3. Individuals with a personality disorder show
an enduring pattern of inner experience.
These patterns are inflexible and pervasive
across a wide rang of social and personal
situations and lead to clinically significant
distress or impairment in social, occupational
and other important areas of functioning.
Overview
4. To understand the concept of personality disorder, one
first has to understand what is meant by personality. this usually
refers to the individual characteristics, behaviours
and emotional qualities of a person, which the person
knows to be themselves. That people differ from each other is
obvious.
How and why they differ is less clear and is the subject of the
scientific study of personality and individual differences.
Personality
6. 1. Definition and aetiology
Learning objectives
You should:
be familiar with the main criteria for
personality disorder
be familiar with different ways of construing
personality.
be aware of the importance of genetic,fami-
lial and environmental factors in relation
to personality.
7. All studies reported improvement in personality
disorders with psychotherapy. Among the three
randomized controlled trials, active psychotherapy
was more effective than no treatment.
8. : an enduring pattern of inner
experience and behaviour that deviates
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.
The formal definition of a personality disorder is
9. evidence of a problem must be present from an early age, as
the adult personality is beginning to form
the behaviour is persistent and resistant to change
behavioural problems are evident in a variety of different
areas of social functioning, e.g. disruptive(分裂) interpersonal
relationships, poor work record, antisocial behaviour, etc.
the behaviour results in damage or distress
to the individual concerned or others.
Key aspects of the definition are
That:
10. Categorical types
Categorical types are used to understand personality in
psychiatric classification systems.
Individuals are grouped together according to particular
characteristics; for example, someone with a schizoid personality
would have the following characteristics:
difficulty in making close social relationships,
a preference for spending time alone,
a cold and distant manner
a tendency to spend a lot of time day dreaming or thinking about
abstract concepts rather than engaging in the real world.
Different ways of understanding personality
11. The different types of personality disorder
are described later, but all are based upon
extreme forms of what are essentially normal
personality variations.
12. there is some evidence that
particular characteristics of personality have a strong
hereditary component (e.g. anxiety traits). Most of the
evidence comes from twin studies, where monozygotic
twins have a much greater probability of shared
personality characteristics than dizygotic twins. However,
the nature versus nurture argument is very difficult to
untangle, and both are probably important.
Etiology
Genetic factors
13. There is very
little hard evidence to confirm a general
assumption that important components of
personality are developed by learning from
parental guidance or behaviour.
Familial and environmental factors
14. Childhood neglect or abuse, however, strongly
associated with the development of certain forms of
personality disorder as an adult.
Therefore, it is easier to demonstrate the influence
of negative childhood events or experiences on
personality than it is to show the subtle effects of
normal or mundane experiences.
15. Learning objectives
You should:
~ be familiar with the main types of personality
disorder
~ know which types of personality disorder are
associated with certain forms of psychiatric illness.
2. Types of personality disorder
16. The main types of personality
disorder, with a brief description, are
shown in Table 1.
Fuller descriptions of the more common types of
disorder are given later in this section.
17. Type of personality
disorder
Paranoid
Schizotypal
Antisocial
Borderline
Brief description of characteristic
patterns of behaviour
Distrust and suspiciousness
Acute discomfort in social relationships,
perceptual distortions bordering on
psychotic experiences, eccentric（古怪）
behaviour
Disregard and violation of others
instability in relationships,impulsivity and
Iow self-esteem
Table 1 Personality disorders
19. Each category is based around a
normal personality trait, which in
the disorder is manifest in an
extreme and pathological manner.
20. Most personality traits convey some kind of
positive advantage provided they are tempered by
recognition of the needs of others and by some kind
of balance within the personality itself.
For example,
moderate obsessional traits may be
advantageous for individuals who have responsible
jobs and have to carry out precise and meticulous
work.
Histrionic traits may be an advantage for
individuals who wish to pursue an artistic career,
and even
antisocial traits may be useful for those in highly
competitive industries where a certain degree of
ruthlessness may be required.
21. Paranoid personality disorder
Characteristics of a paranoid personality disorder include
suspiciousness, marked self-reference, feelings that other people
are hostile or involved in conspiracies against the individual, a
sense of injustice, preoccupation with imagined wrongs, litigious
（好上诉） and aggressive behaviour.
22. Antisocial personality disorder
Individuals with an antisocial personality disorder have a
complete disregard for the thoughts of others. They
are self-centred, selfish and sometimes cruel. They are cold and
affectionless. They rarely form long-term relationships and
usually exploit others with whom they are involved. They are
unable to appreciate the needs or feelings of others or may
even gain pleasure from the humiliation or suffering of others.
They often have a criminal record, which may include violent or
sexual offences. Evidence of antisocial or aberrant behaviour will
be present from an early age. The disorder is more common in
males
23. Drug or alcohol abuse is common, which can result in the
development of short-lived psychotic states or, in the case of
alcohol, long-term brain damage. These individuals may also
receive injuries to their brain because of frequent fighting or
other kinds of reckless activity.
Obsessive-compulsive personality disorder
Individuals with an obsessive-compulsive disorder are extremely
ordered, meticulous and pedantic. They find it difficult to express
emotion or show feelings towards others, although inwardly they
may ruminate and worry about social encounters.
24. They are perfectionistic and often find it difficult
to complete tasks because of such high standards.
They are rigid and find it difficult to adapt to change.
They often have conflicts regarding sex, which they
may regard as messy or dirty. They find it difficult to
develop long-term relationships as most others do
not live up to their high standards.
25. Histrionic(dramatic) personality disorder
Individuals are over dramatic in their behaviour.
Minor troubles or events are perceived as major
disasters.
Individuals are over emotional and frequently
moved to tears. They are self-centred and
attention seeking and are rarely happy unless
surrounded by admirers. They profess to be
deeply moved but appear to be shallow and
immature in relationships.
26. Dependent personality disorder People with a
dependent personality disorder are overly dependent
upon others.
They find it impossible to live on an independent
basis and collapse emotionally whenever they have to
fend for themselves.
They often develop stable but imbalanced
relationships with a very dominant partner, either a
spouse or parent.
27. 3 Assessment and management
You should:
be aware of different methods of assessing personality
be able to assess personality from a clinical perspective
be aware of the specific treatment approaches that have
been evaluated in the treatment of personality disorder
know the principles underlying clinical management.
28. Assessment
The diagnosis of personality disorder is difficult
and often clinicians may disagree about the
nature and severity of the disorder.
29. Various instruments have been developed
to assess personality; some measure
specific traits of personality in a
dimensional form and others take a
categorical approach.
30. clinical assessment
From a clinical perspective, the following
areas of clinical history should be paid
particular attention.
1. Birth history: any evidence of birth
trauma that may have lead to brain injury
2. Childhood brain illness, or head injury
3. Behavioural difficulties at school
(expulsion, referred to educational
psychologist)
31. 4. Evidence of failure to form long-
term friendships(describes self as
loner at school, was bullied or was a
school bully)
5. Cruelty to animals or other children
(torture of small animals or younger
siblings)
6. History of childhood physical or
sexual abuse
7. Childhood neglect (foster care or
parent alcoholic)
32. 8. Criminal record (e.g. history of
petty offences from an early age or
serious offences such as arson or
assault)
9. Evidence of an inability to
sustain employment(e.g. never worked or
no long-term work; history of conflict
with employers)
10. Disruptive and unsettled
interpersonal/sexual
relationships.
33. There is little consensus within psychiatry regarding the
treat ability of personality disorder, particularly patients
with antisocial personality disorder.
Brief treatments are unsuitable and most therapeutic
interventions involve treatments of greater than 6
months in duration.
Cognitive analytic therapy, dialectical behaviour
therapy and psychodynamic interpersonal therapy have
been shown to be helpful in patients with borderline
personality disorder.
34. Intensive inpatient treatment programmes
lasting months to years have been tried in
patients with anti-social personality
disorder. These therapeutic regimens have
usually been implemented in prison
settings for individuals who have
committed serious sexual or violent
crimes. There is some evidence that very
intensive
35. treatment may be helpful for certain individuals, but all
these treatments require further evaluation before any
firm conclusions can be drawn.
36. There is some evidence that different
kinds of personality may respond
differently to treatment. With cognitive
therapy, patients with obsessional or
anxious personality types do better
than those with borderline personality.
Patients with schizotypal personality
disorder and antisocial personality
disorder are more difficult to treat with
psychotherapeutic methods.
37. Jean is a 44-year-olds woman. She has a history of sexual
abuse and spent several years in care as a child. She was
returned home by social services to live with her mother
when she was 15 years old. Her mother showed little
interest in her and was threatened and bullied by her
stepfather. She ran away from home and spent 2 years living
rough on the streets.She survived by working as a street
prostitute. She has had little schooling and is unable to read
and write. She became pregnant at the age of 17 and was
housed in a small flat by social services. After her son was
born, she suffered from postnatal depression（产后） and
received a brief period of inpatient psychiatric care. During
this period, she began to cut herself.
38. By the time she was 21 years old she had
three children, all by different fathers. She
had begun to abuse alcohol and social
services had placed one of three children
on the at-risk register. She had never
formed any close relationships or
friendships in her and finds it difficult to
trust others. She began frequently to
present at the local A〥E department with
39. Cutting to her arms and chest. She said that
cutting helped to relieve tension but also said
wanted to die. On assessment, she did not
have any biological symptoms of depression
although she complained of feeling
depressed and tired most of the time.
