PERSONALITY

DISORDER
AND MANAGEMENT
Block XVIII
Carla R Marchira
Psychiatry Department
Gadjah Mada Medical School

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Personality Disorder and Management

Introduction
Personality: persons observable behavior and his
or her subjectively reportable inner experience (Sadock &
Sadock, 2003)

Personality disorder: enduring subjective

experiences and behavior that deviate from cultural
standards, are rigidly pervasive, have an onset in
adolescence or early adulthood, are stable through time,
and lead to unhappiness and impairment (DSM-IV-TR)

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Personality Disorder and Management

DSM-IV-TR General Diagnostic Criteria

for a Personality Disorder

A.Enduring pattern of inner exp. and behavior

that deviates markedly from the expectations of
the individuals culture. Manifested in 2 or
more of the following areas:
1. Cognitive
2. Affectivity
3. Interpersonal Functioning
4. Impulse Control

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Personality Disorder and Management

B. Enduring pattern is inflexible and pervasive across a broad

range of personal and social situation

C. Enduring pattern leads to clinically significant distress or

impairment in social, occupational, or other important areas of
functioning

D. Pattern is stable and long duration, onset can be traced back

at least to adolescence or adulthood

E. Enduring pattern is not better accounted for as a manifestation

or consequence of another mental disorder

F. Enduring pattern is not due to the direct physiological effects

of a substance (drug abuse, medication) or a general medical
condition (head trauma). 4
Personality Disorder and Management
Multi Axial Diagnosis:

Axis I : Clinical Disorder

Other Condition for Clinical Focus
Axis II : Personality Disorder
Mental Retardation
Axis III : General Medic Condition
Axis IV : Psychosocial and Environmental
Problem
Axis V : Global Assessment and
Functioning Scale (GAF)

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Personality Disorder and Management
Classification

Cluster A: paranoid, schizoid, schizotypal personality disorder

Odd and eccentric

Cluster B: antisocial, borderline, histrionic, narcissistic

dramatic, emotional, and erratic

Cluster C: avoidant, dependent, obsessive-compulsive, NOS

Anxious and fearful

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Personality Disorder and Management
Etiology:

Genetic Factors:
Study of 15,000 twins in US showed among
monozygotic twins the concordance for personality
disorder several times >< dizygotic twins

Cluster A more common in patients with

schizophrenia esp. schizotypal pd

Cluster B, antisocial pd related with alcohol use disorder,

depression with borderline pd, histrionic pd with somatization
Disorder

Cluster C are more common with high anxiety levels 7

Personality Disorder and Management

Biological Factors:

1.Hormones: testosteron, 17-estradiol, estrone

2.Platelet Monoamine Oxidase
3.Eye Movements
4.Neurotransmitters:serotonin, dopamin
5.EEG

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Personality Disorder and Management

Psychoanalytic Factors:

Defense Mechanisms of PD
1. Fantasy
2. Dissociation
3. Projection
4. Splitting
5. Passive Aggressive
6. Acting Out

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Personality Disorder and Management
Paranoid Personality Disorder

Characterized by: long-standing suspiciousness,

mistrust of person in general, refuse responsibility
for their own feelings and assign responsibility to
others, hostile, irritable, angry, bigots, injustice
collectors, pathologically jealous spouses,
litigious cranks

Epidemiology: 0.5 to 2.5 % in general pop.

More common in men
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Personality Disorder and Management

Diagnosis: see DSM-IV-TR

Clinical Features:
Pervasive and unwarranted tendency to interpret
other persons action as demeaning and
threatening

Differential Diagnosis: paranoid schizophrenia,

other pd

Course and prognosis: disorder is lifelong,

problems working and living with others, common
occupational and marital problems
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Personality Disorder and Management

Treatment:

Psychotherapy:
Treatment of choice
Straightforward
Do not use overly warm style
Group psychotherapy is not suggested

Pharmacotherapy:
Antianxiety
Small dosage antypsychotic

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Personality Disorder and Management
Schizoid Personality Disorder

Characterized by a lifelong pattern of social

withdrawal, discomfort with human interaction,
introversion, bland, constricted affect, eccentric,
isolated, lonely

Epidemiology: 7.5% general pop.

Men: women=2:1

Diagnosis: see DSM-IV-TR

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Personality Disorder and Management
Clinical Features: cold and aloof, no involvement
with everyday events and no concerns of others,
quiet, distant, seclusive and
unsociable

Differential Diagnosis: Schizophrenia, other pd

Course and prognosis: Occurs in early childhood, long

lasting

Treatment:
Psychotherapy: similar with paranoid pd

Pharmacotherapy: small dosages of antipsychotic,

antidepressants and psychostimulants
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Personality Disorder and Management

Schizotypal Personality Disorder

Characterized by: odd, strange, magical thinking,

peculiar notions, ideas of reference, illusions,
derealization

Epidemiology: 3% of population, relation with

schizophrenia, dizygotic twins:monozygotic=33%:4%

Diagnosis: see DSM-IV-TR

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Personality Disorder and Management
Clinical Features: disturbed in thinking and
communication, speech distinctive and peculiar,
superstitious, believe of having special power, full vivid
imaginary and fantasies

Differential Diagnosis: Schizophrenia, other pd

Course and prognosis: 10% committed suicide,

premorbid
personality of schizophrenia

Treatment:
Psychoterapy: similar with schizoid pd

Pharmacotherapy: haloperidol, antidepressants 16

Personality Disorder and Management

Antisocial Personality Disorder

Characterized by: inability to conform to social norm,

deceitfulness, impulsivity, irritability and aggressiveness,
irresponsibility

Epidemiology: men:women=3%:1%, common in poor urban

areas, in prison pop. 75%

Diagnosis: see DSM-IV-TR

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 Personality Disorder and Management

Clinical Features: seems normal and charming, lying, truancy,

running away from home, thefts, fights, substance abuse, illegal
activity beginning childhood. Impress opposites-sex clinician
with colorful and seductive aspects, manipulative and demanding
for same-sex clinician. Promiscuity, spouse abuse, child abuse,
and drunk driving are common events

Differential Diagnosis: substance abuse

Course and prognosis: unremitting course. Depressive disorder,

alcohol use, substance abuse are common.

Treatment:
Psychotherapy: Self-help group (among peers)

Pharmacotherapy: Psychostimulants, valproic acid

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Personality Disorder and Management

Borderline Personality Disorder

Characterized by: stand on the border between neurosis and

psychosis, unstable affect, mood, behavior, object relations,
self image, emotionally unstable pd (ICD-10).

Epidemiology: 1-2% pop, women:men=2:1

Diagnosis: see DSM-IV-TR

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Personality Disorder and Management

Clinical Features: appear in state of crisis, mood swings,

argumentative at one moment, depressed next, later no feelings,
highly unpredictable, dependent but hostile, search for
companionship even unsatisfactory. Clinician concept:panphobia,
pananxiety, panambivalence, chaotic sexuality.

Differential Diagnosis: Schizophrenia, other pd

Course and prognosis: High incidence of major depressive disorder

Treatment:
Psychotherapy:
treatment of choice

Pharmacotherapy: depend on the features

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Personality Disorder and Management

Histerionic Personality Disorder

Characterized by: excitable, emotional, behave in colorful,

dramatic, extroverted fashion, inability to maintain deep,
long lasting attachments, use physical appearance to draw
attention, self dramatization, theatricality.

Epidemiology: 2-3%, more in women than men

Diagnosis: see DSM-IV-TR

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Personality Disorder and Management

Clinical Features: attention seeking behavior, exaggerate

their
thoughts and feelings, temper tantrums, tears if not to be the
center of attention, seductive behavior, flirtatious, sensation
seekers

Differential Diagnosis: borderline pd

Course and prognosis: fewer symptoms in later

Treatment:
Psychotherapy: Psychoanalytically oriented

Pharmacotherapy: adjunctive, depend on the features

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Personality Disorder and Management

Narcissistic Personality Disorder

Characterized by: heightened sense of self-importance and

grandiose feelings of uniqueness, requires excessive admiration,
arrogant, preoccupied with fantasies of unlimited success, power,
brilliance, beauty, ideal love.

Epidemiology: 2-16% in clinical pop, <1% in general pop.

Diagnosis: see DSM-IV-TR

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Personality Disorder and Management

Clinical Features: grandiose sense of self importance, feel

special
and expect special treatment, handle criticism poorly, ambitious
to achieve fame and fortune, fragile relationship, unable to show
empathy, prone to depression

Differential Diagnosis: other pd

Course and prognosis: chronic and difficult to treat, aging is

handled poorly, vulnerable to midlife crises

Treatment:
Psychotherapy: remain difficult

Pharmacotherapy: Lithium, antidepressants 24

Personality Disorder and Management

Avoidant Personality Disorder

Characterized by: extreme sensitivity to rejection, socially

withdrawn life, shy, not asocial, great desire for companionship but
need strong guarantees of uncritical acceptance, inferiority complex,
anxious pd (ICD-10)

Epidemiology: 1-10% general pop

Diagnosis: see DSM-IV-TR

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Personality Disorder and Management

Clinical Features: Hypersensitive to rejection, timidity,

express uncertainty, lack of self confidence, afraid to speak up in
public, withdraw from others, no close friends or confidants

Differential Diagnosis: schizoid pd, other pd

Course and prognosis: able to function in protected

environment,
social phobia is common

Treatment:
Psychotherapy: group therapy

Pharmacotherapy: antianxieties, antidepressants

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Personality Disorder and Management

Dependent Personality Disorder

Characterized by: subordinate their needs to others, dependence,

pessimism, fear of sexuality, self-doubt, passivity, suggestibility,
lack of perseverance, intense discomfort when alone.

Epidemiology: 2.5% of all pd, more in women, more in young

children, chronic physical illness in childhood prone to this pd

Diagnosis: see DSM-IV-TR

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 Personality Disorder and Management
Clinical Features: pervasive pattern of dependent and submissive
behavior,
hard to make decision, avoid position and leadership role,
pessimism, self-
doubt, passivity, fears of expressing sexual and aggressive feelings

Differential Diagnosis: other pd

Course and prognosis: social relationship are limited to those on

whom
they can depend, suffer physical or mental abuse because they
cannot
assert themselves

Treatment:
Psychotherapy: treatment of choice with successful outcome

Pharmacotherapy: antianxieties, antidepressants 28

Personality Disorder and Management

Obsessive-Compulsive Personality Disorder

Characterized by: emotional constriction, orderliness,

perseverance, stubbornness, indecisiveness, perfectionism,
inflexibility, anancastic pd (ICD-10)

Epidemiology: more common in men

Diagnosis: see DSM-IV-TR

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Personality Disorder and Management

Clinical Features: preoccupied with rules, regulations, orderliness,

neatness, details, achievement of perfection, inflexibility, intolerant,
formal, serious, lack sense of humor, unable to compromise

Differential Diagnosis: obsessive compulsive disorder

Course and prognosis: late onset depressive disorder is common

Treatment:
Psychotherapy: group therapy and behavioral therapy

Pharmacotherapy: clonazepam, clomipramine

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 Personality Disorder and Management
Personality Disorder-Not Otherwise Specified
Passive-Aggressive Personality Disorder
Characterized by: covert obstructionism, procrastination,
stubbornness,
inefficiency, negativistic pd

Diagnosis: see DSM-IV-TR

Clinical Features: procrastinate, resist for adequate performance, find

excuses for delays, lack assertiveness, pessimistic about future

Differential Diagnosis: other pd

Treatment:
Psychotherapy: supportive psychotherapy
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Pharmacotherapy: depend on the features
Personality Disorder and Management
Depressive Personality Disorder
Characterized by: depressive spectrum, pessimistic, anhedonic, duty
bound,self-doubting, chronically unhappy, newly classified,
melancholic personality (20th century)

Diagnosis: see DSM-IV-TR

Clinical Features: hopelessness, gloominess, cheerlessness,

joylessness,
unhappiness, pessimistic, worthlessness

Differential Diagnosis: dysthymic disorder, other pd

Course and prognosis: great risk for dysthymic and depression

disorder

Treatment:
Psychotherapy: treatment of choice 32
Pharmacotherapy: antidepressants
 Personality Disorder and Management
Personality Change due to a General Medical
Condition

Etiology: structural damage of the brain, i.e. head trauma, tumor,

multiple sclerosis, heavy metal poisoning etc

Diagnosis and Clinical Features: a change personality from

previous pattern, due to general medical condition

Differential Diagnosis: dementia

Course and Prognosis: depend on its cause

Treatment: of the underlying organic condition 33

Personality Disorder and Management
Psychobiological Model of Treatment in PD
Combines psychotherapy and pharmacotherapy

Using DSM-IV-TR or ICD-10

Indonesia: PPDGJ (Pedoman Penggolongan dan Diagnosis
Gangguan Jiwa)

Using ICD-10 (The International Classification of Diseases

and Related Problems) as reference

Multi Axial Diagnosis refer to DSM-IV (The Diagnostic

and
Statistical Manual of Mental Disorder)
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Personality Disorder and Management

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