Normal Personality Development and Personality s Learning Objectives Be able to describe the various personality disorders Be able to apply the personality disorder categories to patient scenarios Janet E. Johnson, MD, MPH Tulane University School of Medicine Department of Psychiatry and Behavioral Sciences Personality Defined as the totality of emotional and behavioral traits that characterize the person in day-to-day living under ordinary conditions. Usual manner of thinking, feeling, behaving and relating to others Relatively stable and predictable. Blend of inborn temperament, genetic strengths and vulnerabilities, and impact of positive and negative life experiences. Normal Personality Development Second half of 1 st year: attachment Internalization: mechanism for building psychological structure Stable pattern of a child s temperament becomes established during second year. Nature versus nurture? Behavioral genetics revealing pervasive genetic influences on normal and abnormal personality. What is Normal? Who s Normal? Who s to say? Circumstances, culture/sub-culture, setting/location, timing, age 1
Who s Normal? Personality assessment Meyers-Brigg Five Factor Model Cloninger s Seven-Factor Model Biogenic Spectrum Model Myers Brigg Questionnaire designed to measure psychological preferences in how people perceive the world and make decisions. Widely utilized Extrapolated from Jung s theories. Two pairs of cognitive functions: Rational functions: thinking and feeling Irrational functions: sensing and intuition Dichotomies Extraversion (E) (I) Introversion Sensing (S) (N) Intuition Thinking (T) (F) Feeling Judgment (J) (P) Perception 16 possible types Example: ESTJ Five Factor Model Neuroticism (anxiety, depression, vulnerability, hostility) Extraversion (warmth, assertiveness, activity, gregariousness) Openness (feelings, fantasy, ideas, values) Agreeableness (trust, altruism, modesty) Conscientiousness (dutifulness, selfdiscipline, deliberation) Seven-Factor Model of Temperament and Character Harm avoidance Reward dependence Novelty seeking Persistence Character factor Self-directedness Cooperativeness Self-transcendence 2
Temperament Factors (harm avoidance, reward dependence, novelty seeking, persistence Independently heritable Manifested early in life Involved in perceptual memory and habit formation Associated with biologic features Novelty seeking decreased dopaminergic activity Harm Avoidance -> high serotonergic activity Reward dependence low noradrenergic activity Personality s A personality disorder is a variant of those character traits that goes beyond the range found in most people. When personality traits are inflexible and maladaptive and cause either significant functional impairment or subjective distress they constitute a class of personality disorder. Patients with personality disorders show deeply ingrained, inflexible, and maladaptive patterns of relating to and perceiving both the environment and themselves General Diagnostic Criteria General Diagnostic Criteria An enduring pattern of inner experience and behavior that deviates markedly from the expectation of the individual s culture. The pattern is manifested in two or more of the following areas: Cognition (perceiving and interpreting self, other people and events) Affectivity (range, intensity, lability appropriateness of emotional response) Interpersonal functioning Impulse control The enduring pattern is inflexible and pervasive across a broad range of personal and social situations. The enduring pattern leads to clinically significant distress or impairment in social, occupational or other important areas of functioning. The pattern is stable and of long duration, and its onset can be traced back at least to adolescence or early adulthood. The enduring pattern is not better accounted for as a manifestation or consequence of another mental disorder. The enduring pattern is not due to the direct effects of a substance or a general medical condition. Personality s Personality s More likely to refuse psychiatric help than other psychiatric disorders Ego-syntonic Regarded as unmotivated for treatment Grouped into three clusters: A, B, C Other: Not otherwise specified and mixed Diagnosed on Axis II Elevated rates of divorce, unemployment, homelessness, perpetration of child abuse, child custody proceedings, separation Common in general population Prevalence of 10-18% Outpatient 30-50% Inpatient > 50% co-morbidity Males and females equal overall Etiology Genetics Psychoanalytic theories Freud: psychosexual development Reich: defense mechanisms 3
Common Defense Mechanisms Projection Splitting Regression Fantasy Dissociation Intellectualization Isolation Reaction formation Repression Acting out Passive aggression Cluster A: Paranoid, Schizoid, Schizotypal Odd, eccentric ( weird ) Key clinical features: social deficits, absence of close relationships Treatment: structure, rehabilitation, support, medication Course: stable Prognosis: poor Genetics: More common in the biological relatives of schizophrenic patients than among control groups. Paranoid Personality Paranoid Diagnostic Criteria Pervasive distrust and suspiciousness of others such that their motives are interpreted as malevolent, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following: Suspects, without sufficient basis, that others are exploiting, harming, or deceiving him or her. Is preoccupied with unjustified doubts about the loyalty or trustworthiness of friends/associates. Is reluctant to confide in others because of unwarranted fear that the information will be used maliciously against him or her. Reads hidden demeaning or threatening meanings into benign remarks or events. Persistently bears grudges, i.e., is unforgiving of insults, injuries, or slights. Paranoid Diagnostic Criteria Paranoid Personality Perceives attacks on his or her character or reputation that are not apparent to others and is quick to react angrily or to counterattack. Has recurrent suspicions, without justification, regarding fidelity of spouse or sexual partner. Does not occur exclusively during the course of schizophrenia, a mood disorder with psychotic features, or another psychotic disorder, and is not due to the direct physiological effects of a general medical condition. Characterized by long-standing suspiciousness and mistrust of people in general. Refuse responsibility for their own feelings; are often angry, hostile, irritable. Bigot, injustice collector, pathologically jealous spouse, litigious crank Prevalence 0.5-2.5 % Male > female Differential diagnosis: schizotypal pd, schizophrenia, delusional d/o Antipsychotic meds sometimes useful 4
Schizoid Personality Schizoid Diagnostic Criteria detachment from social relationships and a restricted range of expression of emotions in interpersonal settings, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following: Neither desires nor enjoys close relationships, including being part of a family. Almost always chooses solitary activities. Has little, if any, interest in having sexual experiences with another person. Takes pleasure in few, if any, activities. Lacks close friends or confidents other than first-degree relatives. Appears indifferent to the praise or criticism of others. Shows emotional coldness, detachment, or flattened affectivity. Schizoid Personality 1-7.5% of population Males diagnosed 2x females Intact reality testing Most function relatively well, generally do not require clinical intervention Psychotherapy treatment of choice (supportive), but rarely seek treatment Differential diagnosis: schizotypal pd, avoidant pd Schizotypal Personality social and interpersonal deficits marked by acute discomfort with, and reduced capacity for, close relationships, as well as by cognitive or perceptual distortions and eccentricities of behavior, beginning by early adulthood and present in a variety of contexts: Schizotypal Diagnostic Criteria Indicated by five or more of the following: Ideas of reference. Odd beliefs or magical thinking that influences behavior and is inconsistent with sub-cultural norms (superstitiousness, clairvoyance, telepathy). Unusual perceptual experiences, including bodily illusions. Odd thinking and speech (vague, metaphorical, stereotyped, circumstantial). Suspiciousness or paranoid ideation. Inappropriate or constricted affect. Behavior or appearance that is odd, eccentric or peculiar. Schizotypal Personality Lack of close friends or confidants other than first degree relatives. Excessive social anxiety that does not diminish with familiarity and tends to be associated with paranoid fears rather than negative judgments about self. Does not occur exclusively during the course of schizophrenia, a mood disorder with psychotic features, another psychotic disorder or a pervasive developmental disorder. 5
Schizotypal Personality Schizophrenia spectrum disorder Some forms involve biologic abnormalities characteristic of schizophrenia Prevalence: 3% of population Males > females Approximately 10% commit suicide Differential diagnosis: schizophrenia, paranoid pd, schizoid pd, avoidant pd Low dose antipsychotics may be helpful CLUSTER B: Antisocial, Borderline, Narcissistic, Histrionic B for bad Dramatic, emotional, erratic, wild Key clinical features: social and interpersonal instability Treatment: support, exploration, sociotherapy, individual therapy, medication Course: unstable Prognosis: some remission with age Genetics: More family members with mood disorders Group see most frequently in clinical practice Borderline Personality instability of interpersonal relationships, self-image, and affects, and marked impulsivity by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following: Borderline Diagnostic Criteria Frantic efforts to avoid real or imagined abandonment. A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation. Identity disturbance: markedly and persistently unstable self-image or sense of self. Impulsivity in at least two areas that are potentially selfdamaging: (spending, sex, substance abuse, reckless driving, binge eating). Borderline Diagnostic Criteria Recurrent suicidal behavior, gestures, or threats, or selfmutilating behavior. Affective instability due to a marked reactivity of mood. Chronic feelings of emptiness. Inappropriate, intense anger or difficulty controlling anger (frequent displays of temper, constant anger, recurrent physical fights). Transient, stress-related paranoid ideation or severe dissociative symptoms. Borderline Personality Prevalence: 2-3% of the population 2:1 female:male ratio Most prevalent personality disorder in all clinical settings (12-15%) 51% of all inpatients 27% of all outpatients with a personality disorder Increased risk for co-morbid mood disorders, eating disorders, substance abuse, PTSD Up to 10% will have completed suicide by age 30 years Increased prevalence of mood disorders in families of borderline patients 6
Borderline Personality Usually diagnosed by age 40 years Course is variable but rarely changes over time Some patients improve in middle age Treatment: several modes of psychotherapy Dialectical behavioral therapy (DBT) Instill intense counter-transference Differential dx: bipolar disorder, schizotypal pd, histrionic pd, narcissistic pd, dependent pd, psychotic disorders Antisocial Personality Pervasive pattern of disregard for and violation of the rights of others occurring since age 15 years, as indicated by three (or more): Antisocial Diagnostic Criteria Antisocial Diagnostic Criteria Failure to conform to social norms with respect to lawful behaviors as indicated by repeatedly performing acts that are grounds for arrest. Deceitfulness, as indicated by repeated lying, use of aliases, conning others for personal profit,pleasure Impulsivity or failure to plan ahead. Irritability & aggressiveness, as indicated by repeated failure to sustain consistent work behavior or honor financial obligations. Lack of remorse, as indicated by being indifferent to, or rationalizing having hurt, mistreated, or stolen from another. The individual is at least 18 years old. There is evidence of conduct disorder with onset before age 15 years. The occurrence of antisocial behavior is not exclusively during the course of schizophrenia or a manic episode. Antisocial Personality Histrionic Personality Sociopath, morally bankrupt Disregard for rights of others and lack of remorse Prevalence: 3% male; 1% female Up to 75% of prison population Occurs 5x more commonly in first-degree relatives of males with the disorder Variable course Differential dx: other Cluster B pd, substance abuse disorders, mania, mental retardation Difficult if not impossible to treat A pervasive pattern of excessive emotionality and attention seeking, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following: 7
Histrionic Diagnostic Criteria Histrionic Diagnostic Criteria Is uncomfortable in situations in which he or she is not the center of attention. Interaction with others is often characterized by inappropriate sexually seductive or provocative behavior. Displays rapidly shifting and shallow expression of emotions. Consistently uses physical appearance to draw attention to self. Has a style of speech that is excessively impressionistic and lacking in detail. Shows self-dramatization, theatricality, and exaggerated expression of emotion. Is suggestible, i.e., easily influenced by others or circumstances. Considers relationships to be more intimate than they actually are. Histrionic Personality 2-3% of the population Females diagnosed more often Males probably under-diagnosed Variable course, often softens with age Treatment is individual psychotherapy Low dose benzodiazepines are useful for transient emotional states Differential dx: dependent pd, borderline pd, narcissistic pd, somatization disorder Narcissistic Personality grandiosity (in fantasy or behavior), need for admiration, and lack of empathy, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following: Narcissistic Diagnostic Criteria Narcissistic Diagnostic Criteria Has a grandiose sense of self-importance (e.g. exaggerates achievements and talents, expects to be recognized as superior without commensurate achievements). Is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love. Believes that he or she is special and unique and can only be understood by, or should associate with, other special or high-status people. Requires excessive admiration. Has a sense of entitlement, i.e., unreasonable expectations of especially favorable treatment or automatic compliance with his or her expectations. Is interpersonally exploitative, i.e., takes advantage of others to achieve his or her own ends. Lacks empathy, is unwilling to recognize or identify with the feelings and needs of others. Is often envious of others or believes that others are envious of him or her. Shows arrogant, haughty behaviors or attitudes. 8
Narcissistic Personality Overwhelming, pathological self-absorption Primary motivation is power Prevalence unknown; <1% general population, 2-15% clinical population Chronic course Co-morbid mood disorders common Aging ultimate blow to self-esteem, prone to severe midlife crises Treatment individual psychotherapy Do not tolerate group therapy Differential dx: borderline pd, histrionic pd, antisocial pd Cluster C: Avoidant, Dependant, Obsessive-Compulsive Anxious and fearful, ( wimpy ) Key clinical features: interpersonal and intrapsychic conflicts Treatment: exploration, individual therapy, group therapy Course: modifiable Prognosis: good Genetics: More relatives with anxiety disorders Avoidant Personality Avoidant Diagnostic Criteria social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following: Avoids occupational activities that involve significant interpersonal contact, because of fears of criticism, disapproval, or rejection. Is unwilling to get involved with people unless certain of being liked. Shows restraint within intimate relationships because of the fear of being shamed or ridiculed. Is preoccupied with being criticized or rejected in social situations. Is inhibited in new interpersonal situations because of feelings of inadequacy. Avoidant Diagnostic Criteria Avoidant Personality Views self as socially inept, personally unappealing, or inferior to others. Is unusually reluctant to take personal risks or to engage in any new activities because they may prove embarrassing. Pathologically shy Common, 1-10% of population Temperament and disfiguring physical illnesses may be predisposing factors Males = females High risk for anxiety disorders Once assured of acceptance and safety, respond to virtually all forms of therapy. Group therapy, SSRIs, anxiolytics Differential dx: social phobia, dependent pd, schizoid pd 9
Dependant Personality A pervasive and excessive need to be taken care of that leads to submissive and clinging behavior and fears of separation, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following: Dependent Diagnostic Criteria Has difficulty making everyday decisions without an excessive amount of advice and reassurance from others. Needs others to assume responsibility for most major areas of his/her life. Has difficulty expressing disagreement with others because of fear of loss of support or approval. Has difficulty initiating projects or doing things on his or her own (because of a lack of self-confidence in judgment or abilities rather than a lack of motivation or energy). Goes to excessive lengths to obtain nurturance and support from others, to the point of volunteering to do things that are unpleasant. Dependent Diagnostic Criteria Feels uncomfortable or helpless when alone because of exaggerated fears of being unable to care for himself/herself. Urgently seeks another relationship as a source of care and support when a close relationship ends. Is unrealistically preoccupied with fears of being left to take care of himself or herself. Dependent Personality Prevalence: 2-4% of general population 2.5% of all personality disorders Females more commonly affected than males Patients with a history of childhood separation anxiety or chronic illness may be predisposed Many patients have co-morbid dysthymia, major depression and alcohol abuse Respond well to group therapy, assertiveness training, social skills training, SSRIs, benzodiazepines Differential diagnosis: histrionic pd, borderline pd, avoidant pd, agoraphobia Obsessive-Compulsive Personality preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness, and efficiency, beginning by early adulthood and present in a variety of contexts: OCPD Diagnostic Criteria Indicated by four or more of the following: Is preoccupied with details, rules, lists, organizations, or schedules to the extent that the major point of the activity is lost. Shows perfectionism that interferes with task completion (e.g. is unable to complete a project because his or her own overly strict standards are not met). Is excessively devoted to work and productivity to the exclusion of leisure activities and friendships (not accounted for by obvious economic necessity). Is over conscientious, scrupulous, and inflexible about matters of morality, ethics, or values (not accounted for by cultural or religious identification). 10
OCPD Diagnostic Criteria Obsessive Compulsive PD Is unable to discard worn-out or worthless objects even when they have no sentimental value. Is reluctant to delegate tasks or to work with others unless they submit to exactly his or her way of doing things. Adopts a miserly spending style toward both self and others; money is viewed as something to be hoarded for future catastrophes. Shows rigidity and stubbornness. Anal retentive Common in general population, exact prevalence unknown Males > females More common among first-degree relatives with this disorder Unlike other personality disorders, these patients often realize the impact of their behavior and seek treatment on their own Group therapy may be very helpful Differential dx: OCD, narcissistic pd Other Personality s Conclusion Not otherwise specified (NOS) Mixed Depressive personality disorder Hippocrates: black gall Negativistic personality disorder passive-aggressive personality disorder Self-defeating personality disorder Subject of much controversy Concern it will be applied to victimized and abused women Placed on separate Axis Indicates unique psychosocial and treatment considerations Personality disorders are common Significant impact on all areas of health and life More research need into etiology and treatment 11