GENERAL PERSONALITY DISORDER

General  personality  disorder :

Definition :

              “An alternative to the categorical approach is the dimensional perspective that personality disorders represent maladaptive variants of personality traits that merge imperceptibly into normality and into one another”.

Cluster A :

• Paranoid personality disorder 
• Schizoid personality disorder
• Schizotypal personality disorder

Cluster B:

• Antisocial personality disorder
• Borderline personality disorder
• Histrionic personality disorder 

 

Cluster A…

Paranoid Personality Disorder

• Diagnostic Features :

Individuals with this disorder assume that other people will exploit, harm, or deceive them, even if no evidence exists to support this expectation (Criterion Al). They suspect on the basis of little or no evidence that others are plotting against them and may attack them suddenly, at any time and without reason. They are preoccupied with unjustified doubts about the loyalty or trustworthiness of their friends and associates, whose actions are minutely scrutinized for evidence of hostile intentions (Criterion A2).Individuals with paranoid personality disorder are reluctant to confide in or become close to others because they fear that the information they share will be used against them (Criterion A3). They may refuse to answer personal questions, saying that the information is "nobody's business." They read hidden meanings that are demeaning and threatening into benign remarks or events (Criterion A4). Individuals with this disorder persistently bear grudges and are unwilling to forgive the insults, injuries, or slights that they think they have received (Criterion A5). They are quick to counterattack and react with anger to perceived insults (Criterion A6). Individuals with this disorder may be pathologically jealous, often suspecting that their spouse or sexual partner is unfaithful without any adequate justification (Criterion A7). They may gather trivial and circumstantial "evidence" to support their jealous beliefs.

Paranoid personality disorder should not be diagnosed if the pattern of behavior occurs

exclusively during the course of schizophrenia, a bipolar disorder or depressive disorder with psychotic features, or another psychotic disorder, or if it is attributable to the physiological effects of a neurological (e.g., temporal lobe epilepsy) or another medical condition (Criterion B).

• Associated Features Supporting Diagnosis

Individuals with paranoid personality disorder are generally difficult to get along with and often have problems with close relationships. Their excessive suspiciousness and hostility may be expressed in overt argumentativeness, in recurrent complaining, or by quiet ,apparently hostile aloofness. Because they are hyper vigilant for potential threats, they may act in a guarded, secretive, or devious manner and appear to be "cold" and lacking in tender feelings.. They are often rigid, critical of others, and unable to collaborate, although they have great difficulty accepting criticism themselves.. Individuals with this disorder seek to confirm their preconceived negative notions regarding people or situations they encounter, attributing malevolent motivations to others that are projections of their own fears. They may exhibit thinly hidden, unrealistic grandiose fantasies, are often attuned to issues of power and rank, and tend to develop negative stereotypes of others, particularly those from population groups distinct from their own. Attracted by simplistic formulations of the world, they are often wary of ambiguous situations. In some instances, paranoid personality disorder may appear as the premorbid antecedent of delusional disorder or schizophrenia. Individuals with paranoid personality disorder may develop major depressive disorder and may be at increased risk for agoraphobia and obsessive-compulsive disorder. Alcohol and other substance use disorders frequently occur. The most common cooccurring personality disorders appear to be schizotypal, schizoid, narcissistic, avoidant, and borderline.

• Prevalence:

A prevalence estimate for paranoid personality suggests a prevalence of 2.3% while the national survey on alcohol suggest prevalence of 4.4%.

• Development and Course:

Paranoid personality disorder may be first apparent in childhood and adolescence with solitariness, poor peer relationships, social anxiety, underachievement in school, hypersensitivity, peculiar thoughts and language, and idiosyncratic fantasies.

• Risk and Prognostic Factors :

Genetic and physiological. There is some evidence for an increased prevalence of paranoid personality disorder and for a more specific familial relationship with delusional disorder, persecutory type.

• Eitiology:

Psychodynamic theories, the oldest of these explanations, trace the pattern to early interactions with demanding parents, particularly distant, rigid fathers and overcontrolling, rejecting mothers. According to one psychodynamic view, some people come to view their environment as hostile as a result of their parents’ persistently unreasonable demands. They must always be on the alert because they cannot trust others, and they are likely to develop feelings of extreme anger. They also project these feelings onto others and, as a result, feel increasingly persecuted, Similarly, some cognitive-bbehavioral theorists suggest that people with paranoid personality disorder generally hold broad maladaptive assumptions, such as “People are evil” and “People will attack you if given the chance”. Biological theorists propose that paranoid personality disorder has genetic causes. A widely reported study that looked at self-reports of suspiciousness in 3,810 Australian twin pairs found that if one twin was excessively suspicious, the other had an increased likelihood of also being suspicious. Once again, however, it is important to note that such similarities between twins might also be the result of common environmental experiences.

• Treatment. :

People with paranoid personality disorder do not typically see themselves as needing help, and few come to treatment willingly. Furthermore, many who are in treatment view the role of patient as inferior and distrust and rebel against their therapists. Thus, it is not surprising that therapy for this disorder, as for most other personality disorders, has limited effect and moves very slowly. Object relations therapists—the psychodynamic therapists who give centre stage to relationships—try to see past the patient’s anger and work on what they view as his or her deep wish for a satisfying relationship. Self-therapists—the psychodynamic clinicians who focus on the need for a healthy and unified self—try to help clients re-establish self- cohesion (a unified personality), which they believe has been lost in the person’s continuing negative focus on others. Cognitive-behavioural therapy has also been used to treat people with paranoid personality disorder. On the behavioural side, therapists help clients to master anxiety-reduction techniques and to improve their skills at solving interpersonal problems. On the cognitive side, therapists guide the clients to develop more realistic interpretations of other people’s words and actions and to become more aware of other people’s points of view. 

Schizoid Personality Disorder.

• Diagnostic Features :

Individuals with schizoid personality disorder appear to lack a desire for intimacy, seem indifferent to opportunities to develop close relationships, and do not seem to derive much satisfaction from being part of a family or other social group (Criterion Al) They often appear to be socially isolated or "loners" and almost always choose solitary activities or hobbies that do not include interaction with others (Criterion A2). They prefer mechanical or abstract tasks, such as computer or mathematical games. They may have very little interest in having sexual experiences with another person (Criterion A3) and take pleasure in few, if any, activities (Criterion A4). These individuals have no close friends or confidants, except possibly a first-degree relative (Criterion A5). Individuals with schizoid personality disorder often seem indifferent to the approval or criticism of others and do not appear to be bothered by what others may think of them (Criterion A6). They usually display a "bland" exterior without visible emotional reactivity and rarely reciprocate gestures or facial expressions, such as smiles or nods (Criterion A7). Schizoid personality disorder should not be diagnosed if the pattern of behavior occurs exclusively during the course of schizophrenia, a bipolar or depressive disorder with psychotic features, another psychotic disorder, or autism spectrum disorder, or if it is attributable to the physiological effects of a neurological (e.g., temporal lobe epilepsy).

• Associated Features Supporting Diagnosis

Individuals with schizoid personality disorder may have particular difficulty expressing anger, even in response to direct provocation, which contributes to the impression lack emotion. Their lives sometimes seem directionless, and they may appear to "drift" in their goals. Such individuals often react passively to adverse circumstances and have difficulty responding appropriately to important life events. Because of their lack of social skills and lack of desire for sexual experiences, individuals with this disorder have few friendships, date infrequently, and often do not marry. Occupational functioning may be impaired, particularly if interpersonal involvement is required, but individuals with this disorder may do well when they work under conditions of social isolation. Particularly in response to stress, individuals with this disorder may experience very brief psychotic episodes (lasting minutes to hours). In some instances, schizoid personality disorder may appear as the premorbid antecedent of delusional disorder or schizophrenia. Individuals with this disorder may sometimes develop major depressive disorder .Schizoid personality disorder most often co-occurs with schizotypal, paranoid, and avoidant personality disorders.

• Prevalence

A prevalence estimate for schizoid personality based on a probability .Replication suggests a prevalence of 4.9%. Data from the 2001-2002 National Epidemiologic Survey on Alcohol and Related Conditions suggest a prevalence of 3.1%.

• Development and Course

Schizoid personality disorder may be first apparent in childhood and adolescence with solitariness, poor peer relationships, and underachievement in school, which mark these children or adolescents as different and make them subject to teasing.

• Risk  Prognostic Factors

Genetic and physiological. Schizoid personality disorder may have increased prevalence in the relatives of individuals with schizophrenia or schizotypal personality disorder

• Eitiology: 

Many psychodynamic theorists, particularly object relations theorists, propose that schizoid personality disorder has its roots in an unsatisfied need for human contact. The parents of people with this disorder, like those of people with paranoid personality disorder, are believed to have been unaccepting or even abusive of their children. Whereas people with paranoid symptoms react to such parenting chiefly with distrust, those with schizoid personality disorder are left unable to give or receive love. They cope by avoiding all relationships. Cognitive-behavioral theorists propose, not surprisingly, that people with schizoid personality disorder suffer from deficiencies in their thinking. Their thoughts tend to be vague, empty, and without much meaning, and they have trouble scanning the environment to arrive at accurate perceptions. Unable to pick up emotional cues from others, they simply cannot respond to emotions. As this theory might predict, children with schizoid personality disorder develop language and motor skills very slowly, whatever their level of intelligence.

• Treatment. 

Their social withdrawal prevents most people with schizoid personality disorder from entering therapy unless some other disorder, such as alcoholism, makes treatment necessary. These clients are likely to remain emotionally distant from the therapist, seem not to care about their treatment, and make limited progress at best. Cognitive-behavioral therapists have sometimes been able to help people with this disorder experience more positive emotions and more satisfying social interactions. On the cognitive end, their techniques include presenting clients with lists of emotions to think about or having them write down and remember pleasurable experiences. On the behavioral end, therapists have sometimes had success teaching social skills to such clients, using role-playing, exposure techniques, and homework assignments as tools. Group therapy is apparently useful when it offers a safe setting for social contact, although people with schizoid personality disorder may resist pressure to take part. As with paranoid personality disorder, drug therapy seems to offer limited help

Schizotypal Personality Disorder

• Diagnostic feature

The essential feature of schizotypal personality disorder is 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.Individuals with schizotypal personality disorder often have ideas of reference (i.e., in-correct interpretations of casual incidents and external events as having a particular and unusual meaning specifically for the person) (Criterion Al).. These individuals may be superstitious or preoccupied with paranormal phenomena that are outside the norms of their subculture (Criterion A2). They may feel that they have special powers to sense events before they happen or to read others' thoughts. They may believe that they have magical control over others, which can be implemented directly (e.g., believing that their spouse's taking the dog out for a walk is the direct result of thinking an hour earlier it should be done) or indirectly through compliance with magical rituals (e.g., walking past a specific object three times to avoid a certain harmful outcome). Perceptual alterations may be present (e.g., sensing that another person is present or hearing a voice murmuring his or her name) (Criterion A3). Their speech may include unusual or idiosyncratic phrasing and construction. It is often loose, digressive, or vague, but without actual derailment or incoherence (Criterion A4). Individuals with this disorder are often suspicious and may have paranoid ideation (e.g., believing their colleagues at work are intent on undermining their reputation with the boss) (Criterion A5), They are usually not able to negotiate the full range of affects and interpersonal cuing required for successful relationships and thus often appear to interact with others in an inappropriate, stiff, or constricted fashion (Criterion A6). These individuals are often considered to be odd or eccentric because of unusual mannerisms, an often unkempt manner of dress that does not quite "fit together," and inattention to the usual social conventions (e.g., the individual may avoid eye contact, wear clothes that are ink stained and ill-fitting, and be unable to join in the give-and-take banter of co-workers) (Criterion A7).. Although they may express unhappiness about their lack of relationships, their behavior suggests a decreased desire for intimate contacts. As a result, they usually have no or few close friends or confidants other than a first-degree relative (Criterion A8). They are anxious in social situations, particularly those involving unfamiliar people (Criterion A9).

• Associated Features Supporting Diagnosis

Individuals with schizotypal personality disorder often seek treatment for the associated symptoms of anxiety or depression rather than for the personality disorder features per se. Particularly in response to stress, individuals with this disorder may experience transient psychotic episodes (lasting minutes to hours), although they usually are insufficient in duration to warrant an additional diagnosis such as brief psychotic disorder or schizophren form disorder. In some cases, clinically significant psychotic symptoms may develop that meet criteria for brief psychotic disorder, schizophreniform disorder, delusional disorder,or schizophrenia. Over half may have a history of at least one major depressive episode .From 30% to 50% of individuals diagnosed with this disorder have a concurrent diagnosis of major depressive disorder when admitted to a clinical setting..

• Prevalence:

The prevalence of schizotypal personality disorder in clinical populations seems to be infrequent (0%-1.9%), with a higher estimated prevalence in the general population (3.9%) found in the National Epidemiologic Survey on Alcohol and Related Conditions.

• Development and Course:

Schizotypal personality disorder has a relatively stable course, with only a small proportion of individuals going on to develop schizophrenia or another psychotic disorder. Schizotypal personality disorder may be first apparent in childhood and adolescence with solitariness, poor peer relationships, social anxiety, underachievement in school, hyper-sensitivity, peculiar thoughts and language, and bizarre fantasies. 

• Risk and Prognostic Factors:

Genetic and physiological. Schizotypal personality disorder appears to aggregate familially and is more prevalent among the first-degree biological relatives of individuals with schizophrenia than among the general population.

• Eitiology:

Investigators have found that schizotypal symptoms, like schizophrenic patterns, are often linked to family conflicts and to psychological disorders in parents. They have also learned that defects in attention and short-term memory may contribute to schizotypal personality disorder, just as they apparently do to schizophrenia. For example, research participants with either disorder perform poorly on backward masking, a laboratory test of attention that requires a person to identify a visual stimulus immediately after a previous stimulus has flashed on and off the screen. People with these disorders have a hard time shutting out the first stimulus in order to focus on the second. Finally, researchers have linked schizotypal personality disorder to some of the same biological factors found in schizophrenia, such as high activity of the neurotransmitter dopamine, enlarged brain ventricles, smaller temporal lobes, and loss of gray matter. There are indications that these biological factors may have a genetic basis. Although these findings do suggest a close relationship between schizotypal personality disorder and schizophrenia, the personality disorder also has been linked to disorders of mood. Around two-thirds of people with schizotypal personality disorder also suffer from major depressive disorder or bipolar disorder at some point in their lives. Moreover, relatives of people with depression have a higher than usual rate of schizotypal personality disorder, and vice versa. Thus, at the very least, this personality disorder is not tied exclusively to schizophrenia.

• Treatment. 

Therapy is as difficult in cases of schizotypal personality disorder as it is incising of paranoid and schizoid personality disorders. Most therapists agree on the need to help these clients “reconnect” with the world and recognize the limits of their thinking and their powers. Cognitive-behavioral therapists further combine cognitive and behavioral techniques to help people with schizotypal personality disorder function more effectively. Using cognitive interventions, they try to teach clients to evaluate their unusual thoughts or perceptions objectively and to ignore the inappropriate ones.

Antipsychotic drugs have been given to people with schizotypal personality disorder, again because of the disorder’s similarity to schizophrenia. In low doses the drugs appear to have helped some people, usually by reducing certain of their thought problems.

Cluster B..

Antisocial Personality Disorder.

• Diagnostic Features:

The essential feature of antisocial personality disorder is a pervasive pattern of disregard for, and violation of, the rights of others that begins in childhood or early adolescence and continues into adulthood. This pattern has also been referred to as psychopathy, sociopathy, or dyssocial personality disorder. The pattern of antisocial behavior continues into adulthood. Individuals with antisocial personality disorder fail to conform to social norms with respect to lawful behavior (Criterion Al). They are frequently deceitful and manipulative in order to gain personal profit or pleasure (e.g., to obtain money, sex, or power) (Criterion A2). They may repeatedly lie, use an alias, con others, or malinger. A pattern of impulsivity may be manifested by a failure to plan ahead (Criterion A3) Individuals with antisocial personality disorder tend to be irritable and aggressive and may repeatedly get into physical fights or commit acts of physical assault (including spouse beating or child beating) (Criterion A4) These individuals also display a reckless disregard for the safety of themselves or others (Criterion A5). This may be evidenced in their driving behavior (i.e., recurrent speeding, driving while intoxicated, multiple accidents). Individuals with antisocial personality disorder also tend to be consistently and extremely irresponsible (Criterion A6). Irresponsible work behavior may be indicated by significant periods of unemployment despite available job opportunities, or by abandonment of several jobs without a realistic plan for getting another job. Individuals with antisocial personality disorder show little remorse for the consequences of their acts (Criterion A7).

• Associated Features Supporting Diagnosis:

Individuals with antisocial personality disorder frequently lack empathy and tend to be callous, cynical, and contemptuous of the feelings, rights, and sufferings of others. They may have an inflated and arrogant self-appraisal (e.g., feel that ordinary work is beneath them or lack a realistic concern about their current problems or their future) and may be excessively opinionated, self-assured, or cocky. They may display a glib, superficial charm and can be quite voluble and verbally facile (e.g., using technical terms or jargon that might impress someone who is unfamiliar with the topic). These individuals may also be irresponsible and exploitative in their sexual relationships. They may have a history of many sexual partners and may never have sustained a monogamous relationship. They may be irresponsible as parents, as evidenced by malnutrition of a child, an illness in the child resulting from a of minimal hygiene, a child's dependence on neighbors or nonresident relatives for food or shelter, a failure to arrange for a caretaker for a young child when the individual is away from home, or repeated squandering of money required for household necessities. Individuals with antisocial personality disorder may also experience dysphoria, including complaints of tension, inability to tolerate boredom, and depressed mood. They may have associated anxiety disorders, depressive disorders, substance use disorders, somatic symptom disorder, gambling disorder, and other disorders of impulse control. Individuals with antisocial personality disorder also often have personality features that meet criteria for other personality disorders, particularly borderline, histrionic, and narcissistic personality disorders. Child abuse or neglect, unstable or erratic parenting, or inconsistent parental discipline may increase the likelihood that conduct disorder will evolve into antisocial personality disorder.

• Prevalence

Twelve-month prevalence rates of antisocial personality disorder, using criteria from previous DSMs, are between 0.2% and 3.3%. The highest prevalence of antisocial personality disorder (greater than 70%) is among most severe samples of males with alcohol use disorder and from substance abuse clinics, prisons, or other forensic settings..

• Development and Course:

Antisocial personality disorder has a chronic course but may become less evident or remit as the individual grows older, particularly by the fourth decade of life. By definition, antisocial personality cannot be diagnosed before age 18 years.

• Risk and Prognostic Factors:

Genetic and physiological. Antisocial personality disorder is more common among the first-degree biological relatives of those with the disorder than in the general population. The risk to biological relatives of females with the disorder tends to be higher than the risk to biological relatives of males with the disorder.

• Etiology:

PSYCHODYNAMIC FACTORS As with many other personality disorders, psychodynamic theorists propose that this one begins with an absence of parental love during infancy, leading to a lack of basic trust. In this view, some children—the ones who develop antisocial personality disorder—respond to the early inadequacies by becoming emotionally distant, and they bond with others through the use of power and destructiveness. In support of the psychodynamic explanation, researchers have found that people with this disorder are more likely than others to have had significant stress in their childhoods, particularly in such forms as family poverty, family violence, child abuse, and parental conflict or divorce.

COGNITIVE-BEHAVIORAL FACTORS On the behavioral side, many theorists have suggested that antisocial symptoms may be learned through principles of conditioning, particularly modeling, or imitation. As evidence, they point to the higher rate of antisocial personality disorder found among the parents and close relatives of people with this disorder (Black, 2016; APA, 2013). The modeling explanation is also supported by studies of friends and associates of people with antisocial personality disorder. For example, one investigation found that middle school students who were attracted to antisocial peers went on to engage in antisocial behavior themselves in order to gain acceptance.

BIOLOGICAL FACTORS A wide range of studies suggest that biological factors play an important role in antisocial personality disorder. First, there are indications that people may inherit a biological predisposition to the disorder. For example, twin research has found that 67 percent of the identical twins of people with antisocial personality disorder also display the disorder themselves, in contrast to 31 percent of fraternal twins of people with the disorder. In a similar vein, some genetic research suggests that the disorder may be linked to particular genes.

• Treatment:

Treatments for people with antisocial personality disorder are typically ineffective. Major obstacles to treatment include the individual’s lacking a conscience, a desire to change, or respect for therapy. Most of those in therapy have been forced to participate by an employer, their school, or the law, or they come to the attention of therapists when they also develop another psychological disorder. Some cognitive-behavioral therapists try to guide clients with antisocial personality disorder to think about moral issues and about the needs of other people.

 

Borderline Personality Disorder

• Diagnostic Features:

The essential feature of borderline personality disorder is a pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity that begins by early adulthood and is present in a variety of contexts .Individuals with borderline personality disorder make frantic efforts to avoid real or imagined abandonment (Criterion 1). Individuals with borderline personality disorder have a pattern of unstable and intense relationships (Criterion 2). These individuals are prone to sudden and dramatic shifts in their view of others, who may alternatively be seen as beneficent supports or as cruelly punitive. Such shifts often reflect disillusionment with a caregiver whose nurturing qualities had been idealized or whose rejection or abandonment is expected .There may be an identity disturbance characterized by markedly and persistently unstable self-image or sense of self (Criterion 3).These individuals may show worse performance in unstructured work or school situations .Individuals with borderline personality disorder display impulsivity in at least two areas that are potentially self-damaging (Criterion 4). Individuals with this disorder display recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior (Criterion 5)..Individuals with borderline personality disorder may display affective instability that is due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days) (Criterion 6).. These episodes may reflect the individual's extreme reactivity to interpersonal stresses. Individuals with borderline personality disorder may be troubled by chronic feelings of emptiness (Criterion 7). Easily bored, they may constantly seek something to do. Individuals with this disorder frequently express inappropriate, intense anger or have difficulty controlling their anger (Criterion 8).. During periods of extreme stress, transient paranoid ideation or dissociative symptoms (e.g., depersonalization) may occur (Criterion 9), but these are generally of insufficient severity or duration to warrant an additional diagnosis. These episodes occur most frequently in response to a real or imagined abandonment. Symptoms tend to be transient, lasting minutes or hours. The real or perceived return of the caregiver's nurturance may result in a remission of symptoms.

• Associated Features Supporting Diagnosis

Individuals with borderline personality disorder may have a pattern of undermining themselves at the moment a goal is about to be realized (e.g., dropping out of school just before graduation; regressing severely after a discussion of how well therapy is going; destroying a good relationship just when it is clear that the relationship could last). Some individuals develop psychotic-like symptoms (e.g., hallucinations, body-image distortions, ideas of reference, hypnagogic phenomena) during times of stress. Individuals with this disorder may feel more secure with transitional objects (i.e., a pet or inanimate possession) than in interpersonal relationships. Premature death from suicide may occur in individuals with this disorder, especially in those with co-occurring depressive disorders or substance use disorders. Physical handicaps may result from self-inflicted abuse behaviors or failed suicide attempts. Borderline personlity disorder also frequently co-occurs with the other personality disorders.

• Prevalence:

. The prevalence of borderline personality disorder is about 6% in primary care settings, about 10% among individuals seen in outpatient mental health clinics, and about 20% among psychiatric inpatients. 

• Development and Course

The impairment from the disorder and the risk of suicide are greatest in the young-adult years and gradually wane with advancing age. Although the tendency toward intense emotions, impulsivity, and intensity in relationships is often lifelong, During their 30s and 40s, the majority of individuals with this disorder attain greater stability in their relationships and vocational functioning. 

• Risk and Prognostic Factors

Genetic and physiological. Borderline personality disorder is about five times more common among first-degree biological relatives of those with the disorder than in the general population..

• Etiology. 

PSYCHOLOGICAL FACTORS Because a fear of abandonment tortures so many people with borderline personality disorder, psychodynamic theorists have looked once again to early parental relationships to explain the disorder. Object relations theorists, for example, propose that an early lack of acceptance by parents may lead to a loss of self-esteem, increased dependence, and an inability to cope with separation.

BIOLOGICAL FACTORS There are indications that people may inherit a biological predisposition to develop borderline personality disorder, although the impact of this factor seems to be less influential for this disorder than for antisocial personality disorder. In twin research, for example, it has been found that 35 percent of the identical twins of people with borderline personality disorder also display the disorder themselves, in contrast to 19 percent of fraternal twins of people with the disorder.

SOCIOCULTURAL FACTORS Some sociocultural theorists suggest that cases of borderline personality disorder are particularly likely to emerge in cultures that change rapidly. As a culture loses its stability, they argue, it inevitably leaves many of its members with problems of identity, a sense of emptiness, high anxiety, and fears of abandonment.

• Treatment. 

It appears that psychotherapy can eventually lead to some degree of improvement for people with borderline personality disorder. It is, however, extraordinarily difficult for a therapist to strike a balance between empathizing with the borderline client’s dependency and anger and challenging his or her way of thinking. Contemporary psychodynamic approaches, particularly relational psychoanalytic therapy, in which therapists take a more supportive posture and focus primarily on the therapist−patient relationship, have been more effective than traditional psychoanalytic approaches. In approaches of this kind, therapists work to provide an empathic setting within which borderline clients can explore their unconscious conflicts and pay attention to their central relationship disturbance, poor sense of self, and pervasive loneliness and emptiness.

Histrionic Personality Disorder

• Diagnostic Features:

The essential feature of histrionic personality disorder is pervasive and excessive emotionality and attention-seeking behavior. This pattern begins by early adulthood and is present in a variety of contexts .Individuals with histrionic personality disorder are uncomfortable or feel unappreciated when they are not the center of attention (Criterion 1)..The appearance and behavior of individuals with this disorder are often inappropriately sexually provocative or seductive (Criterion 2). This behavior not only is directed toward persons in whom the individual has a sexual or romantic interest but also occurs in a wide variety of social, occupational, and professional relationships beyond what is For example appropriate for the social context. Emotional expression may be shallow and rapidly shifting (Criterion 3). Individuals with this disorder consistently use physical appearance to draw attention to themselves (Criterion 4). They may "fish for compliments" regarding appearance and may be easilyand excessively upset by a critical conunent about how they look or by a photograph that they regard as unflattering.These individuals have a style of speech that is excessively impressionistic and lacking in detail (Criterion 5). Strong opinions are expressed with dramatic flair, but underlying reasons are usually vague and diffuse, without supporting facts and details., an individual with histrionic personality disorder may comment that a certain individual is a wonderful human being, yet be unable to provide any specific examples of good qualities to support this opinion. Individuals with this disorder are characterized by self-dramatization, theatricality, and an exaggerated expression of emotion (Criterion 6). .Individuals with histrionic personality disorder have a high degree of suggestibility (Criterion 7). Individuals with this disorder often consider relationships more intimate than they actually are, describing almost every acquaintance as "my dear, dear friend" or referring to physicians met only once or twice under professional circumstances by their first names (Criterion 8).

• Associated Features Supporting Diagnosis

Individuals with histrionic personality disorder may have difficulty achieving emotional intimacy in romantic or sexual relationships.. Individuals with this disorder often have impaired relationships with same-sex friends because their sexually provocative interpersonal style may seem a threat to their friends' relationships. These individuals may also alienate friends with demands for constant attention. They often become depressed and upset when they are not the center of attention. They may crave novelty, stimulation, and excitement and have a tendency to become bored with their usual routine. These individuals are often intolerant of, or frustrated by, situations that involve delayed gratification, and their actions are often directed at obtaining immediate satisfaction.. Longer-term relationships may be neglected to make way for the excitement of new relationships .The actual risk of suicide is not known, but clinical experience suggests that individuals with this disorder are at increased risk for suicidal gestures and threats to get attention and coerce better caregiving..

• Prevalence

Data from the 2001-2002 National Epidemiologic Survey on Alcohol and Related Conditions suggest a prevalence of histrionic personality of 1.84%.

• Etiology. 

The psychodynamic perspective was originally developed to help explain cases of hysteria, so it is no surprise that psychodynamic theorists continue to have a strong interest in histrionic personality disorder. Most psychodynamic theorists believe that as children, people with this disorder had cold and controlling parents who left them feeling unloved and afraid of abandonment. To defend against deep-seated fears of loss, the children learned to behave dramatically, inventing crises that would require other people to act protectively.

Cognitive-behavioral explanations look instead at the lack of substance and extreme suggestibility that people with histrionic personality disorder have. Cognitive-behavioral theorists see these people as becoming less and less interested in knowing about the world at large because they are so self-focused and emotional. With no detailed memories of what they never learned, they must rely on hunches or on other people to provide them with direction in life.

• Treatment. 

People with histrionic personality disorder are more likely than those with most other personality disorders to seek out treatment on their own. Working with them can be very difficult, however, because of the demands, tantrums, and seductiveness they are likely to deploy. Another problem is that these clients may pretend to have important insights or to change during treatment merely to please the therapist. To head off such problems, therapists must remain objective and maintain strict professional boundaries. Cognitive-behavioral therapists have tried to help people with this disorder to change their belief that they are helpless and also to develop better, more deliberate ways of thinking and solving problems. Psychodynamic therapy and various group therapy formats have also been used.

Narcissistic Personality Disorder

• Diagnostic Features

The essential feature of narcissistic personality disorder is a pervasive pattern of grandiosity, need for admiration, and lack of empathy that begins by early adulthood and is present in a variety of contexts. Individuals with this disorder have a grandiose sense of self-importance (Criterion 1). Individuals with narcissistic personality disorder are often preoccupied with fantasies of unlimited success, power, brilliance ,beauty, or ideal love (Criterion 2). .Individuals with narcissistic personality disorder believe that they are superior, special, or unique and expect others to recognize them as such (Criterion 3).. They are likely to insist on having only the "top" person (doctor, lawyer, hairdresser, instructor) or being affiliated with the "best" institutions but may devalue the credentials of those who disappoint them. Individuals with this disorder generally require excessive admiration (Criterion 4). They may constantly fish for compliments, often with great charm. A sense of entitlement is evident in these individuals' unreasonable expectation of especially favorable treatment (Criterion 5). They expect to be catered to and are puzzled or furious when this does not happen. For example, they may assume that they do not have to wait in line and that their priorities are so important that others should defer to them, and then get irritated when others fail to assist "in their very important work." This sense of entitlement, combined with a lack of sensitivity to the wants and needs of others, may result in the conscious or unwitting exploitation of others (Criterion 6). They often special privileges and extra resources that they believe they deserve because they are so special .Individuals with narcissistic personality disorder generally have a lack of empathy and have difficulty recognizing the desires, subjective experiences, and feelings of others (Criterion 7)..These individuals are often envious of others or believe that are envious of them (Criterion 8). They may begrudge others their successes or possessions, feeling that they better deserve those achievements, admiration, or privileges. They may harshly devalue the contributions of others, particularly when those individuals have received acknowledgment or praise for their accomplishments. Arrogant, haughty behaviors characterize these individuals; they often display snobbish, disdainful, or patronizing attitudes (Criterion 9). For example, an individual with this disorder may complain about a clumsy waiter's "rudeness" or "stupidity" or conclude a medical evaluation with a condescending evaluation of the physician.

• Associated Features Supporting Diagnosis

Vulnerability in self-esteem makes individuals with narcissistic personality disorder very sensitive to "injury" from criticism or defeat. Although they may not show it outwardly, criticism may haunt these individuals and may leave them feeling humiliated, degraded, hollow, and empty.. Though overweening ambition and confidence may lead to high achievement, performance may be disrupted because of intolerance of criticism or defeat.Sometimes vocational functioning can be very low, reflecting an unwillingness to take a risk in competitive or other situations in which defeat is possible. Sustained feelings of shame or humiliation and the attendant self-criticism may be associated with social with drawal, depressed mood, and persistent depressive disorder (dysthymia) or major depressive disorder. In contrast, sustained periods of grandiosity may be associated with a hypomanie mood. Narcissistic personality disorder is also associated with anorexia nervosa and substance use Histrionic, borderline, antisocial, and paranoid personality disorders may be associated with narcissistic personality disorder.

 

• Prevalence

Prevalence estimates for narcissistic personality disorder, based on DSM-IV definitions, range from 0% to 6.2% in community samples.

• Development and Course

Narcissistic traits may be particularly common in adolescents and do not necessarily indicate that the individual will go on to have narcissistic personality disorder. 

• Etiology. 

Psychodynamic theorists more than others have theorized about narcissistic personality disorder, and they again propose that the problem begins with cold, rejecting parents. They argue that some people with this background spend their lives defending against feeling unsatisfied, rejected, unworthy, ashamed, and wary of the world. They do so by repeatedly telling themselves that they are actually perfect and desirable, and also by seeking admiration from others. A number of cognitive-behavioral theorists propose that narcissistic personality disorder may develop when people are treated too positively rather than too negatively in early life. They hold that certain children acquire a superior and grandiose attitude when their “admiring or doting parents” teach them to “overvalue their self-worth,” repeatedly rewarding them for minor accomplishments or for no accomplishment at all.

• Treatment. 

Narcissistic personality disorder is one of the most difficult personality patterns to treat because the clients are unable to acknowledge weaknesses, to appreciate the effect of their behavior on others, or to incorporate feedback from others. The clients who consult therapists usually do so because of a related disorder such as depression. Once in treatment, the clients may try to manipulate the therapist into supporting their sense of superiority. Some also seem to project their grandiose attitudes onto their therapists and develop a love-hate stance toward them (Colli et al., 2014; Shapiro, 2004). Psychodynamic therapists seek to help people with this disorder recognize and work through their basic insecurities and defenses. Cognitive-behavioral therapists, focusing on the self-centered thinking of such individuals, try to redirect the clients’ focus onto the opinions of others, teach them to interpret criticism more rationally, increase their ability to empathize, and change their all-or-nothing notion. None of the approaches have had clear success.

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