PERSONALITY DISORDER: CONCEPT &

CLASSIFICATION

Dr. Nishant Goyal

Personality
• Personality is defined as, “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”
(American Psychiatric Association)

• “Personality is the sum total of the physical, mental, emotional, and

social characteristics of an individual. Personality is a global
concept that includes all those characteristics that make every
person an individual, different from every other person. Personality
is not static; it is developed over the years and is always in the
process of becoming” (Rice)
Contd…

• Personality:- “Dynamic organization within the individuals of those

psychophysical systems that determine his or her unique adjustment
to the environment” - Gordon Allport

• “The distinctive patterns of behavior (including thoughts and

emotions) that characterize each individuals adaptation to the
situations of his or her life”- Walter Mischell

• Temperament: Stylistic component (how) of behavior

• Character: The social and cultural contributions to personality

• Disorder: A Syndrome with a given course

Components Of Allport’s Definition

Dynamic organization: refers to Allport’s view that to be healthy, we

need to integrate all parts of our personality into a whole

Psychophysical Systems: Allport argued that biology influences our

personality development. He accepted the idea that temperament,
constitutes an inherited biological foundation for personality

Determinative: Allport argued that traits are not just predictor’s of

behavior, they actually determine (cause) behavior
What purpose does personality serve?

• for myself or for society?

• adaptation or creativity?

• my wellbeing or survival?
Eight Modalities of Personal Functioning

• Individuality, Independence
• Relationship, Attachment, Security

• Spontaneity, Desire for New Experiences, Instability

• Stability, Self control, Security

• Wellbeing, Pleasure

(according to Fiedler/Millon)
• Allowing and accepting pain, Melancholy
• Actively structuring life − Manipulation

• Passive Receiving, letting things happen

Common themes in normality

• strength of character • flexibility/ability to adjust

• ability to learn from experience • ability to laugh

• ability to work • ability to love another

• ability to achieve insight • degree of acculturation

• absence of symptoms/conflict

• ability to experience pleasure

without conflict
Where is the line?

• It’s all a matter of degree and which traits:

– To be a successful pilot, a person must have a
degree of narcissism (healthy sense of self-
confidence) and obsessive compulsive (attention
to detail, conscientious)
See the whole person

• Therefore, don’t rely on a single, “slice-in-time” conclusion when

considering traits

• The most normal person can look pretty disordered at times

when stressed
Characteristics of Personality Disorders

• An enduring pattern of inner experience and behavior that

deviates markedly from the expectations of the individual’s
culture,

• is pervasive and inflexible,

• has an onset in adolescence or early adulthood,

• is stable over time,

• and leads to distress or impairment.

Evolution of the concept
• Plato 428-348 BC
– Appetites
– Passions
– Reason

• Hippocrates 400BC
– Sanguine (vigorous)
– Melancholic (pessimistic)
– Choleric (hot-tempered)
– Phlegmatic (Calm)
Contd…
• Aristotle
– Traits: courage, ambition, friendliness, etc

• Threophrastus – satirical description of annoying personality types-

1st description of personality

• 19th Century: present day descriptions emerged from

• Pinel 1809: articulated the concept ‘manie sans delire’ to describe

outbursts of aggression in the absence of mental illness
A Brief History
• James Prichard’s “Moral Insanity”

• Eugen Kahn “Psychopathy”

• Koch’s Psychopathic inferiority in 1891

• Pierre Janet (1901) and Freud/Breuer described psychological traits

associated with hysteria, the forerunner of Histrionic PD

• Object relation theorists emphasized the role of early interpersonal

interaction.( Dependent traits results from parental deprivation, OC
traits from control struggle with parental figures etc)
Contd…

• Carl Gustav Jung Shifted the focus from archaic stereotypical

forms to modern dimensional typologies

• Ernst Kretschmer Typologies based on biological speculation

– Athletic
– Asthenic
– Dysplastic
– Pyknic

• Sheldon
– Endomorphic
– Mesomorphic
– Ectomorphic
 Contd…

• 1920s Kraepelin described personality types in terms of the

spectrum concept

– Personality types are biogenetically related variants of the

paranoid and affective psychosis

– These are forerunners of current

• Paranoid,
• Schizotypal,
• Cyclothymic and
• Depressive Traits
Contd…
– Schneider (1923) – considered PDs as socially deviant extreme
variant of normally occurring personality

– First comprehensive system of Personality Disorder categories

(1958)

– In his book Psychopathic personalities described

• Hyperthymic
• Depressive
• Insecure
• Fanatical
• Lacking in self-esteem
• Labile Affect
• Explosive
• Abulic
• Asthenic
• Wicked
Current Nosology
• ICD 9 relies exclusively on Kurt Schneider’s Work on 10
personalities

• ICD 10 corresponds more closely with DSM IV

• The Anglo-American concept of PD originated from James

Prichard’s Moral Insanity – later termed “sociopathy”.

• Other disorders in DSM can be traced back to Schneider’s Work

• The Theoretical underpinnings however changed over time

Current Nosology
• DSM I: (1952) PD traits that malfunction under stressful
circumstances

• DSM II (1968): PD causes distress and impairment and they are

not merely deviant personalities

• DSM III (1987): Several Major Changes in conceptualization and

classification
The Paradigm Shift…
• DSM-III
– A shift from dynamic, interpretative understanding to
atheoretical, descriptive approach
– Introduction of Multiaxial System
– Included in AXIS II
– Specific Diagnostic criteria were added

An exponential increase in international interest after

1980s..
• DSM III-R & IV: Attempted to increase the validity of PD
categories by incorporating findings from growing literature

• DSM-IV TR: Updated text drawing upon recent literature

Indian Approach to Classification of Personality
• According to Ancient Indian thought personality has been
understood on the basis of 3 vrittis and 3 doshas
• Mind has 3 gunas: satya (goodness), rajas (passion), tamas
(darkness)
• Charak Sanhita: 16 personality types- Sattvik (7) Rajas (6), Tamas
(3).
• Patanjali yoga: 3 types
– Karma, Jnana, Bhakti

Buddha Typology:
– Sensual
– Hateful
– Delude
– Arhats & Pratyekabudhhas
Approaches towards personality

• Two approaches:

– Nomothetic: Type & Trait theories

– Idiographic: Psychoanalytic, Humanistic, learning

A nomothetic approach describes those theories that portray

human personality in terms of “shared attributes”

A Idiographic approach focuses on individual nuances

Type theories
• A “Type” is simply a class of individuals said to share a common
collection of characteristics (eg. Introvert, extrovert)

• ICD 10 And DSM IV / TR personality classes are based on typology

1. Eysenck’s Three Factor Theory (Neuroticism, Introversion,

Extraversion)
(assessment: EPQ, EPQ-R)

2. Costa & McCrae’s Five Factor Model (NEO-PI):

– Neuroticism
– Extraversion
– Openness
– Agreeableness
– Conscientiousness
• In collaboration with his wife, Sybil Eysenck, a third factor,
psychoticism-socialization, was added to the theory in the 1970s

• Psychoticism-socialization measured the propensity for

psychotic or aggressive features and testosterone levels were
considered the contributing physiological marker
Type theories
3. Cloninger’s Three Factor Model : (Based on TPQ)
– Novelty Seeking
– Harm Avoidance
– Reward Dependence

4. Cloninger’s Seven Factor Model: (TCI)

A) Temperament:
Novelty Seeking
Harm Avoidance
Reward Dependence
Persistence
B) Character:
Self Directedness
Cooperativeness
Self Transcendence
Cloninger's 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
Cloninger's 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
Trait Theories..
Traits Are characteristics that lead people to behave in more or less
distinctive and consistent ways across situations

1) Allport’s Theory: Traits = “Distinctive and personal forms of behavior”

Rich collection of trait-like terms in English lit. provide way of capturing
uniqueness of individuals.

Cardinal Trait = Dominant, has ability to describe all of the individual action
Central Trait = Outstanding characteristics
Secondary Traits = Least generalized characteristics

2) Cattle’s 16 Factor Theory

Obtained source traits of personality from linguistic term factor
analysis (Tough, Poised, Independent etc.)
Narrow Trait Theories
3) Julian Rottrer’s “Locus Of Control”
( Degree to which we believe that we cause or control events in our
lives)

4) Type A / Type B Personality (Friedman & Rosenman)

Type A: Hostility,
Work alcoholics,
Competitive,
Time Urgency,
Ambitious
Aggressive

5) Goldberg’s “Lexical Model”

(emotional stability was included as opposite factor of Neuroticism)
Idiographic approach

• Criticizes Nomothetic approach as it misses the uniqueness of a

person

Psychodynamic Approach
• Summarization of the work of Freud, Post Freudians, and Neo
Freudians

• Unlike Trait approaches Dynamic approach involve a search for

underlying processes (Motivation, Needs, Impulses)

• Character Traits are residues of mature defenses (Anna Freud and

Otto Fenichel)
Idiographic approach
Humanistic Approach
• Criticisizes that Freud was pessimistic

• Motivation for normal development of personality depends upon

satisfaction of hierarchy of needs (Physiological-security-Love &
belongingness-self esteem-self actualization) Abraham Maslow

• Carl Roger’s “Unconditional positive regard”

Behaviorists:
Personality consists of set of behaviors which are learned
behaviors
Types of Personality Disorders
Why to study Personality Disorder?
• Major social, scientific, medical problem

• 1 in every 10 individuals has a Personality disorder

• Tend to be
– less educated,
– sexual offenders,
– drug addicts, (70-90% have one PD)
– unemployed
– poorly adjusted in marital life
– Criminals (70-80%) – (Jordan, et al 1996, Arch Gen Psychiatry)
– Suicide and Homicide
– Prone for accidents
Why to study Personality Disorder?
• In psychiatry, 50% AXIS I comorbidity associated

• Seen frequently in somatic medicine set up (Angina, HIV infection,

etc)

• Carries poor prognosis, poor treatment response, non-compliance

to medications

• Comorbid Personality Disorder has been shown to have poor

treatment response in: MDD, OCD, Bipolar Disorder, Panic
Disorder, and Substance dependence

• Comorbid PD predicts relapse and incomplete remission in

MDD, Bipolar disorder and GAD
The Prevalence..
Prevalence in general population

• All clinicians frequently

encounters patients
with personality 10-13%
disorder
Diagnosed,
15%
• 30-50% outpatients
have one or other
Personality disorder

Undiagnosed
as an adult,
85%

Lenzenweger, et al.,
Arch Gen Psychiatry; 1997
Classification of personality disorder
• Difference between “normal” vs “Abnormal” relies largely on an
arbitrary cutoff point on the continuum between two extremes of a
behavior

• The distinction is context dependent (culture, situation)

• Both pervasive personal and social patterns

ICD 10 (AXIS I) and DSM-IV TR (Axis II)

• Difference:
– Not arranged into clusters like DSM
– Excludes Schizotypal Personality
– Anankastic instead of Obsessive compulsive
– Dissocial instead of Antisocial
– Emotionally Unstable (impulsive and Borderline) instead of
Borderline
ICD 10
• 10 PDs (including other specified PDs, and PD unspecified)

• Mixed PDs: (Features of several PDs are present but no

individual criteria is met)

• Enduring Personality Changes, Not Attributable to Brain

Damage and Disease
– Enduring Personality Change After Catastrophic Experiences
– Enduring Personality Change After Psychiatric Illness

• Troublesome Personality Changes:

(Not classifiable in Specific PDs or Enduring Personality Change,
and regarded as secondary to an affective illness or anxiety
disorder)
DSM IV
• Factor analysis of data

• Three independent clusters based on descriptive similarities (11

PDs)

• Compulsiveness tends to form a separate cluster

• Useful in research and educational purpose

• Studies support construct validity, lacks epidemiological studies to

validate as independent clusters as mixture is commoner

• DSM IV includes two separate entities:

– Passive Aggressive Personality Disorder
– Depressive Personality Disorder

In “ Criteria sets and Axes Provided for Further Study” in Appendix B

DSM IV Diagnosis
↓ Reward Dependence

↑Novelty Seeking

↑ Harm Avoidance
• Personality Disorder N.O.S.
– Like Mixed PD in ICD 10
– Appendix B Personality Disorders

• Allows Diagnosis of PDs in an individual < 18 years of age

(except Antisocial PD)

• The features should be present for more than 1 year

Pathogenesis of Personality Disorders

• Psychodynamic Models

• Psychobiological Models
Psychodynamic Models
• People with PDs use immature and neurotic defenses
• “Neurotic Character” :

– One who uses excessive Neurotic defenses which become

inflexible, pervasive and ego-syntonic patterns of everyday
behavior
– E.g., Hypermorality is a reaction formation against
aggression

• “Character Neurosis”:
– Observed when an inflexible neurotic character trait interferes
with the healthy part of the personality.
– ( e.g., Hypermorality interfere with normative social
interaction as frustrating and undesirable)
Psychobiology of Personality Disorder
Genetic
Personality develops through the interaction of heredity and environment
– reciprocal necessity of genetic endowment and environmental
influences
Temperament
Genetic difference account for 50% variance
25-30% non-shared environment
15-20% measurement error (Loehlin, 1992; large twin study)

The 4 temperaments are genetically independent clusters that occur in

all possible factorial combinations, rather than mutually exclusive
categories.

In a large Swedish sample temperament at 10 yrs predicted personality

at 15, 18, 27 yrs. – Temperament is relatively stable part of personality

Arch Gen Psychiatry, 1993

Temperament
• Temperament refers to the characteristic phenomena of an
individual’s emotional nature, including his susceptibility to
emotional stimulation, his customary strength and speed of
response, the quality of his prevailing mood, and all the
peculiarities of fluctuation and intensity of mood, these
phenomena being regarded as dependent upon constitutional
make-up and therefore largely hereditary in origin (Allport)

• The stylistic component of behavior—that is, the how of

behavior as differentiated from motivation, the why of behavior,
and abilities, the what of behavior (Thomas & Chess)
Personality Vs Temperament
• Temperament is part of the overall expression of personality

• The temperament components of personality are considered

predispositions
– with a stronger biological basis than personality traits,

– are developmentally evident earlier,

– and are less mediated by environmental influences

• Temperament may be conceptualized as a foundational

substrate for the subsequent development of personality
Temperament
• Temperament represents sensation, association and motivation that
underlies the acquisition of skills and habits based on emotion

• Temperament is thus the “emotional core” of personality

• Temperament is conceptualized as heritable biases in emotionality

that underlie the acquisition of emotion based automatic behavior
traits that is observable early in life.

• Jerome Kagan shows that certain children are irritable, fearful and
inhibited when confronted with new situation – the Behavioral
Inhibition Phenotype.

• These traits can be identified early and remains unaltered till latest 7
years when environment starts to shape temperament.

• BI phenotype has strong predictive validly of future Anxious traits

• Alexander Thomas and Stella Chess (The New York longitudinal
study) also found temperamental traits in early infancy which
could be traced till adolescence. (difficult child-conduct disorder-
ASPD)

• Procedural memory (Non-declarative) underlies “associative

learning” and involves presemantic perceptual processing of
visuo-spatial information and affective valance.

• Cortico-thalamo-Limbic circuit is involved in regulation of

procedural memory – responsible for acquisition of
Temperament
Character
• Character represents the process symbolization and abstraction
based on conceptual learning, i.e., propositional learning

• Neocortical Structures are responsible for propositional learning –

character codes are stored in fronto-temporal cortex

• Character represents roughly environmental contributions to

personality

• Different PDs have different T:C ratios

– Paranoid & Schizotypal PD have strongest genetic component

– Schizotaxia
 4 Dissociable brain systems influencing Stimulus-
response Patterns underlying temperament
Brain System (related Principal Relevant stimuli Behavioral Response
personality dimension) neuromodulators

Behavioral Activation Dopamine Novelty Exploratory pursuit

(Novelty Seeking) Monotony Active Avoidance

Behavioral Inhibition GABA Aversive conditioning Avoidance

(Harm avoidance) Serotonin (Dorsal for novelty
Raphe)

Social Attachment Norepinephrine Reward conditioning Formation of appetitive

(Reward Dependence) Serotonin (medial CS
Raphe)

Glutamate Intermittent Resistance to extinction

Partial reinforcement Serotonin (Dorsal reinforcement
(Persistence) Raphe)
Character

• Electrophysiological markers of neocortical processing - P300, &

CNV are correlated with Character but not with temperament

• Self-directedness correlates with parietal P300

• Cooperativeness correlates with CNV

Seiver & Davis Model
• All Axis I & II disorders can be classified under 4 dimensions

– Cognitive-perceptual Disorganization (Schizophrenia spectrum,

Cluster I) (Defect In SPEM, etc)

– Impulsivity Aggression (Borderline PD, Bipolar Disorder, Axis II)

(Low CSF HIAA)

– Affective Instability (Borderline, Histrionic PD) (Dysregulation of

CNS 5HT & NE system)

– Anxiety Inhibition (Cluster C, Anxiety disorder) (GABA-ergic

Dysregulation)
Personality Disorders
• Cluster A

• Schizoid PD - pervasive pattern of social detachment and a

restricted range of expressed emotions

• Indifference to praise and criticism

• Preference for solitary activities and fantasy (so-called loners)

• Lack of interest in sexual interactions

Contd…

• Lack of desire or pleasure in close relationships

• Emotional coldness, detachment, or flattened affectivity

• No close friends or confidants other than family members

• Pleasure experienced in few, if any, activities

Contd…

…associated features include

• Difficulty in expressing anger, even in response to direct

provocation, which contributes to the following features

• Impression of flattened affect

• Passivity in adverse circumstances

• Severe lack of social skills

• more commonly diagnosed in men and may cause more

impairment in them

• Prevalence rates varying from uncommon (DSM-IV-TR) to 7.5

percent in the general population
Paranoid Personality Disorder
Cluster A

• Excessive suspiciousness and distrust of others

• Hypersensitivity to and unforgiveness of insults, slights, and rebuffs

• Unwarranted tendency to question the loyalty of friends or the fidelity of

spouse or sexual partners

• Reluctance to confide in others because of unwarranted fear that the

information will be used against them

• Preoccupation with conspirational explanations of and hidden

demeaning or threatening meanings into benign events or remarks

• Unwarranted tendency to perceive attacks on their character or

reputation with angry reactions or counterattacks
Contd…

….associated features
• Excessive need to be self-sufficient and strong sense of
autonomy

• Pervasive inability to relax and to compromise

• Frequent involvement in legal disputes

• Frequently impress others as fanatics

• Tendency to form closed groups or cults consisting of people

with similar beliefs

• Peculiar ability to generate fear in others

Contd…

• More commonly diagnosed in men

• Prevalence rates of 0.5 to 2.5 percent in the general population, 10

to 30 percent for psychiatric inpatients, and 2 to 10 percent for
psychiatric outpatients
Schizotypal Personality Disorder
Cluster A

• Social and interpersonal deficits as indicated by pervasive discomfort

with reduced capacity for close relationships, as well as cognitive and
perceptual distortions and eccentric behavior (not severe enough to
meet criteria for schizophrenia)

• Ideas of reference (not delusions)

• Odd beliefs and magical thinking (superstitiousness; beliefs in

clairvoyance; telepathy, also known as sixth sense; and, in children
and adolescents, bizarre fantasies or preoccupation)
Contd…

• Unusual perceptual disturbances (illusions, including bodily illusions and

sensing a presence of a person nearby)

• Paranoid ideation and suspiciousness

• Odd, eccentric, peculiar behavior

• Lack of close friends, except family members

• Odd thinking and speech without incoherence (e.g., vague,

metaphorical, overelaborated, and stereotypical)

• Inappropriate or constricted affect

• Social anxiety that does not diminish with familiarity and that is
associated with paranoid fears
Contd…

• The sex ratio is unknown (slightly more common in males)

• A prevalence rate of 3 percent in the general population. Earlier

reports suggested a range between 2 and 6 percent

• There is an increased prevalence of this personality disorder among

the first-degree relatives of probands with schizophrenia.

• Also, there is an increased prevalence of schizophrenia and other

psychoses in the relatives of probands with schizotypal personality
disorder
Cluster B: Histrionic PD
• Evolution
• ‘hysteria' described by Hippocrates

• Kraepelin described multiple symptoms, including capricious

and inconsistent behaviour, histrionic exaggeration, and a life
of illness

• Charcot and Janet linked hysteria with conversion

• Freud recognized the relationship between hysterical neurosis

and ‘erotic personality’

• Term “histrionic” coined by Brody and Sata

• Pervasive and excessive self-dramatization, excessive emotionality,
and attention seeking
• Inappropriate sexual seductiveness or provocativeness
• Excessive need to be in the center of attention
• Rapidly shifting and shallow expression of emotions
• Suggestibility
• Physical appearance used for attention seeking purposes
• Impressionistic speech lacking detail
• Self-dramatization, theatricality, and exaggerated expression of
emotions
• Relationships considered to be more intimate than they really are
Histrionic PD
…associated features

• Difficulties in achieving emotional intimacy in romantic or

sexual relationships

• Craving for excitement and stimulation

• Promiscuity or complete sexual naiveté

• Low tolerance for delayed gratification

Contd…

• occurs far more frequently among women. May be more common in

males than reported

• Prevalence rates of 2 to 3 percent in the general population and 10

to 15 percent for psychiatric inpatients and outpatients
Narcissistic PD
• Evolution
• Narcissism originates from the Greek myth of Narcissus who
was infatuated with his own reflection in the mirror-lake

• Freud described primary (normal) and secondary (pathological)

narcissism. He also described the narcissistic character type

• Jones gave a detailed description of narcissistic individuals, who

exhibit a ‘God complex' and have some cognitive peculiarities

• Nemiah described ‘narcissistic character disorder', which was

later elaborated by two leading workers in the field, Heinz Kohut
and Otto Kernberg
Contd…

• Kohut, in The Analysis of the Self, described narcissistic personality

disorder as presenting a failure to internalize healthy self-esteem; it
is a derivative of normal infantile grandiosity, causing a poor self-
image against which narcissism develops as a defensive reaction.

• Kernberg divided narcissism into normal infantile, normal adult, and

pathological
 Contd…

• Clinical Features
• Pervasive sense of grandiosity (in fantasy or in behavior), a need
for admiration, a lack of empathy, and chronic, intense envy
• Grandiose sense of self-importance and specialness
• Preoccupation with fantasies of unlimited success, power,
brilliance, beauty, or ideal love
• Sense of entitlement
• Interpersonal exploitation, such as taking advantage of others to
achieve own needs
• Lack of empathy
• Excessive need for admiration and acclaim
• Intensive and chronic envy
• Arrogant and haughty attitude
Contd…

…associated features
• Fragile self-esteem (which exclusively depends on external
admiration) with hypersensitivity to criticism

• High achievements more frequent than in any other

personality disorder

• Strong feelings of shame and humiliation

• Exhibitionism (behavior motivated by the pleasure of being

looked at)

• Fear of having hidden imperfections and flaws revealed

Contd…

• More commonly diagnosed in men (50 to 75 percent of

diagnosed cases are men)

• Prevalence rates of 2 to 16 percent in the clinical population and

less than 1 percent in the general population
Antisocial PD
• Pinel ‘manie sans délire’
• Cleckley's seminal work The Mask of Sanity
• Robins' follow-up study Deviant Children Grown Up described
antisocial personality as beginning before the age of 8 and continuing
into adult life
Clinical Features…
• Pervasive disregard for and violation of rights of others occurring
since 15 years of age and continuing into adulthood
• Failure to conform to social norms (resulting in frequent arrests)
• Deceitfulness, including lying and conning others for personal profit
or pleasure
• Impulsivity or failure to plan ahead
• Irritability and aggressiveness, including repeated physical fights or
assaults
• Recklessness, with disregard for safety of self and others
• Irresponsibility, indicated by the failure to honor financial obligations
or to sustain consistent work behavior
• Lack of remorse, indicated by indifference or rationalization of having
hurt, mistreated, or stolen from others
Contd…

….associated features include

• Promiscuity and inability to sustain a monogamous relationship

• Lack of empathy, cynicism, and contempt for feelings, rights, or
suffering of others
• Inflated and arrogant self-appraisal
• Abusiveness and irresponsibility toward children
• more common (3 : 1) in men
• Prevalence rates of 3 % for men and 1 % for women in the general
population and 3 to 30 % in clinical settings, with even higher rates
for forensic samples and substance abusers
Borderline PD
• Stern was the first to use the term ‘borderline' in 1938, placing
borderline patients on the border between neuroses and
psychoses

• Spitzer et al. introduced diagnostic criteria, labelling the condition

‘unstable personality‘

• Otto Kernberg proposed ‘borderline personality organization', a

broad concept encompassing all severe personality disorders.
Borderline personality organization is a stable permanent state
based on three criteria: diffuse identity, primitive defences
centered around splitting and intact reality testing

• Gunderson focused attention on ‘borderline personality disorder'

as a distinct entity which could be distinguished from both other
mental disorders and other personality disorders
Clinical Features

• Pervasive and excessive instability of affects, self-image, and

interpersonal relationships, as well as marked impulsivity
•
• Frantic efforts to avoid real or imagined abandonment (Note: Do not
include suicidal or self-mutilating behavior covered in Criterion 5)

• Unstable and intense interpersonal relationships with alternating

between idealization and devaluation

• Markedly and persistently unstable self-image or sense of self

• Impulsivity in at least two potentially self-damaging areas (spending,

sex, substance abuse, binge eating, and reckless driving) (Note: Do
not include suicidal or self-mutilating behavior covered in Criterion 5)
Contd…

• Recurrent suicidal behavior, gestures, threats, or self-mutilating

behaviors
• Instability of affect due to marked reactivity of mood
• Chronic feelings of emptiness
• Inappropriately intense anger or difficulty controlling anger
• Stress-related, transient paranoid ideation or dissociative
symptoms
• Tendency to undermine self when close to realizing a goal
• Feeling more secure with non-human objects (pets and
inanimate objects) than in interpersonal relationships
ICD DCR criteria: Emotionally unstable personality disorder:
Impulsive type (F60.30)

A. The general criteria of personality disorder (F60) must be met.

B. At least three of the following must be present, one of which is 2

1. A marked tendency to act unexpectedly and without

consideration of the consequences

2. A marked tendency to quarrelsome behaviour and to conflicts

with others, especially when impulsive acts are thwarted or
criticized

3. Liability to outbursts of anger or violence, with inability to control

the resulting behavioural explosions

4. Difficulty in maintaining any course of action that offers no

immediate reward

5. Unstable and capricious mood

ICD DCR criteria: Emotionally unstable personality
disorder: Borderline type (F60.31)
B. At least three of the symptoms mentioned above in criterion B
(F60.30) must be present, and in addition at least two of the
following:

6. Disturbances in and uncertainty about self-image, aims and

internal preferences (including sexual)

7. Liability to become involved in intense and unstable relationships,

often leading to emotional crises

8. Excessive efforts to avoid abandonment

9. Recurrent threats or acts of self-harm

10. Chronic feelings of emptiness

Contd…

– more commonly diagnosed in women (75 percent of

diagnosed cases are women)

– 2 percent in the general population, 10 percent for psychiatric

outpatients, 20 percent for psychiatric inpatients, and 30 to 60
percent among patients with personality disorders
Cluster C Personality Disorders
• Avoidant Personality Disorder
• Pervasive and excessive hypersensitivity to negative evaluation,
social inhibition, and feelings of inadequacy
• Avoidance of occupational activities that involve significant
interpersonal contact because of fears of criticism, rejection, or
disapproval
• Unwillingness to be involved with others unless certain of being
liked
• Restraint in intimate relationships because of the fear of being
shamed or ridiculed
• Preoccupation of being criticized or rejected in social situations
• Inhibition in new social situations because of feelings of
inadequacy
Contd…

• Reluctance to take personal risks or to engage in any new

activities, because they may prove embarrassing

• Views self as socially inept, personally unappealing, or inferior to

others

• Fearful and tense demeanor

• Fear of blushing or crying in front of others in response to

criticism

• Social isolation accompanied by craving social relations and

fantasizing about ideal relationships with others
Contd…

• Disorder is equally frequent in men and women

• Prevalence rates of 0.5 to 1.0 percent in the general population

and 10 percent for psychiatric outpatients
Dependent Personality Disorder
• Pervasive and excessive need to be taken care of that leads to
clinging behavior, submissiveness, fear of separation, and
interpersonal dependency

• Difficulty in making everyday decisions without excessive

reassurance and advice from others Need for others to assume
responsibility for major areas of his or her life

• Difficulties expressing disagreement with others because of fear

of loss of support or approval. (Note: Do not include realistic fears
of retribution)
Contd…
• Lack of initiative

• Unrealistic preoccupation with fears of being left to take care of

self

• Urgent search for another relationship as a source of care and

support when a close relationship ends

• Extensive efforts to obtain nurturance and support from others

(to the point of volunteering to do unpleasant things)

• Uncomfortable and helpless feelings when alone because of

exaggerated fears of being unable to take care of self

• Low self-esteem with self-doubt and self-defeating demeanor

Contd…

• Equally frequent in men and women (DSM-IV-TR)

• This disorder is reported in DSM-IV-TR to be the most frequent

of personality disorders
Obsessive-Compulsive Personality Disorder

• Preoccupation with orderliness, perfectionism, and mental and

interpersonal control, at the expense of flexibility, openness, and
efficiency
• Preoccupation with details, rules, lists, order, procedures,
organization, or schedules to the extent that the major point of
activity is lost
• Perfectionism that interferes with task completion
• Excessive devotion to work and productivity to the exclusion of
leisure activities and friendships (not accounted for by obvious
economic necessity)
• Over-consciousness, scrupulousness, and inflexibility about matters
of morality, ethics, or values (not accounted for by religion or culture)
Contd…

• Inability to discard worn-out or worthless objects with no

sentimental value

• Reluctance to delegate tasks or work with others unless they

submit exactly to his or her way of doing things

• Stinginess (money viewed as something to be hoarded for

future catastrophes)

• Rigidity and stubbornness

Contd…

….associated features include

• Decision-making difficulties when no strict rules or established

procedures dictate correct action
• Anger and frustration when not able to maintain control of
physical or interpersonal environment (anger is typically not
expressed directly)
• Excessive attentiveness to their relative status in dominance–
submission relationships
• Controlled and restricted emotional expression and reserved
personal style
• Formal and serious quality of everyday relationships
Contd…

• This disorder is twice as common in men as in women

• Prevalence rates of 1 percent in the general population and 3 to

10 percent for psychiatric outpatients
Passive-aggressive PD
• Pervasive pattern of negativistic attitudes and passive resistance to
demands for adequate performance, beginning by early adulthood and
present in a variety of context

• Passively resists fulfilling routine social tasks

• Complaints of being misunderstood by others

• Argumentative

• Criticizes authority

• Envy towards those apparently fortunate

• Persistent complaints of personal misfortune
Depressive PD
• Pervasive pattern of depressive cognition and behaviour
• Gloominess of mood

• Beliefs of worthlessness

• Critical toward self and others

• Pessimistic

• Guilt feelings
Personality Disorders: Assessment
• Whom to assess for PD

• When to assess for PD

Personality Disorders-Assessment
• Clinical interview

• Self report Inventories e.g., Minnesota Multiphasic Personality

Inventory, Millon Multiaxial Clinical Inventory, Personality
Diagnostic Questionnaire

• Semi structured interview

• 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
Clinical Assessment…
Outline given below can be followed in
all instances
• Social relations

• Intellectual activities and leisure activities

• Prevailing mood

• Character
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
Contd…
 yes

No
The_Temperament_Assessment_Scale_for_Children.pdf
Temperament Character Inventory (TCI)
• Temperament Character Inventory (TCI) (Cloninger et al, 1993)
– TCI measures four major temperament dimensions (harm avoidance,
novelty seeking, reward dependence and persistence) and three
major character dimensions (self-directedness, cooperativeness and
self-transcendence)

– The major temperament dimensions are composed of component

facets (subscales) to evaluate response patterns elicited by specific
stimuli

– The TCI is a family of tests with several specialized versions

designed for varying types of informants (self-report, peer ratings,
and interviewers)

– The test measuring the temperament dimensions only was originally

called the Tridimensional Personality Questionnaire (TPQ)

– TCI is a 240-item test available in true–false and five-point Likert

formats
TCI profiles of PD
• Poorly developed character traits, especially self-directedness
and cooperativeness, are a common denominator aross all
subtypes of personality disorder

• High self-transcendence correlates with schizotypal and paranoid

symptoms (depicting primary process thinking and fanaticism,
respectively) 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), or, on the other hand, it may predispose to high
creativity (when other two character traits are high)
Contd…

• Once the probability for the presence of personality disorder is

established based on character, temperament traits are used for
differential diagnosis

• 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
NEO Personality Inventory–Revised
• It is a concise measure of the five major domains of personality, as
well as the six traits or facets that define each domain

• The instrument provides a detailed assessment of normal adult

personality in a variety of settings: counselling, clinical psychology,
psychiatry, behavioural medicine and health psychology, vocational
counselling and industrial/ organisational psychology, and
educational and personality research

• Each version contains 240 items and 3 validity items, requiring Year
6 reading level
Domains and Facets of the NEO PI-R
Contd…

• NEO PI R personality profiles in PD

• In clinical samples studies showed that neuroticism, extroversion,

and low agreeableness predict personality disorder symptoms

• Excessive conscientiousness in OCPD

MCMI
• Evaluates long-term behavior traits systematized as ten basic
personality patterns (dependent, avoidant, schizoid, passive-
aggressive, narcissistic, antisocial, hysterical, compulsive,
aggressive, and self-defeating) and three pathological
personality disorders (borderline, schizotypal, and paranoid)

• The latter indicate the severity of the ten basic personality

patterns

• The test also evaluates nine Axis I clinical syndromes

Affective Temperaments
• Popularised by Hagop Akiskal

• Temperament classically refers to an adaptive mixture of traits which, in

the extreme, can lead to illness or modify the expression of superimposed
affective states

• DEPRESSIVE (OR MELANCHOLIC) TYPE

– In the Hippocratic school it was considered as part of the broader
concept of melancholia (‘‘black bile’’)

– Core characteristics of such individuals encountered in contemporary

practice: gloomy, sombre, and incapable of having fun; brooding, self-
critical, and guilt-prone; lack of confidence, low self-esteem,
preoccupation with failure; pessimistic, easily discouraged; easy to
tire, sluggish, and bound to routine; non-assertive,self-denying, and
devoted; shy and sensitive
Contd…

• THE CYCLOTHYMIC TYPE

– Features are lethargy alternating with eutonia;
– shaky self-esteem alternating between low self-confidence and
overconfidence;
– decreased verbal output alternating with talkativeness; mental
confusion alternating with sharpened and creative thinking
– unexplained tearfulness alternating with excessive punning and
jocularity
– introverted self-absorption alternating with uninhibited
peopleseeking
– hypersomnia alternating with decreased need for sleep
– unevenness in quantity and quality of productivity-associated
unusual working hours.
Contd…

• THE HYPERTHYMIC TYPE

– Features are
• cheerful, overoptimistic, or exuberant
• extraverted and people-seeking, often to the point of being
overinvolved or meddlesome
• overtalkative, eloquent, and jocular
• uninhibited, stimulus-seeking, and sexually-driven
• vigorous, full of plans
• overconfident, self-assured, and boastful attitudes that may
reach grandiose proportions.
Personality Disorders-Treatment
Personality Disorders-Treatment
• Cluster A
– There is preliminary evidence that low doses of antipsychotic
medication (1–2mg per day of haloperidol equivalent) are effective in,
at least temporarily, reducing or relieving the psychotic-like symptoms
of schizotypal PD

– Low doses of risperidone can also reduce symptom severity

(negative, positive, and general symptoms) in patients with SPD

– Particularly in response to stress, individuals with Schizotypal PD

may experience very brief psychotic episodes (lasting minutes to
hours)

– Schizotypal Personality Disorder has a relatively stable course, with

only a small proportion of individuals going on to develop
Schizophrenia or another psychotic disorder
Personality Disorders-Treatment
• Antisocial PD

• Treatment effects moderate at the best.

• Depends upon therapeutic alliance
• Those with comorbid depression do better with psychotherapy
• Some modalities include
– Transcendental meditation
– Coherence therapy
• Pharmacology: Aggression
– Lithium
– Other mood stabilizers
– Atypical antipsychotics
Contd…

– Substantial numbers of individuals with ASPD ‘‘mature’’ in

character, ‘‘burn out’’ or stop their criminal behaviour 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.

– Improvement occurred most often between ages of 30 and 40

Contd…

– Matured individuals may develop satisfying social relationships,

recognize criminal activity as foolish and self-defeating, redirect
their goals and values to legitimate work, and become less self-
centred, rebellious, and hedonistic

– Such individuals may continue to have impulsive–aggressive

temperamental traits even if they mature in character

– Furthermore, individuals who are intelligent and socially

successful may still have ASPD
Personality Disorders-Treatment
• Borderline PD

– Currently the approaches most widely employed are the

supportive, the cognitive-behavioural, and psychoanalytically
oriented psychotherapy:
• Cognitive-behavioural therapies (CBT) emphasize working with the
patient’s faulty assumptions about self and others through the use of
reason, as in the therapies of Beck and Ellis
• Linehan’s DBT represents an adaptation of CBT specifically for BPD
patients
• The psychoanalytically oriented approaches emphasize work with the
transference, but mostly in relation to the ‘‘here-and-now’’, rather than
to early childhood (as in classical analysis)
• Kernberg proposed ‘‘transference-focused therapy’’ and Gunderson
advocated ‘‘exploratory therapy’’
– Recently, the American Psychiatric Association published a set of
guidelines that embodies elements of all three approaches
Contd…

• Borderline PD
– SSRIs, atypical antipsychotics such as olanzapine, and mood stabilizers
have been found useful in alleviating impulsive aggression.
– SSRIs for depression
– Mood stabilizers like lithium, valproic acid or lamotrigine for mood
fluctuations
– Lithium for suicidality

– One major study showed that many patients, as they entered their 30s,
began to improve significantly, and no longer met criteria for BPD
– 8% or 10% of the adolescents or young adults with BPD went on to
develop various forms of affective disorder (bipolar II, or unipolar
depression)
Personality Disorders-Treatment
• Histrionic PD
• There is need for limit-setting (in relation to the acting out),
confrontation (about the hidden meanings behind their emotional
displays), and emphasis on the need for regularity about
appointments

• Psychodynamic therapy relies on interpretation of transference

and countertransference to accomplish the necessary goals

• Cognitive therapy relies on working with the irrational schemata

encountered in HPD, such as the assumption that ‘‘Unless I
captivate people, I am nothing’’

• Supportive therapists will utilize such interventions as sympathy,

exhortation, education, and advice-giving.
Personality Disorders-Treatment
• Narcissistic PD

• Two psychoanalytic strategies have proved effective:

– One, suggested by Kernberg, relies heavily on reality testing and
confrontation and interpretation of the pathological grandiose self and the
negative transference

– The other approach, developed by Kohut, focuses on empathic observations

and the development and working through of three types of transference—
mirroring, idealizing and twinship or alter ego transference as a way of
correcting the structural deficits that characterize narcissistic disorders

• Recent new treatment strategies include

– Cognitive
– Short term
– Group
– Couples and family
– Therapeutic milieu
Personality Disorders-Treatment
• Cluster C PD

• Cognitive behaviour therapy has been tried

• Nidotherapy, named after the Latin nidus (nest), attempts to

systematically alter the environment, both physical and social, so
that a better fit is created. It has been introduced for those who
find it difficult to change and who might be better helped by
creating a better adaptive fit with their environment

• SSRI’s and other antidepressants for mood and anxiety

symptoms
Contd…

• OCPD

• Traditional approach to treatment is intensive psychoanalysis. During

the long course of interaction with the therapist and interpretation by
the therapist of transference feelings and behaviours, it is hoped that
the patient will become aware of the defences he marshals to control
anxiety (intellectualization, isolation, displacement, and reaction
formation) and how these interfere with a satisfying interpersonal life
Contd…

• OCPD
• Time-limited treatment approaches include brief and group
psychotherapy

• More recently, cognitive-behavioural therapies have been the

treatment of choice for OCPD. 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