Personality Disorders

Dr Ayomide ADEBAYODocAyomide.com

4-12%

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Diagnosable PD in ~10% (2008 study)

Clinically severe in ~4%35% psychiatric inpatientsPrisoners: female 50%; male 60-80%Nearly all marked by impaired impulse

control à ↑risk of addictive behaviour

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Qu’est que c’est?An enduring pattern of inner experience

& behaviour that differs markedly from the expectations of the individual’s culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable

over time, and leads to distress or impairment.DSM-IV-TR

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Qu’est que c’est?A severe disturbance in the

characterological condition and behavioural tendencies of the individual,

usually involving several areas of the personality, and nearly always associated

with considerable personal and social disruption.

WHO

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Simple English

Deeply ingrained maladapative patterns of behaviour

Extreme deviation from average cultural norms of perceiving, thinking, feeling & relating à problems for the person

“Weird” or “different”

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What’s Really Going On…Internally

Disturbed ways of thinking

Difficulties with mood &

impulse control

Externally

Disturbed ways of relating

Disturbed behaviour

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5-Factor Model of Personality

Openness to ExperienceConscientiousnessExtraversionAgreeablenessNeuroticism

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DSM Clusters

Cluster A(odd, eccentric)

Cluster B(dramatic, emotional)

Cluster C(anxious, fearful)

ParanoidSchizoid

Schizotypal

AntisocialBorderlineHistrionicNarcisstic

AvoidantDependentObsessive-compulsive

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PsychopathyExtreme form of antisocial/dissocial PDNarrower group – often also fulfil criteria

for antisocial, narcissistic, histrionic & paranoid

Strongly correlated with risk of future violence

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PCL-RGlibness, superficial charmPromiscuous sexuallyGrandiose sense of self-

worthEarly behaviour problemsPathological lyingImpulsivityCunning/manipulativeNo realistic long term goalsNeed stimulation/prone to

boredom

IrresponsibilityLack of remorse/ guiltFailure to accept

responsibilityShallow affectCallous/lack of empathyJuvenile delinquencyParasitic lifestyleCriminal versatilityPoor behavioural controlMultiple short-term marital

relationshipsDocAyomide.com

Psychodynamic ModelTheory of unconscious motivations: not all

“manipulative” behaviour is consciously under the person’s control

Developmental view & focus on defence mechanisms

Attempts to understand the internal processesProblem: not easily generalisable to provide

simple plan of action

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Psychiatric ModelReconsidered for ICD-11 & DSM-VPeople often fit more than one categorySame diagnoses with different symptomsTypes shown to alter & changeImprecise, too much overlap, despite

efforts to pin categories

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RelationshipsParanoid/schizotypal PD ≡ delusional disorders

or schizophreniaBorderline PD ≡ disorders of mood & anxiety,

impulse control, eating, substance use or ADHD

Avoidant PD ≡ social anxiety disorder

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DSM-5

Single axisHybrid method (further study)

Borderline Obsessive-CompulsiveAvoidant SchizotypalAntisocial NarcissisticPD-TS

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ManagementPsychotherapy coreBasis: symptoms ß poor/limited coping skillsAim: ↑perception of & response to social

stressorsInpatient care rare – occasional short stay

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Management Principles*ConsistencyReliabilityEncouraging autonomySensitive management of change

*BMJ 2013;347:f5276

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Medication

Minimal roleAdjunct to psychotherapyFor symptom clusters

cognitive-perceptual symptomsaffective dysregulationimpulsive-behavioural dyscontrol

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Issues in PD

Under-diagnosisStigmaTreatment optionsPrognosisResearch

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