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Personality disorder
Dr. Roger Ho Assistant Professor and Consultant Psychiatrist
Department of Psychological Medicine NUHS
Why do we need to study personality?
The duo had posted a greeCng for the Muslim fasCng month of Ramadan on social networking site Facebook last week, showing a poster of them eaCng
pork, which is forbidden in Islam. They later apologised in a video on YouTube for the posCng, which sparked
widespread anger. Their Facebook page is no longer accessible. The other charges were causing disharmony on the grounds of religion and possessing or producing obscene material, which is punishable by up to five
years in jail, the official said.
How do you describe their personality?
What is personality?
• Enduring paOerns of perceiving, relaCng to and thinking about the environment and oneself that are exhibited across numerous social and interpersonal contexts.
– APA DSMIV TR 2000 • Personality traits are found in people without psychiatric illnesses.
• The person can funcCon with his or her personality trait.
What is personality disorder?
• Personality disorder is associated with distorted thinking about self and others.
• MaladapCve paOerns of mentally represenCng • self and others serve as substrates for personality psychopathology.
DSM criteria of personality disorder A. An enduring paOern of inner experience and behavior that deviates markedly from the expectaCons of the individual's culture. This paOern is manifested in two (or more) of the following areas: – (1) cogniCon (i.e., ways of perceiving and interpreCng self, other people, and events) – (2) affecCvity (i.e., the range, intensity, lability, and appropriateness of emoConal response) – (3) interpersonal funcConing – (4) impulse control B. The enduring paOern is inflexible and pervasive across a broad range of personal and social situaCons. C. The enduring paOern leads to clinically significant distress or impairment in social, occupaConal, or other important areas of funcConing. D. The paOern is stable and of long duraCon and its onset can be traced back at least to adolescence or early adulthood. E. The enduring paOern is not beOer accounted for as a manifestaCon or consequence of another mental disorder. F. The enduring paOern is not due to the direct physiological effects of a substance or a general medical condiCon.
What are cluster A,B,C personality disorders?
AeCology
• GeneCc and Environmental ContribuCons to Dimensions of personality disorder
– Heritability parallels normal personality • 40-‐60% heritability from twin studies AddiCve geneCc influences and unique environment • Cluster A: liOle environmental effects • Cluster B: BPD and ASPD closest geneCc links • Cluster C: OCPD disCnct from others
AeCology: environmental Environmental risks – Low SES, raised by single parent, welfare, parental death, social isolaCon • Behavioural ObservaCons age 3 to 21 (Caspi 1996) – Effects small • Poorly controlled kids-‐ ↑ ASPD/crime – Low parental affecCon associated with • ASPD, Dependent PD, Borderline PD
– Aversive parenCng associated with • BPD, Paranoid PD, Passive Aggressive PD
AeCology: abuse • Personality disorder: higher self report childhood maltreatment
and trauma – MaladapCve childhood traits→ adverse effect on parenCng behaviour • Neglect independent predictor –BPD, ASPD Physical abuse – ASPD, BPD Sexual abuse – BPD independent predictor – All personality disorders but varying strengths • EmoConal abuse – All personality disorders, BPD independent predictor
Which personality disorder is most prevalent?
Case summary
• You are a resident working at the accident and emergency department.
• You are seeing a paCent who is very angry with the doctors and want to lodge a compliant.
Video
What is your diagnosis?
What are your DDX?
How to different personality disorder from other DDX?
Personality disorder vs psychoCc disorders: – relaCvely intact capacity for reality tesCng – ability to disCnguish between thoughts of their own and others. Personality disorder vs “neuroCc disorders” – use of immature, reality distorCng defenses (projecCon, denial) – difficulty with forming mature, mulC-‐faceted representaCons of themselves and others.
Can personality disorder occur at the same Cme with another
psychiatric diagnosis?
• Axis I psychiatric disorders with personality disorder
• Greater and more widespread impairment • More chronicity • Overall poorer response to treatment requiring more intensive and prolonged care
What are the predisposing factors?
What is the defence mechanism when he menCons about people at
Fraternity?
Name one other defence mechanism common in this
condiCon.
Can you comment on his mental state?
Do you admit this paCent to the psychiatric ward?
How would you manage this paCent?
General treatment principles
Goal is rehab not cure • RealisCc – Modify expression of traits • Time – many years but can be intermiOent • Goal Oriented • CollaboraCve • RealisCc achievable goals • More evidence for psychotherapy (BPD) than medicaCons
Name several types of psychotherapy which are useful for
this paCent.
How does psychodynamic psychotherapy can help paCents
with personality disorder?
3 aims: – stable and posiCve sense of self – to help the paCent to understand how the past influences the present. – establishment of mutually graCfying and enduring relaConship
State some psychotropic medicaCons which are useful for
personality disorder.
• SSRIs: reduce anger, self-‐harm and depression • Valproate, Topiramate, Lamotrigine -‐ possibly decrease aggression/anger
• Avoidant PD: meds (SSRI, SNRI) for social • phobia may be effecCve • Avoid meds that can be abused (long term benzodiazepine) or high risk if overdose ( TCA)
• Most evidence for low dose anCpsychoCcs • – Olanzapine: ↓ impulsivity, cogniCve distorCons,
• dissociaCon, depersonalizaCon, • – Typicals/Atypicals: irritability and aggression • – Schizotypal PD • – Use in lower doses than needed for psychosis
What is the risk of suicide?
Have you come across a friend who has been misusing Facebook?
‘Using Facebook excessively is the online equivalent of staring at
yourself in the mirror.’ Daily Mail, UK
September, 2010
Self-‐presenta,on 2.0: narcissism and self-‐esteem on Facebook. Mehdizadeh S
Cyberpsychol Behav Soc Netw. 2010 Aug;13(4):357-‐64 • Self-‐esteem and narcissisCc personality self-‐reports were collected from 100 Facebook users at York University, Canada.
• ParCcipant Web pages were also coded based on self-‐promoConal content features.
• CorrelaCon analyses revealed that individuals higher in narcissism and lower in self-‐esteem were related to greater online acCvity as well as some self-‐promoConal content.
Two types of NarcissisCc personality disorder paCents Psychodynamic Psychiatry in PracCce (Gabbard)
The Oblivious Narcissist The Hypervigiliant Narcissist
1. No awareness of reacCons of others 1 Highly sensiCve to reacCons of others
2. Arrogant and aggressive 2. Inhibited and shy
3 Self – absorbed 3. Direct aOenCon more towards others than toward self.
4 Needs to be centre of aOenCon 4. Shuns being the centre of aOenCon
5 Has a sender but no receiver (e.g. broadcasCng lengthy messages about oneself on facebook)
5. Listens to others carefully for evidence of slights or criCcisms
6. Is apparently impervious to having feelings hurt by others
6. Has easily hurt feelings; is prone to feeling ashamed or humuliated.
A paCent can alternate between the oblivious and hypervigilant state.
Mnemonics of personality disorder
Schizoid personality disorder
Borderline Personality Disorder
Histronic personality disorder
NarcissisCc personality disorder
AnCsocial personality disorder
