings unique stamp of personality is considered
  largely determined by his or her characteristic
  defense mechanisms.Each personality disorder in
  AxisII has a cluster of defenses that help
  psychodynamic clinicians recognize the type of
  character pathology present.
• Persons with paranoid personality disorder, use
  projection,
• Schizoid personality disorder is associated with
  withdrawal

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• When defenses work effectively, persons with
  personality disorders master feelings of anxiety,
  depression, anger, shame, guilt, and other
  affects.
• They often view their behavior as 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
• important in controlling unpleasant affects, they
  are not interested in surrendering them.

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• In addition to characteristic defenses in
  personality disorders, another central feature is
  internal object relations. During development,
  particular patterns of self in relation to others
  are internalized. Through introjection, children
  internalize a parent or another signi?cant person
  as an internal presence that continues to feel
  like an object rather than a self. Through
  identi?cation, children internalize parents and
  others in such a way that the traits of the
  external object are incorporated into the self
  and the child owns the traits. These internal
  self-representations and object representations
  are crucial in developing the personality and
  ,through externalization and projective
  identi?cation, are played out in interpersona
  lscenarios in which others are coerced into
  playing a role in the persons internal
  life.Hence, persons with personality disorders
  are also identi?ed by particular pat-terns of
  interpersonal relatedness that stem from these
  interna l object relations patterns.

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DefenseMechanisms.

• The unconscious mental processes that the ego
  uses t resolve con?icts among the four lodestars
  of the innerlife instinct(wish or need),
  reality, important persons, and conscience.

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• When defenses are most effective, especially in
  those with per-sonality disorders, they can
  abolish anxiety and depression.
• Thus, abandoning a defense increases conscious
  anxiety and depression a major reason that those
  with personality disorders are reluctant to alter
  their behavior

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FANTASY

• Many persons who are often labeled schizoidthose
  who are eccentric, lonely, or frightened seek
  solace and satisfaction within themselves by
  creating imaginary lives, especially imaginary
  friends. In their extensive dependence on
  fantasy, these persons often seem to be
  strikingly aloof.
• Therapists must understand that the
  unsociableness of these patients rests on a fear
  of intimacy.
• Rather than criticizing the morfeeling rebuffed
  by their rejection,therapists should maintain a
  quiet,reassuring,and considerate interest without
  insisting on recip-rocal responses.
• Recognition of patients fear of closeness and
  respect for their eccentric ways are both
  therapeutic and useful

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Dissociation

• Dissociation or denial is a Pollyanna-like
  re-placement of unpleasant affects with pleasant
  ones.Persons who frequently dissociate are often
  seen as dramatizing and emotion-ally shallow
• They may be labeled histrionic personalities.
• They behave l ike anxious adolescents who, to
  erase anxiety, carelessly exposethemselves to
  exciting dangers.
• Accepting such patients a sexuberant and
  seductive is to overlook their anxiety, but
  confronting them with their vulnerabilities and
  defects makes them still more defensive. Because
  these patients seek appreciation of their courage
  and attractiveness, therapists should not behave
  with inordinate reserve.
• While remainingcalm and ?rm,clini-cians should
  realize that these patients are often inadvertent
  liars, but they bene?t from ventilating their own
  anxieties and may in the process remember what
  theyforgot.
• Often therapists deal best with dissociation and
  denial by using displacement.
• Thus, clinicians may talk with patients about an
  ssue of denial in an unthreatening circumstance.
• Empathizing with the denied affect without
  directly confronting patients with the facts may
  allow them to raise the original topic themselves

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ISOLATION.

• Isolation is characteristic of the orderly,
  controlled persons who are often labeled
  obsessive-compulsiveperson-alities.
• Unlike those with histrionic personality, persons
  with obsessive-compulsivepersonality remember the
  truth in?ne de-tail but without affect.
• In a crisis, patients may show intensi-?ed
  self-restraint, overly formal social behavior,
  and obstinacy. Patients quests for control may
  annoy clinicians or maket hem anxious. Often,
  such patients respond well to precise,
  systematic, and rational explanations and value
  ef?ciency, cleanliness, and punctuality as much
  as they do clinicians effective responsive-ness.
  Whenever possible,therapists should allow such
  patients to control their own care and should not
  engage in a battle of wills.

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PROJECTION

• In projection, patients attribute their own
  unac-knowledged feelings to others.
• Patients excessive fault?nding and sensitivity
  to criticism may appear to therapists as
  preju-diced, hypervigilantin justice collecting,
  but should not be met by defensiveness and
  argument.
• Instead,clinicians should frankly acknowledge
  even minor mistakes on their part and should
  dis-cuss the possibility of future dif?culties.
• Strict honesty, concern for patients rights, and
  maintaining the same formal, concerned distance
  as used with patients who use fantasy defenses
  are all helpful.
• Confrontation guarantees a lasting enemy and
  early termination of the interview.
• Therapists need not agree with patients in
  justice collecting, but they should ask whether
  both can agree to disagree.
• The technique of counterprojection is especially
  helpful. Clinicians acknowledge and give paranoid
  patients full credit for their feelings and
  perceptions
• They neither dispute patients complaints nor
  reinforce them, but agree that the world
  described by patients is conceivable.
• Interviewers can then talk about real motives
  and feelings, misattributed to some one else, and
  begin to cement an alliance with patients

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