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PERSONALITY DISORDER: EPIDEMIOLOGY & ETIOLOGY Presented by: Dr. S.M. Yasir Arafat Phase A Resident Psychiatry, BSMMU October 16, 2014.

Personality disorder epidemiology & etiology

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Personality Disorder- Etiology & Epidemiology

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Page 1: Personality disorder  epidemiology & etiology

PERSONALITY DISORDER: EPIDEMIOLOGY & ETIOLOGY

Presented by:

Dr. S.M. Yasir Arafat

Phase A Resident

Psychiatry, BSMMU

October 16, 2014.

Page 2: Personality disorder  epidemiology & etiology

Epidemiology

Page 3: Personality disorder  epidemiology & etiology

Epidemiology: Introduction Personality disorder is a common and chronic disorder. Its prevalence is 10-20% in the general population and

its duration is expressed in decades. Approximately one half of all psychiatric patients have

personality disorder. Predisposing factor of

substance use suicide affective disorders impulse-control disorders eating disorders anxiety disorders

Page 4: Personality disorder  epidemiology & etiology

Epidemiology: At different level

Community care: 2-18% (generally accepted approximate is 10%). It is more in younger adults, and may be more in males.

Primary care: 5-8% will have a primary diagnosis of PD. The rate of comorbid PD is 20-30%.

Outpatients patients 30-40% and 40-50% of inpatients have a PD. A primary diagnosis of PD occurs in about 5-15% of inpatients.

Others: 25-75% of prisoners, Antisocial PD is most prevalent.

Page 5: Personality disorder  epidemiology & etiology

Prevalence: At a glance

Cluster TypeNo. of Study

Mean Prevalence

General ppl- DSM

AParanoid 13 1.6 0.5-3Schizoid 13 0.8 0.5-7Schizotypal 13 0.7 0.5-5

B

Antisocial 25 1.5 2-3.5Borderline 15 1.6 1.5-2Histrionic 12 1.8 2-3Narcisstic 10 0.2 0.5-1

CAvoidant 13 1.3 0.5-5Dependent 12 0.9 0.5-5OCPD 13 2 1-2

OthersPassive-Aggressive 8 1.7  

Page 6: Personality disorder  epidemiology & etiology

Epidemiology-Paranoid

The prevalence of paranoid PD is 0.5-2.5% of the

general population.

Referred to treatment by a spouse or an employer.

Relatives of patients with schizophrenia show a

higher incidence of paranoid PD.

The disorder is more common in men.

Higher among minority groups, immigrants, and

persons who are deaf than it is in the general

population.

Page 7: Personality disorder  epidemiology & etiology

Epidemiology-Schizoid

The schizoid PD may affect 7.5% of the general population.

The sex ratio is 2:1 male-to-female ratio.

Persons with the disorder tend to gravitate toward solitary jobs & many prefer night work to day work that involve little or no contact with others.

Page 8: Personality disorder  epidemiology & etiology

Epidemiology-Schizotypal

Schizotypal PD occurs in about 3 %.

A greater association of cases exists among the biological relatives of patients with schizophrenia.

A higher incidence among monozygotic twins than among dizygotic twins (33% versus 4%).

Page 9: Personality disorder  epidemiology & etiology

Epidemiology-Antisocial

The prevalence of antisocial PD is 3 % in men & 1 % in women.

It is most common in poor urban areas and among mobile residents.

Boys with the disorder come from larger families. The onset of the disorder is before the age of 15. In prison, the prevalence of antisocial PD is as

high as 75%. A familial pattern is present; the disorder is 5

times more common among first-degree relatives of men with the disorder.

Page 10: Personality disorder  epidemiology & etiology

Epidemiology-Borderline

Borderline PD is thought to be present in about 1-2% of the population and is twice as common in women.

An increased prevalence of MDD, alcohol use disorders, and substance abuse is found in first-degree relatives.

Page 11: Personality disorder  epidemiology & etiology

Epidemiology-Histrionic

Prevalence of histrionic PD of about 2 -3%.

Rates of about 10 -15% have been reported

when structured assessment is used.

The disorder is more frequent in women.

Association with somatization disorder and

alcohol use disorders.

Page 12: Personality disorder  epidemiology & etiology

Epidemiology-Narcissistic

Prevalence of narcissistic PD range from 2-16% in the clinical population and less than 1% in the general population.

Offspring of such parents may have a higher than usual risk for developing the disorder themselves.

The number of cases of narcissistic PD is increasing steadily.

Page 13: Personality disorder  epidemiology & etiology

Epidemiology-Avoidant

The prevalence of the disorder is 1-10 % of the general population.

Infants classified as having a timid temperament may be more susceptible to the disorder.

Page 14: Personality disorder  epidemiology & etiology

Epidemiology-Dependant

Dependent PD is more common in women.

It is more common in young children than in older ones.

Persons with chronic physical illness in childhood may be most susceptible to the disorder.

Page 15: Personality disorder  epidemiology & etiology

Epidemiology-OCPD

It is more common in men and is diagnosed most often in oldest children.

The disorder also occurs more frequently in first-degree biological relatives of persons with the disorder than in the general population.

Patients often have backgrounds characterized by harsh discipline.

Page 16: Personality disorder  epidemiology & etiology

Epidemiology-Others

NOS

Passive-Aggressive PD

Depressive PD- to occur in families in

which depressive disorders are found.

Sadomasochistic PD

Sadistic PD

Personality Change due to a GMC

Page 17: Personality disorder  epidemiology & etiology

Genetic Factor

Early life experience

Etiology

Page 18: Personality disorder  epidemiology & etiology

Etiology: Genetic factor

15,000 pairs of twins in the USA. Among monozygotic twins, the concordance for personality disorders was several times that among dizygotic twins.

Monozygotic twins reared apart are about as similar as monozygotic twins reared together. Similarities include multiple measures of personality and temperament, occupational and leisure-time interests, and social attitudes.

Page 19: Personality disorder  epidemiology & etiology

Etiology: Genetic-Cluster A

Cluster A PDs are more common in the biological relatives of patients with schizophrenia.

More relatives with schizotypal PD occur in the family histories of persons with schizophrenia.

Less correlation exists between paranoid or

schizoid PD and schizophrenia.

Page 20: Personality disorder  epidemiology & etiology

Etiology: Genetic-Cluster B

Cluster B PDs apparently have a genetic base.

Antisocial PD is associated with alcohol use disorders.

Depression is common in the family backgrounds of patients with borderline PD.

Page 21: Personality disorder  epidemiology & etiology

Etiology: Genetic-Cluster C

Cluster C PDs may also have a genetic base.

Obsessive-compulsive traits are more common in monozygotic twins than in dizygotic twins, and patients with OCPD show some signs associated with depression.

Page 22: Personality disorder  epidemiology & etiology

Etiology: Biological Factors

Hormone: Persons who exhibit impulsive traits also

often show high levels of testosterone, 17-estradiol & estrone.

Androgens increase the likelihood of aggression and sexual behavior.

DST results are abnormal in some patients with borderline personality disorder who also have depressive symptoms.

Page 23: Personality disorder  epidemiology & etiology

Etiology: continue

Platelet Monoamine Oxidase:

College students with low platelet MAO levels report spending more time in social activities than students with high platelet MAO levels.

Low platelet MAO levels have also been noted in some patients with schizotypal disorders

Page 24: Personality disorder  epidemiology & etiology

Etiology: continue

Neurotransmitters: Levels of 5-hydroxyindoleacetic acid (5-HIAA), are low in

persons who attempt suicide and in patients who are impulsive and aggressive.

Raising serotonin levels with serotonergic agents can produce dramatic changes in some character traits of personality. In many persons, serotonin reduces depression, impulsiveness, and rumination, and can produce a sense of general well-being.

Increased dopamine concentrations in the central nervous system, produced by certain psychostimulants can induce euphoria.

The effects of neurotransmitters on personality traits have generated much interest and controversy about whether personality traits are inborn or acquired.

Page 25: Personality disorder  epidemiology & etiology

Etiology: continue

Electrophysiology:

Changes in electrical conductance on the EEG occur in some patients with PD.

Most commonly antisocial and borderline types; these changes appear as slow-wave activity on EEGs.

Page 26: Personality disorder  epidemiology & etiology

Etiology: Childhood experience

Difficult infant temperament may proceed to conduct disorder in childhood and PD.

ADHD may be a risk factor for later antisocial PD.

Insecure attachment may predict later PD. Harsh and inconsistent parenting and family

pathology are related to conduct disorder, and may therefore be related to later antisocial PD.

Severe trauma in childhood may be a risk factor for borderline PD and other cluster B disorders.

Page 27: Personality disorder  epidemiology & etiology

Psychodynamic theories

Freudian explanations of arrested development at oral, anal, and genital stages leading to dependent, obsessional, and histrionic personalities; borderline personality organisation.

Narcissistic and borderline personalities seen as displaying primitive defence mechanisms such as splitting and projective identification.

Some see antisocial personalities as lacking aspects of superego, but more sophisticated explanation is in terms of a reaction to an overly harsh superego.

Page 28: Personality disorder  epidemiology & etiology

Cognitive-behavioural theories

There are maladaptive schemata. These schemata represent core beliefs which are derived from an interaction between childhood experience and pre-programmed patterns of behaviour and environmental responses.

Schemata are unconditional compared with those found in affective disorders and are formed early, often pre-verbally.

Page 29: Personality disorder  epidemiology & etiology

Cognitive-analytical model

Cognitive-analytical model: Borderline patients experience a range of partially dissociated self state which arise initially as a response to unmanageable external threats and are maintained by repeated threats or internal cues (memories).

Abusive experiences in childhood lead to internalisation of the harsh parental object leading to intrapsychic conflict which is repressed or produces symptomatic behaviours.

Deficits in self-reflection, poor emotional vocabulary, and narrow focus of attention lead to incoherent sense of self and others.

Page 30: Personality disorder  epidemiology & etiology

Dialectical behavioural model

Dialectical behavioural model: Innate temperamental vulnerability interacts with certain dysfunctional environments leading to problems with emotional regulation.

Abnormal behaviours which are manifested represent products of this emotional dysregulation or attempts to regulate intense emotional states by maladaptive problem solving.

Page 31: Personality disorder  epidemiology & etiology

Etiology: Defense Mechanisms Fantasy-Schizoid Dissociation or Denial- Histrionic Isolation-OCPD Projection Splitting Acting out Projective identification- Borderline PDs

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References

1. Kaplan & Sadock's Synopsis of Psychiatry:

Behavioral Sciences, 10th Edition

2. Shorter Oxford Text Book of Psychiatry, 6th

Edition

3. Oxford Handbook of Psychiatry, 3rd Edition

4. Different journals

Page 33: Personality disorder  epidemiology & etiology