Personality disorder

H.M.Zainie Hassan A.R.

dr.SpKJ(K)

WHAT IS Character
traits/Personality traits?

Freud(1913) distinguished between neurotic

symptoms and personality/ character traits.
Character traits owe their existence to the
success of repression, that is , to the defense
system that achieves its aim through a
persistent pattern of reaction formation and
sublimation.
Character
and
personality
are
used
interchange ably. Character is influenced by
constitutional temperament.

DSM-IV-TR(Diagnostic and Statistic Manual of

Mental Disorders)
Personality : A persons totality of emotional and
behavioural traits apparent in ordinary
life, that usually stable and predictable

if differ & exceeds the range of variation found in

most people , and
if personality traits are rigid, maladaptive &
produce functional impairment, subjective distress

Personality disorders

DSM-IV-TR(Diagnostic and Statistic Manual of

Mental Disorders)

Enduring
subjective experiences &
behaviour that
deviate from
cultural standards
Rigidly pervasive
Onset in adolescence / early adulthood
Stable through time
Lead to unhappiness & impairment

Personality disorders are grouped

into three clusters in DSM-IV-TR
Cluster A covers the paranoid, schizoid, and
schizotypal personality disorders;often perceived
as odd and eccentric.
Cluster B is made up of the antisocial, borderline,
histrionic, and narcissistic personality disorders;
often seem dramatic, emotional, and erratic.
Cluster C includes the avoidant, dependent,
obsessive compulsive, passive agressive,
depressive personality disorder; often seem
anxious or fearful.

ICD 10 - PPDGJ 3
Specific
personality
disorders
(
paranoid,
schizoid
,
dissocial,emotionally
unstable
:
impulsiveborderline,
histrionic,
anankastic,
anxious
/
avoidant,
dependent, other & unspecified )

DISORDER OF PERSONALITY AND

BEHAVIOUR (F69 - F69)
F. 60 Specific personality disorders
F. 62 Enduring personality changes , not attributable to brain
damage and disease
F. 63 Habit and impulse disorders
F. 64 Gender identity disorders
F. 65 Disorder of sexual preference
F. 66 Psychological and behavioural disorders associated with
sexual development and orientation
F. 68

Other disorders of adult personality and behaviour

F. 60 Specific personality disorders

Criteria
ICD 10 - PPDGJ 3

Severe disturbance of personality and behaviour that are

pronounced deviations from normal cultural patterns

Disturbance of long standing duration in several areas of

functioning

Pervasive , maladaptive behaviour

Onset in childhood / adolescence & continuation into adulthood
Considerable personality distress
Usually significant problems in work & social behaviour

General Characteristics
Alloplastic
Ego syntonic
Do not feel anxious - disturbed due to the maladaptive
behaviour
deny problems , refuse (psychiatric) help,
disinterested in treatment , impervious to
recovery

Classification
ICD 10 - PPDGJ 3
Specific personality disorders ( paranoid, schizoid ,
dissocial,
emotionally unstable : impulsive , borderline,
histrionic, anankastic, anxious / avoidant,
dependent,
other & unspecified )

DSM IV
Cluster A : paranoid , .schizoid, schizotypal : odd &
eccentric
Cluster B : antisocial, borderline, histrionic, narcissistic :
dramatic, emotional, erratic.
Cluster C : avoidant, dependent, obsessive - compulsive,
passive - aggressive, depressive : anxious, fearful

Etiology
Genetic - Biological
Concordance mono dizygotic twins
Cluster A more common among biological relatives of SR patients;
B apparently have a genetic base; C, probably
Testosterone , 17 estradiol, estrone : impulsive traits
Androgens : aggressions & sexual behaviour
MAO : low platelet level sociability
Endorphins phlegmatic
Serotonin depression , impulsiveness , rumination, sense of
wellbeing
Dopamine

: euphoria

EEG : slow wave activity antisocial, borderline personality disorders

Psychological
Fixation at one psychosexual stage of development
(oral : passive dependent, anal : stubborn , highly conscientious )
Defense mechanisms : unconscious mental processes that ego
uses to resolve conflicts among four important aspects of inner life
(instinct, reality, important people and conscience ) each
human beings unique stamp of personality is considered largely
determined by his / her characteristic defense mechanisms
(schizoid: fantasy; histrionic: dissociation; paranoid: projection etc).

Temprament, Familial, Environmental

Fearful children avoidant personality, childhood MBD
antisocial personality, poor parental fit, cultural factors etc.

Types of specific personality disorder

Paranoid
0.5 - 2.5 % of gen. pop, M F, minority groups,
immigrants, deaf people .
Early adulthood pervasive suspiciousness, mistrust,
pathological jealousy, hostile, irritable, angry, ideas
of reference, lack of warmth, arrogant.
DD/ delusional disorder, paranoid SR
Lifelong , occupational, marital problems
Psychotherapy : straightforward, no defensive explanation,
limited interpretation , limitation of intimacy
Pharmacotherapy : diazepam, haloperidol, thioridazine.

Schizoid
7.5 % of gen pop. M : F = 2 : 1 , solitary jobs, night workers
Very limited eye contact, inappropriately serious, short answers, no
spontaneous conversation, cold, aloof, quiet, distant, seclusive,
unsociable, introvert , eccentric , lonely, little need for emotional
ties (human being) , prefer solitary non-competitive jobs, threats
faced by fantasy or resignation, heterosexual relations postponed
indefinitely.
DD/ SR, schizotypal pers. dis.
Onset in early childhood , long lasting, SR ?
Psychotherapy : individual, group (respect pt silency & solitarian attitude )
Pharmacotherapy : anti psychotics , antidepressant (SSRI), psycho
stimulants

Schizotypal *
3 % of gen pop, mono > dizygotic twins (33% : 4 %),
> biol relatives of SR.
Odd, strange, thinking & communication disturbed
(magical-peculiar way of thinking) , speech has a personal
meaning & often need interpretation, sensitive to negative
feeling of others, ideas of reference, derealization, may act
inappropriately , claim of having special abilities, illusion.
DD / SR, schizoid pers dis
Lifelong , 10 % committed suicide, SR.
Psychotherapy : do not ridicule pt strange activities
Pharmacotherapy : haloperidol, antidepressant

Dissocial ( antisocial * )
3 % of men , 1 % of women in the gen. pop. ( 75 % of prison pop); poor
urban areas ( mobile residents); onset < 15 y.o.a.
Composed, credible, charming, ingratiating, lying, truancy, running away
from home, thefts, fights, substance abuse, illegal activities
(beginning in childhood) , seductive, manipulative, demanding,
untrustworthy, spouse & child abuse, promiscuity, no anxiety /
depression / remorse, abn EEG, soft neurological signs
DD / Criminality, MR, SR, Affective dis (mania)
Unremitting course (peak : adolescence )
Psychotherapy : firm limits.
Pharmacotherapy : cautiously
(anti anxiety, antidepressant, psychostimulants , DA, anti epileptic )

Emotionally unstable pers dis : Impulsive,

Borderline
( Borderline* )
1 - 2 % of the gen pop. M : F = 1 : 2
In the border between neurosis & psychosis (panphobia , pananxiety ,
panambivalence , chaotic sexuality) , almost always in state of crisis,
extraordinary unstable affect-mood - behaviour - self image , mood
swings, micro psychotic episodes, highly unpredictable behaviour, self
destructive acts, tumultuous interpersonal relations, frantic need of
companionship, feeling of emptiness, boredom , depression .
DD/ SR , schizotypal pers. dis.
Change little over time
Psychotherpy ( individual , group : hospital setting ), behaviour therapy
Pharmacotherapy : anti - psychotics, - depressant - convulsant .

 Impulsive type : emotional instability, lack of impulse

control; outburst of violence or threatening behaviour are
common, esp. in response to criticism by others
(explosive personality dis)
Borderline type

Histrionic
2-3% of gen pop
Attention seeking behaviour, excitable, emotional,
colorful, dramatic, extroverted, exagerate thoughts &
feelings, dependent, superficial-manipulative
relationships, seductive, but usually also have
psychosexual dysfunction; under stress, reality testing
easily impaired
DD/ Borderline pers dis, somatization dis
Age , symptoms (lack of energy); sensation seekers
trouble with the law, PAS abuse, promiscuity
Psychotherapy
Pharmacotherapy : antidepressant, antianxiety,
antipsychotic

Anankastic/Obsessive-Compulsive
M > F; 1st degree biol relatives
Harsh childhood discipline
Emotional constriction, stubbornness, indecisiveness,
fear of making mistakes, pervasive pattern of
perfectionism & inflexibility, preoccupied with rules,
regulations, orderliness, neatness, details and the
achievement of perfection, limited interpersonal skills &
relations
DD/ OCD traits
Course variable, unpredictable, enjoy detailed
predictable work, vulnerable to unexpected changes
(SR, major depressive dis)
Psychotherapy (long, complex); group th/, behaviour th/
Pharmaco th/ clomipramine, SSRI

Anxious/Avoidant
1-10% of gen pop
Timid, shy, hypersensitive to rejection, criticism, lack
of self-confidence, inferioriy complex, socially
withdrawn life, avoid social/occupational activities that
involve significant interpersonal contact because of
fear of criticism, disapproval or rejection
DD/ Schizoid, Dependent per dis
Need protective-supportive environment
Psychoth/ : allianceship, assertiveness training
Pharmacoth/ : beta blockers

Dependent
2.5% of pers dis, F > M
Pervasive dependency & submissiveness, lack of selfconfidence, self-doubt, pessimistic, passive, fear to
express sexual-aggressive feelings, let others make
most of the important life decisions, limited capacity to
make everyday decisions, feel helpless when alone
DD/ Histrionic, Borderline pers dis; Agoraphobia
Impaired occupational functioning, limited social
relations
Psychotherapy, Behaviour th/
Pharmacoth/: antianxiety, SSRI

Others
Narcissistic
< 1% of gen pop
Heightened sense of self-importance & uniqueness
need special treatment, unable to tolerate critics,
ambitious for fame and fortune, superficial-exploitative
relationships, fragile self-esteem depression
DD/ Borderline, Histrionic, Antisocial pers dis
Chronic, aging is handled poorly
Psychotherapy
Pharmacoth/ : lithium, SSRI

Passive-aggressive
Covert obstructionism, procrastination, stubbornness,
resist demands for adequate performance, find
excuses for delays, inefficient, blaming others, lack of
assertiveness, needs-wishes-goals are not clear,
punitive-manipulative style of relationships, lack of
self-confidence, pessimistic
DD/ Histrionic, Borderline, pers dis
Mostly will have persistent psychiatric problems
(irritability, anxiety, depression, somatic complaints)
Psychoth/ : supportive
Pharmacoth/ : antidepressant, bzd, psychostimulant

Depressive
M=F
Early loss, poor parenting, punitive SE, guilt feelings
>>, abn adrenergic & serotonergic system, genetic
predisposisition
Chronic feelings of unhappiness, self-crtitical, selfderogatory, pessimistic, anhedonic, poor posture,
depressed facies, hoarse voice, psychomotor
retardation
DD/ Dysthymic dis, Avoidant pers dis
Higher rates of mood dis
Psychoterapy (longterm)
Pharmacoth/ : SSRI, psychostimulant

Sadomasochistic
Sadism : a desire to cause others pain by sexually
abusive or generally physically/psychologically
abusive
Masochism : achievement of sexual gratification by
inflicting (physical/psychological) pain to ownself
A person who has the elements of both sadistic &
masochistic behaviour
Psychotherapy
Sadistic
Pervasive pattern of cruel, demeaning & aggressive
behaviour toward others, not motivated solely by
sexual motives
Fascinated by violence, weapons, injury or torture

F 62 Enduring personality changes, not attributable

to brain damage and disease
Criteria, ICD 10-PPDGJ 3
Develop following catastrophic/excessive prolonged
stress or following a severe psychiatric illness, in
people with no previous personality dis definite,
enduring change in a persons pattern of perceiving,
relating to, or thinking about the environment and the
self inflexible, maladaptive behaviour

After catastrophic experience

A hostile, mistrust attitude towards the world, social
withdrawal, feelings of emptiness, hopelessness, a
chronic feeling of as if constantly threatened,
estrangement
After psychiatric illness
Excessive dependence on and demanding attitude
towards others, conviction of being changed, leading
to social isolation, passivity, reduced interest (incl in
leisure activities), persistent complaints of being ill
(hypochondriacal claims), dysphoric/labile mood,
impairment in social & occupational functioning
The above manifestations must have been present for a
period of 2 years or more

F 63 Habit and impulse disorder

Criteria
ICD 10-PPDGJ 3
Uncontrollable repeated acts that have no clear rational
motivation and that generally harm the patients own
interests and those of other people
DSM IV
Patients do not resist impulses, drives or enticements to
do something harmful to themselves or to others
Pt may/may not try to resist the impulses and plan
their behaviours
Before the act : increase tension; afterward : feelings
of pleasure, satisfaction, +/- remorse, guilt
Ego-syntonic

Etiology
Psychodynamic
To decrease tension related to heightened instinctual
drives/diminished ego defenses
To master anxiety, guilt, depression & other painful
affects by means of action
Weak SE, E due to childhood deprivation
Biological
Limbic sys abn, testosterone, temporal lobe epilepsy:
violent, aggressive and impulsive behaviour
ADHD; abn of SE,DA,NA-ergic system
Psychosocial
Early life events : improper model for identification
and parental figures

Types
Pathological gambling
1-3% of gen pop (USA), M > F
Persistent recurrent maladaptive gambling behaviour
preoccupation with gambling despite the consequences
(family, social, monetary, vocational, legal problems)
Early loss (<15 yrs), inappropriate parental discipline,
exposure to gambling activity, family emphasis on
material-financial symbols, catecholamine & SE abn
DD/ Social gambling, Manic episodes, Antisocial pers
dis
Onset in adolescence (M) or late in life (F) : chronicity
3 phases of gambling : winningprogressive
lossdesperate (15 yrs)totally deteriorated (2 yrs)
Th/ Gamblers Anonymous; hospitalization (3 mos, prep.
for psychoth/), SSRI, lithium, clomipramine

Pathological fire-setting (pyromania)

M > F, mildly retarded, antisocial traits
Deliberate-purposeful fire-setting on more than one
occasion due just to fascination with, interest in,
curiousity about or attraction to fire and the activities and
equipment associated with fire fighting not related to
monetary, sociopolitical, criminal reasons or vengeance
Sexual excitation, abn craving for power, symbol of
braveness, compensation for inferiority complex, longing
for (an absent) father
DD/ Conduct dis, Antisocial pers dis, SR, Brain dysfunct
Onset usually in childhood (high recurrency); if treated
prog is better than if the onset is in
adolescence/adulthood
Th/ Incarceration : behaviour th/; children: intensive
intervention

Pathological stealing (kleptomania)

3.8%-24% of arrested shoplifters, F > M
Recurrent intrusive, irresistible urges to steal
(unplanned) not needed, not valuable objects
(returned surreptitiously, discarded, hoarded) the
act of stealing is the ultimate goal, not the object
Losses, separations, endings of important
relationships, feelings of being neglected, unwanted,
symbolism (sexual act, aggression, oneness of
mother-child etc), brain dis, mental retardation
DD/ Stealing, Malingering, SR
Begin in childhood, tends to be chronic
Psychoth/, behaviour th/, SSRI, tricyclics, ECT

Trichotillomania
F>M
Recurrent failure to resist impulses to pull out hairs
which can cause noticeable hair loss
Onset related to stressful situations; disturbance of
mother-child relationships, fear of being left alone,
recent object loss, depression, self stimulation
DD/ OCD, Factitious dis
Generally begins in childhood/adolescence; late
onset may be associated with chronicity
Psychoth/, behaviour th/, hypnoth/, SSRI, lithium,
anxiolytic with antihistamine properties

Others
Intermittent explosive disorder
M>F
Discrete episodes of losing control of aggressive
impulses which are grossly out of proportion to any
precipitating stressors, followed by sincere regret/selfreproach
Unfavorable childhood environment, brain damage,
decreases in serotonergic transmission
Psychoth/, anticonvulsant, SSRI, neurosurgery (?)
Oniomania
F>M
Compulsive buying; low self-esteem, anxiety, reduce
stress
Psychoth/, Debtors Anonymous, antipsychotic,
antianxiety, antidepressant, SSRI

F 64 Gender identity disorder

Gender identity is a psychological state that reflects the
selfs sense of being male or female
Assigned sex is how a person reared sexually; gender
identity is consonant with sex of rearing
Gender role is everything that people say and do
(external behavioural pattern that reflects a persons
inner sense of gender identity) to indicate they are
male or female; usually gender identity is match with
gender role
Sex/biological sex is the anatomical & physiological
characteristics that indicate whether a person is male
or female
Sexual orientation is a persons erotic response
tendency (object choises, erotic fantasies etc)

 A strong & persistent cross-gender identification

Persistent discomfort about ones assigned sex or a
sense of inappropriateness in the gender role of that
sex
Persistent preoccupation with getting rid of their
primary & secondary sex characteristics and with
acquiring the sex characteristics of the other sex
The wish to dress and live as a member of the other
sex

 M>F
E/
Biological
Resting tissue is initially F; maleness & masculinity
depend on fetal & perinatal androgens
Psychosocial
Assigned sex; culturally acceptable gender roles
(learned); resolution of Oedipal complex; parenthood
problems (hostile mothering, rejected/abuse children;
absence of mother/father figures)
Clinical features
Children : boysh girl, girly boys; claim & wish to be the
opposite sex completely

Adolescent & adult: continuation of the childhood claim

& wish, plus the desire to live & treated as the other
sex and the desire to acquire the sex characteristics
of the opposite sex (I feel that Im a woman trapped
in a male body or vice versa) ask for hormonal
th/, sex surgery
Sexual object choice : M, F, both, neither
Homosexuality develop in 1/3 - 2/3 of cases; < 10%
become transsexual; impaired social, occupational
functioning; depression
Th/ role model behaviour; parental counseling;
psychoth/ (be comfortable with the desired gender
identity); hormonal treatment (changes of secondary
sex characteristics); sex reassignment surgery :
definitive cross gender living 3 mos-1 yr &
hormonal treatment 50% still want surgery

Types
Transsexualism
A persistent desire (at least 2 yrs) to live and be accepted
as a member of the opposite sex, usually accompanied
by a sense of discomfort with ones anatomic sex and
wish to have hormonal th/ & surgery to be as congruent
as possible with the preferred sex
Dual-role transvestism
The wearing of clothes of the opposite sex in order to
enjoy temporary experience of being the other sex, with
no desire for (permanent) sex change, also no sexual
excitement accompanies the cross-dressing
Gender identity of childhood
Persistent, intense distress about assigned sex & a desire
to be the other sex, usually first manifest during early
childhood

F 65 Disorders of sexual preference (paraphilias)

Criteria
Unusual fantasies or sexual urges or behaviours that are
recurrent and sexually arousing, and an intense urge to
act out the fantasy, occur at least 6 mos, cause
clinically significant distress/impairment in social,
occupational or other important areas of functioning
(can involve illegal activities) a special fantasy is the
pathognomonic element; sexual arousal & orgasm are
associated phenomena
M >>; 50% onset before age 18, peaks between 15-25
E/ Psychosocial: Failure to complete normal
psychosexual dev; early sexual experience; modeling,
mimicking
Biological : abn hormonal levels, chromosomal
abn, soft neurological signs

 DD/ Experimental act, foreplay, brain disease

Early onset, high frequency, no remorse/shame,
substance abuse : poor prognosis
Th/ Individual psychoth/, group th/ behaviour th/.
antipsychotics, antidepressants, antiandrogen
Types
Exhibitionism
M
Recurrent urge to expose the genital to a stranger or
unsuspecting person (opposite sex); orgasm is
brought by masturbation during or after the event
To assert masculinity : showing fright, surprise
reaction of the spectators

Fetishism
M
Sexual focus are objects intimately associated with
human body (shoes, gloves, panties, bras, stockings),
sometimes with a particular texture (rubber, leather,
plastic)
Orgasm reached by masturbation with/into the objects
or the objects incorporated into sexual intercourse
The objects are symbol of phallus, associated with
sexual stimulation at an early age
Transvestic fetishism
Fantasies & sexual urges to wear the opposite sex
clothing for arousal & adjunct to masturbation/coitus
M > F ; begins in childhood/early adolescence, crossdressing may become permanent; overt symptoms :
since latency, mostly at pubescence/adolescence

Voyeurism (scopophilia)
Recurrent preoccupation with fantasies and acts to
look at people who are naked or engaging in grooming
or sexual activity (without the observed people being
aware), usually followed with masturbation to orgasm
Mostly M, first act usually during childhood
Paedophilia
Recurrent, intense sexual urges toward/arousal by
prepubertal/early pubertal children, for at least 6 mos
(the perpetrator aged 16 yrs/more, at least 5 yrs older
than the victim); mostly M
Genital fondling, oral sex
95% perpetrators are heterosexual, 60% victims are
boys; some perpetrators are interested only to girls,
some to boys and some in both sexes

Sadomasochism
A preference for sexual activity that involves
bondage, infliction of pain or humiliation; M > F
Prefer to be the recipient : masochism childhood
experience, that pain is a prerequisite for pleasure
Prefer to be the provider : sadism defense against
fears of castration
Contributory causes : hereditary predisposition,
hormonal malfunctioning, pathological relationships,
a history of sexual abuse, having other mental illness

Others
Frotteurism
M, passive, isolated
Penis (hands) rubbed against the buttocks or other
part of a fully cloth woman to achieve orgasm
Telephone and computer scatologia
M ; obscene phone calling to unsuspecting person +
masturbation
Necrophilia
Obsession of obtaining sexual gratification from
corpses inflicting the greatest humiliation to the
lifeless victims: psychosis ?
Partialism, oralism
Oral sex is the only source of sexual gratification;
no coitus

Zoophilia
Animals are preferentially incorporated into arousal
fantasies or sexual activities
Coprophilia & Klismaphilia
Attraction to sexual pleasure associated with the
desire to defecate on a partner, to be defecated on,
or to eat feces (coprophagia) or compulsive utterance
of obscene words (coprolalia)
Use of enemas as part of sexual stimulation
fixation at anal stage
Urophilia
Interest in sexual pleasure associated with the desire
to urinate on a partner or to be urinated on; may be
associated with masturbatory technique (insertion of
foreign objects into the urethra for sexual stimulation)

Masturbation
Achieving sexual pleasure-orgasm by ownself is
prefered than sex with a partner
Hypoxyphilia
Desire to achieve an altered state of consciousness
due to hypoxia while experiencing orgasm

F 66 Psychological and behavioural disorders

associated with sexual development and
orientation
Sexual maturation disorder
Uncertainity about gender identity/sexual orientation
anxiety, depression
Egodystonic sexual orientation
Dissatisfaction with sexual (homosexual) arousal
pattern
a desire to increase heterosexual arousal
strong negative feelings of being homosexual
Sexual reorientation (psychoth/ behaviour th/), or be a
happy homosexual

F 68 Other disorders of adult personality and

behaviour
Elaboration of physical symptoms for psychological
reasons (Compensation neurosis)
Elaboration of physical symptoms for psychological
reasons
Physical symptoms due to a confirmed physical
disorder /disease/disability become
exaggerated/prolonged dissatisfaction with the
result of treatment, disappointment with the personal
attention received in wards/clinics, possibility of
financial compensation

Intentional production or feigning of symptoms or

disabilities, either physical or psychological
(Factitious disorder, Munchhausens syndrome
Characterized by physical (cuts, abrasion, self injection
of toxic substance etc) or psychological symptoms that
are intentionally produced or feigned to assume the sick
role
No external incentive; hospitalization is the primary
objective
M > F; 9% among hospitalized patient
Childhood abuse, deprivation frequent hospitalization
hospitalization is an escape from traumatic home
situation and a place to find loving, caring caretakers
DD/ Malingering : intentional production or feigning of
physical/psychological symptoms/disabilities for certain
incentive (monetary)