PERSONALITY DISORDER

What is a Personality Disorder?
A deeply ingrained and maladaptive pattern of behaviour of a specified kind, typically apparent by the time of adolescence, causing long-term difficulties in personal relationships or functioning in the society.

Types of Personality Disorders

• • Cluster A (Odd, bizarre, eccentric) – Paranoid PD, Schizoid PD, Schizotypal PD
  • Cluster B (Dramatic, erratic) – Antisocial PD, Borderline PD, Histrionic PD, Narcissistic PD
  • Cluster C (Anxious, fearful) – Avoidant PD, Dependent PD, Obsessive-compulsive PD

The majority of people with a personality disorder never come into contact with mentalhealth services, and those who do usually do so in the context of another mental disorder or at a time of crisis, commonly after self-harming or breaking the law.

Nevertheless, personality disorders are important to health professionals because they predispose to mental disorder, and affect the presentation and management of existing mental disorder. They also result in considerable distress and impairment, and so may need to be treated ‘in their own right’

Cluster – A

Paranoid personality disorder

Paranoid personality disorder is characterized by a pervasive distrust of others, including even friends, family, and partner. As a result, the person is guarded and suspicious, and constantly on the lookout for clues or suggestions to validate his fears. He also has a strong sense of personal rights, is overly sensitive to setbacks and rebuffs, easily feels shame and humiliation and persistently bears grudges. He tends to withdraw from others and to struggle with building close relationships. The principal ego defense in paranoid PD is projection, which involves attributing one’s unacceptable thoughts and feelings to other people. A large long-term twin study found that paranoid PD is heritable and that it shares a portion of its genetic and environmental risk factors with schizoid PD and schizotypal PD.

Schizoid personality disorder

The term ‘schizoid’ designates a natural tendency to direct attention toward one’s inner life and away from the external world. A person with schizoid PD is detached and aloof and prone to introspection and fantasy. He has no desire for social or sexual relationships, is indifferent to others and to social norms and conventions, and lacks emotional response. They experience a deep longing for intimacy but find initiating and maintaining close relationships too difficult or distressing and so retreat into their inner world. People with schizoid PD rarely present to medical attention because, despite their reluctance to form close relationships, they are generally well functioning, and quite untroubled by their apparent oddness

Schizotypal disorder

Schizotypal PD is characterized by oddities of appearance, behavior, speech, unusual perceptual experiences, and anomalies of thinking similar to those seen inschizophrenia. It includes odd beliefs, magical thinking (for instance, thinking that speaking of the devil can make him appear), suspiciousness, and obsessive ruminations. People with schizotypal PD often fear social interaction and think of others as harmful. This may lead them to develop so-called ideas of reference, that is, beliefs or intuitions that events and happenings are somehow related to them. So whereas people with schizotypal PD and people with schizoid PD both avoid social interaction, with the former it is because they fear others, whereas with the latter it is because they have no desire to interact with others or find interacting with others too difficult. People with schizotypal PD have a higher than average probability of developing schizophrenia and the condition used to be called ‘latent schizophrenia’.

Cluster – B

Antisocial personality disorder

Antisocial PD is much more common in men than in women and is characterized by a callous unconcern for the feelings of others. The person disregards social rules and obligations, is irritable and aggressive, acts impulsively, lacks guilt and fails to learn from experience. In many cases, he has no difficulty finding relationships—and can even appear superficially charming (the so-called ‘charming psychopath’)—but these relationships are usually fiery, turbulent, and short-lived. As antisocial PD is the mental disorder most closely correlated with crime, he is likely to have a criminal record or a history of being in and out of prison.

Borderline personality disorder

In borderline PD (or emotionally unstable PD), the person essentially lacks a sense of self and as a result experiences feelings of emptiness and fears of abandonment. There is a pattern of intense but unstable relationships, emotional instability, outbursts of anger and violence (especially in response to criticism), and impulsive behaviour. Suicidal threats and acts of self-harm are common, for which reason many people with borderline PD frequently come to medical attention. It has been suggested that borderline personality disorder often results from childhood sexual abuse, and that it is more common in women in part because women are more likely to suffer sexual abuse.

Histrionic personality disorder

People with histrionic PD lack a sense of self-worthand depend for their wellbeing on attracting the attention and approval of others. They often seem to be dramatizing or ‘playing a part’ in a bid to be heard and seen. People with histrionic PD may take great care of their appearance and behave in a manner that is overly charming or inappropriately seductive. As they crave excitement and act on impulse or suggestion, they can place them- selves at risk of accident or exploitation. Their dealings with others often seem insincere or superficial, which, in the longer term, can adversely impact their social and romantic relationships. This is especially distressing to them, as they are sensitive to criticism and rejection, and react badly to loss or failure. A vicious circle may take hold in which the more rejected they feel, the more histrionic they become; and the more histrionic they become, the more rejected they feel.

Narcissistic personality disorder

In narcissistic PD, the person has an extreme feeling of self-importance, a sense of entitlement, and a need to be admired. He is envious of others and expects them to be the same of him. He lacks empathy and readily exploits others to achieve his aims. To others, he may seem self-absorbed, controlling, intolerant, selfish, or insensitive. If he feels obstructed or ridiculed, he can fly into a fit of destructive anger and revenge. Such a reaction is sometimes called ‘narcissistic rage’, and can have disastrous consequences for all those involved.

Cluster – C

Avoidant personality disorder

People with avoidant PD believe that they are socially inept, unappealing, or inferior, and constantly fear being embarrassed, criticized, or rejected. They avoid meeting others unless they are certain of being liked, and are restrained even in their intimate relationships. Avoidant PD is strongly associated with anxiety disorders, and may also be associated with actual or felt rejection by parents or peers in childhood. Research suggests that people with avoidant PD excessively monitor internal reactions, both their own and those of others, which prevents them from engaging naturally or fluently in social situations. A vicious circle takes hold in which the more they monitor their internal reactions, the more inept they feel; and the more inept they feel, the more they monitor their internal reactions.

Dependent personality disorder

Dependent PD is characterized by a lack of self-confidence and an excessive need to be looked after. The person needs a lot of help in making everyday decisions and surrenders important life decisions to the care of others. He greatly fears abandonment and may go through considerable lengths to secure and maintain relationships. A person with dependent PD sees himself as inadequate and helpless, and so surrenders personal responsibility and submits himself to one or more protective others. Overall, people with dependent PD maintain a naïve and child-like perspective, and have limited insight into themselves and others. This entrenches their dependency, and leaves them vulnerable to abuse and exploitation.

Anankastic/ Obsessive Compulsive personality disorder

Anankastic PD is characterized by excessive preoccupation with details, rules, lists, order, organization, or schedules, perfectionism so extreme that it prevents a task from being completed and devotion to work and productivity at the expense of leisure and relationships. A person with anankastic PD is typically doubting and cautious, rigid and controlling, humorless, and miserly. His underlying anxiety arises from a perceived lack of control over a world that eludes his understanding; and the more he tries to exert control, the more out of control he feels. In consequence, he has little tolerance for complexity or nuance, and tends to simplify the world by seeing things as either all good or all bad. His relationships with colleagues, friends, and family are often strained by the unreasonable and inflexible demands that he makes upon them.

When rules and established procedures do not dictate the correct answer, decision making may become a time-consuming, often painful process. Individuals with Obsessive-Compulsive Personality Disorder may have such difficulty deciding which tasks take priority or what is the best way of doing some particular task that they may never get started on anything.

Age of onset -Onset usually occurs during adolescence or in early adulthood. Anti-social personality disorder is frequently found among prisoners (up to 50%). Of hospitalizations for personality disorders in general hospitals, 78% are among young adults between 15 and 44 years of age.

Causes

Broadly speaking, there are two interrelated factors that contribute to the development of people’s personality, and therefore, to the development of personality disorders. These are:

Biological factors -meaning people’s genetic make-up and temperament, and

Environmental factors -meaning people’s life experiences, particularly early childhood experiences.

People’s genetics and their early life experiences interact in complex ways to influence the development of their personalities and subsequently, their vulnerability to the development of personality disorders. This interaction between people’s biological, genetic dispositions and their environmental, life experience is often referred to as the “nature-nurture” dynamic.

People’s genetics and their early life experiences interact in complex ways to influence the development of their personalities and subsequently, their vulnerability to the development of personality disorders. This interaction between people’s biological, genetic dispositions and their environmental, life experience is often referred to as the “nature-nurture” dynamic.

• Bio psychosocial Model -This model suggests that biological, psychological and social factors all come together to explain the development of personality disorder

Biology + psychology + social factors = personality disorder.

• Biology -Genetic factors make an individual more vulnerable to developing PD. Genes are also thought to determine personality traits and these become exaggerated or amplified in a personality disorder.
• Psychological factors – It emphasizes on the role of traumatic experiences in childhood and difficult, dysfunctional family environments. One study found a link between the number and type of childhood traumas and the development of personality disorders.
• Social factors – The broader social setting or society in which people live is crucial in the development of personality disorder. Personality disorders are more commonly seen among people who have a biological vulnerability and have experienced abuse, mistreatment and/or family dysfunction (i.e. psychological factors).
• Verbal Abuse -Children who had experienced such verbal abuse were three times as likely as other children to have borderline, narcissistic, obsessive-compulsive or paranoid personality disorders in adulthood.

Treatment Approaches

• • Psychopharmacological Treatment – Medications should be viewed as an adjunct to psychotherapy so that the patient may productively engage in psychotherapy. However, medications may be prescribed to treat associated problems, such as depression, anxiety or psychotic symptoms.For example, if you have moderate to severe symptoms of depression that make it difficult to approach your therapy with confidence or enthusiasm, you may be prescribed a type of antidepressant called a selective serotonin reuptake inhibitor (SSRI).Some people, especially those with BPD, have found mood-stabilizing medication helpful.
  • Psychotherapy -Psychotherapy is at the core of care for personality disorders. Because personality disorders produce symptoms as a result of poor or limited coping skills, psychotherapy aims to improve perceptions of and responses to social and environmental stressors. It is a treatment that involves discussion of thoughts, emotions and behaviours with a trained professional. The aim of all psychological therapies is to improve people’s ability to regulate their thoughts and emotions.
    1. • Cognitive Behaviour Therapy (CBT) – Cognitive therapy (also called cognitive behavior therapy [CBT]) is based on the idea that cognitive errors stemming from long-standing beliefs influence the meaning attached to interpersonal events. It deals with how people think about their world and with their perception of it. This very active form of therapy identifies the distortions and engages the patient in efforts to reformulate perceptions and behaviors. CBT is typically limited to once-weekly treatments over a period of 6-20 weeks. In the case of personality disorders, such episodes of therapy are repeated often over the course of years.
       • Dialectical behaviour therapy (DBT) – It offers group therapy alongside individual treatment and can be very effective, especially with BPD. DBT teaches new skills to help you manage emotions, such as distress, and improve the way you interact with others. It helps change the behaviour that causes you most problems so you can deal better with day-to-day crises.
       • Psychodynamic psychotherapy -It examines the ways that patients perceive events, based on the assumption that perceptions are shaped by early life experiences. Psychotherapy aims to identify perceptual distortions and their historical sources and to facilitate the development of more adaptive modes of perception and response. Treatment is usually extended over the course of several years at a frequency ranging from several times a week to once a month.
       • Interpersonal therapy (IPT) -It is based on the idea that patients’ difficulties result from a limited range of interpersonal problems, including such issues as role definition and grief. Current problems are interpreted narrowly through the screen of these formulations, and solutions are framed in interpersonal terms. Therapy is usually weekly for a period of 6-20 sessions.
       • Group psychotherapy -Group psychotherapy allows interpersonal psychopathology to display itself among peer patients, whose feedback is used by the therapist to identify and correct maladaptive ideas, communication, and behavior. Sessions are usually once weekly over a course that may range from several months to years.

    Risk Factors for Personality Disorders

    Certain factors seem to increase the risk of developing or triggering personality disorders, including:

    • • Family history of personality disorders or other mental illness
      • Low level of education and lower social and economic status
      • Verbal, physical or sexual abuse during childhood
      • Neglect or an unstable or chaotic family life during childhood
      • Being diagnosed with childhood conduct disorder
      • Variations in brain chemistry and structure
      • Loss of parents through death or traumatic divorce during childhood

    Protective factors for preventing PD

    • • • Easy temperament
        • Good social and emotional skills
        • Positive coping style
        • Optimistic outlook on life
        • Good attachment to parents or carers
        • Family harmony and stability
        • Supportive parenting
        • Strong family values
        • Consistency (firm boundaries and limits)
        • Positive school climate
        • Sense of belonging and connectedness between family and school
        • Strong cultural identity and pride

    WHEN TO SEE A DOCTOR / PSYCHOLOGIST??

    I Always Felt Different From Others And Had No Sense Of Belonging Anywhere. My Life Was Always Chaotic, As Were My Feelings – Never Consistent Or Stable, But Changeable And Unpredictable. I Felt Like An Outcast Of Society – Undeserving Of Anything. I Secretly Longed For A Better Way Of Life, But Didn’t Know How To Achieve It And Lacked Confidence That I Could Change.

    If you have any such feelings, signs or symptoms, see your doctor / psychologist, mental health provider or other health care professional. Untreated, personality disorders can cause significant problems in your life that may get worse without treatment.

    MUMBAI PSYCHIATRY CLINICS

    We at Mumbai Psychiatry Clinics have a dedicated team of counsellors and clinical psychologists who will help you with your problems, cite interventions and assess the progress on regular intervals. There are experienced psychiatrists who will be guiding you throughout your journey and our Multidisciplinary team will try to assure you with the best help possible.

    We at Mumbai Psychiatry Clinics have a dedicated team of counsellors and clinical psychologists who will help you with your problems, cite interventions and assess the progress on regular intervals. There are experienced psychiatrists who will be guiding you throughout your journey and our Multidisciplinary team will try to assure you with the best help possible.

    References

    https://www.mind.org.uk/information-support/types-of-mental-health-problems/personality-disorders/#.Vm_gItJ97IU
    https://www.mentalhelp.net/articles/what-causes-personality-disorders/
    https://psychcentral.com/disorders/obsessive-compulsive-personality-disorder-symptoms
    Social Factors in the Personality Disorders

    What causes PD- Mentalhelp.net

    “Where Personality Goes Awry” APA monitor on Psychology

    Personality Disorders Treatment & Management