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Normal Personality Development and Personality Disorders

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Title: Normal Personality Development and Personality Disorders


1
Normal Personality Development and Personality
Disorders
  • Janet E. Johnson, MD, MPH
  • Tulane University School of Medicine
  • Department of Psychiatry and Behavioral Sciences

2
Objectives
  • At the conclusion of this learning module, the
    student should be able
  • Be familiar with personality development List the
    personality disorders included in DSM-IV-TR
  • List the major diagnostic criteria for each and
    be familiar with general characteristics of each
    disorder, including epidemiology
  • Discuss the differential diagnosis for each
    disorder
  • Be familiar with contributing biological theories
    and genetics for personality disorders

3
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.

4
Normal Personality Development
  • Second half of 1st year attachment
  • Internalization mechanism for building
    psychological structure
  • Stable pattern of a childs temperament becomes
    established during second year.
  • Nature versus nurture?
  • Behavioral genetics revealing pervasive genetic
    influences on normal and abnormal personality.

5
What is Normal?
  • Whos to say?
  • Circumstances, culture/sub-culture,
    setting/location, timing, age

6
Whos Normal?
7
Whos Normal?
8
Personality assessment
  • Meyers-Brigg
  • Five Factor Model
  • Cloningers Seven-Factor Model
  • Biogenic Spectrum Model

9
Myers Brigg
  • Questionnaire designed to measure psychological
    preferences in how people perceive the world and
    make decisions.
  • Widely utilized
  • Extrapolated from Jungs theories.
  • Two pairs of cognitive functions
  • Rational functions thinking and feeling
  • Irrational functions sensing and intuition

10
Dichotomies
  • Extraversion (E) (I) Introversion
  • Sensing (S) (N) Intuition
  • Thinking (T) (F) Feeling
  • Judgment (J) (P) Perception
  • 16 possible types
  • Example ESTJ

11
Five Factor Model
  • Neuroticism (anxiety, depression,
    vulnerability, hostility)
  • Extraversion (warmth, assertiveness,
    activity, gregariousness)
  • Openness (feelings, fantasy, ideas, values)
  • Agreeableness (trust, altruism, modesty)
  • Conscientiousness (dutifulness,
    self- discipline, deliberation)

12
Seven-Factor Model of Temperament and Character
  • Harm avoidance
  • Reward dependence
  • Novelty seeking
  • Persistence
  • Character factor
  • Self-directedness
  • Cooperativeness
  • Self-transcendence

13
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 -gt high serotonergic activity
  • Reward dependence ? low noradrenergic activity

14
Personality Disorders
  • 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

15
General Diagnostic Criteria
  • An enduring pattern of inner experience and
    behavior that deviates markedly from the
    expectation of the individuals 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

16
General Diagnostic Criteria
  • 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.

17
Personality Disorders
  • 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

18
Personality Disorders
  • Common in general population
  • Prevalence of 10-18
  • Outpatient 30-50
  • Inpatient gt 50 co-morbidity
  • Males and females equal overall
  • Etiology
  • Genetics
  • Psychoanalytic theories
  • Freud psychosexual development
  • Reich defense mechanisms

19
Common Defense Mechanisms
  • Projection
  • Splitting
  • Regression
  • Fantasy
  • Dissociation
  • Intellectualization
  • Isolation
  • Reaction formation
  • Repression
  • Acting out
  • Passive aggression

20
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.

21
Paranoid Personality Disorder
  • 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

22
Paranoid Diagnostic Criteria
  • 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.

23
Paranoid Diagnostic Criteria
  • 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.

24
Paranoid Personality Disorder
  • 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 gt female
  • Differential diagnosis schizotypal pd,
    schizophrenia, delusional d/o
  • Antipsychotic meds sometimes useful

25
Schizoid Personality Disorder
  • A pervasive pattern of 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

26
Schizoid Diagnostic Criteria
  • 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.

27
Schizoid Personality Disorder
  • 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

28
Schizotypal Personality Disorder
  • A pervasive pattern of 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

29
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.

30
Schizotypal Personality Disorder
  • 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.

31
Schizotypal Personality Disorder
  • Schizophrenia spectrum disorder
  • Some forms involve biologic abnormalities
    characteristic of schizophrenia
  • Prevalence 3 of population
  • Males gt females
  • Approximately 10 commit suicide
  • Differential diagnosis schizophrenia, paranoid
    pd, schizoid pd, avoidant pd
  • Low dose antipsychotics may be helpful

32
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

33
Borderline Personality Disorder
  • A pervasive pattern of 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

34
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 self-damaging (spending, sex,
    substance abuse, reckless driving, binge eating).

35
Borderline Diagnostic Criteria
  • Recurrent suicidal behavior, gestures, or
    threats, or self-mutilating 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.

36
Borderline Personality Disorder
  • Prevalence 2-3 of the population
  • 21 femalemale 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

37
Borderline Personality Disorder
  • 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

38
Antisocial Personality Disorder
  • Pervasive pattern of disregard for and violation
    of the rights of others occurring since age 15
    years, as indicated by three (or more)

39
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.

40
Antisocial Diagnostic Criteria
  • 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.

41
Antisocial Personality Disorder
  • 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

42
Histrionic Personality Disorder
  • 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

43
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.

44
Histrionic Diagnostic Criteria
  • 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.

45
Histrionic Personality Disorder
  • 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

46
Narcissistic Personality Disorder
  • A pervasive pattern of 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

47
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.

48
Narcissistic Diagnostic Criteria
  • 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.

49
Narcissistic Personality Disorder
  • Overwhelming, pathological self-absorption
  • Primary motivation is power
  • Prevalence unknown lt1 general population, 2-15
    clinical population
  • Chronic course
  • Co-morbid mood disorders common
  • Aging ultimate blow to self-esteem, prone to
    severe mid-life crises
  • Treatment individual psychotherapy
  • Do not tolerate group therapy
  • Differential dx borderline pd, histrionic pd,
  • antisocial pd

50
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

51
Avoidant Personality Disorder
  • A pervasive pattern of 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

52
Avoidant Diagnostic Criteria
  • 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.

53
Avoidant Diagnostic Criteria
  • 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

54
Avoidant Personality Disorder
  • 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

55
Dependant Personality Disorder
  • 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

56
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.

57
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.

58
Dependent Personality Disorder
  • 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

59
Obsessive-Compulsive Personality Disorder
  • A pervasive pattern of 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

60
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).

61
OCPD Diagnostic Criteria
  • 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.

62
Obsessive Compulsive PD
  • Anal retentive
  • Common in general population, exact prevalence
    unknown
  • Males gt 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

63
Other Personality Disorders
  • 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

64
Conclusion
  • 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
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