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Author Topic: Overview of Personality Disorders - John G. Gunderson, MD  (Read 565 times)
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« on: June 09, 2008, 03:21:27 PM »

Merck Manual

Personality disorders are patterns of perceiving, reacting, and relating to other people and events that are relatively inflexible and that impair a person's ability to function socially.

Everyone has characteristic patterns of perceiving and relating to other people and events (personality traits). That is, people tend to cope with stresses in an individual but consistent way. For example, some people respond to a troubling situation by seeking someone else's help; others prefer to deal with problems on their own. Some people minimize problems; others exaggerate them. Regardless of their usual style, however, mentally healthy people are likely to try an alternative approach if their first response is ineffective.

In contrast, people with a personality disorder are rigid and tend to respond inappropriately to problems, to the point that relationships with family members, friends, and coworkers are affected. These maladaptive responses usually begin in adolescence or early adulthood and do not change over time. Personality disorders vary in severity. They are usually mild and rarely severe.

Most people with a personality disorder are distressed about their life and have problems with relationships at work or in social situations. Many people also have mood, anxiety, substance abuse, or eating disorders.

People with a personality disorder are unaware that their thought or behavior patterns are inappropriate; thus, they tend not to seek help on their own. Instead, they may be referred by their friends, family members, or a social agency because their behavior is causing difficulty for others. When they seek help on their own, usually because of the life stresses created by their personality disorder, or troubling symptoms (for example, anxiety, depression, or substance abuse), they tend to believe their problems are caused by other people or by circumstances beyond their control.

Until fairly recently, many psychiatrists and psychologists felt that treatment did not help people with a personality disorder. However, specific types of psychotherapy (talk therapy), sometimes with drugs, have now been shown to help many people. Choosing an experienced, understanding therapist is essential.

Personality disorders are grouped into three clusters. Cluster A personality disorders involve odd or eccentric behavior; cluster B, dramatic or erratic behavior; and cluster C, anxious or inhibited behavior.

Cluster A: Odd or Eccentric Behavior

Paranoid Personality: People with a paranoid personality are distrustful and suspicious of others. Based on little or no evidence, they suspect that others are out to harm them and usually find hostile or malicious motives behind other people's actions. Thus, people with a paranoid personality may take actions that they feel are justifiable retaliation but that others find baffling. This behavior often leads to rejection by others, which seems to justify their original feelings. They are generally cold and distant in their relationships.

People with a paranoid personality often take legal action against others, especially if they feel righteously indignant. They are unable to see their own role in a conflict. They usually work in relative isolation and may be highly efficient and conscientious.

Sometimes people who already feel alienated because of a defect or handicap (such as deafness) are more likely to suspect that other people have negative ideas or attitudes toward them. Such heightened suspicion, however, is not evidence of a paranoid personality unless it involves wrongly attributing malice to others.

Schizoid Personality:  People with a schizoid personality are introverted, withdrawn, and solitary. They are emotionally cold and socially distant. They are most often absorbed with their own thoughts and feelings and are fearful of closeness and intimacy with others. They talk little, are given to daydreaming, and prefer theoretical speculation to practical action. Fantasizing is a common coping (defense) mechanism.

Schizotypal Personality: People with a schizotypal personality, like those with a schizoid personality, are socially and emotionally detached. In addition, they display oddities of thinking, perceiving, and communicating similar to those of people with schizophrenia (see Schizophrenia and Delusional Disorder: Schizophrenia). Although schizotypal personality is sometimes present in people with schizophrenia before they become ill, most adults with a schizotypal personality do not develop schizophrenia.

Some people with a schizotypal personality show signs of magical thinking—that is, they believe that their thoughts or actions can control something or someone. For example, people may believe that they can harm others by thinking angry thoughts. People with a schizotypal personality may also have paranoid ideas.

Cluster B: Dramatic or Erratic Behavior

Histrionic (Hysterical) Personality: People with a histrionic personality conspicuously seek attention, are dramatic and excessively emotional, and are overly concerned with appearance. Their lively, expressive manner results in easily established but often superficial and transient relationships. Their expression of emotions often seems exaggerated, childish, and contrived to evoke sympathy or attention (often erotic or sexual) from others.

People with a histrionic personality are prone to sexually provocative behavior or to sexualizing nonsexual relationships. However, they may not really want a sexual relationship; rather, their seductive behavior often masks their wish to be dependent and protected. Some people with a histrionic personality also are hypochondriacal and exaggerate their physical problems to get the attention they need.

Narcissistic Personality: People with a narcissistic personality have a sense of superiority, a need for admiration, and a lack of empathy. They have an exaggerated belief in their own value or importance, which is what therapists call grandiosity. They may be extremely sensitive to failure, defeat, or criticism. When confronted by a failure to fulfill their high opinion of themselves, they can easily become enraged or severely depressed. Because they believe themselves to be superior in their relationships with other people, they expect to be admired and often suspect that others envy them. They believe they are entitled to having their needs met without waiting, so they exploit others, whose needs or beliefs they deem to be less important. Their behavior is usually offensive to others, who view them as being self-centered, arrogant, or selfish. This personality disorder typically occurs in high achievers, although it may also occur in people with few achievements.

Antisocial Personality: People with an antisocial personality (previously called psychopathic or sociopathic personality), most of whom are male, show callous disregard for the rights and feelings of others. Dishonesty and deceit permeate their relationships. They exploit others for material gain or personal gratification (unlike narcissistic people, who exploit others because they think their superiority justifies it).

Characteristically, people with an antisocial personality act out their conflicts impulsively and irresponsibly. They tolerate frustration poorly, and sometimes they are hostile or violent. Often they do not anticipate the negative consequences of their antisocial behaviors and, despite the problems or harm they cause others, do not feel remorse or guilt. Rather, they glibly rationalize their behavior or blame it on others. Frustration and punishment do not motivate them to modify their behaviors or improve their judgment and foresight but, rather, usually confirm their harshly unsentimental view of the world.

People with an antisocial personality are prone to alcoholism, drug addiction, sexual deviation, promiscuity, and imprisonment. They are likely to fail at their jobs and move from one area to another. They often have a family history of antisocial behavior, substance abuse, divorce, and physical abuse. As children, many were emotionally neglected and physically abused. People with an antisocial personality have a shorter life expectancy than the general population. The disorder tends to diminish or stabilize with age.

Borderline Personality: People with a borderline personality, most of whom are women, are unstable in their self-image, moods, behavior, and interpersonal relationships. Their thought processes are more disturbed than those of people with an antisocial personality, and their aggression is more often turned against the self. They are angrier, more impulsive, and more confused about their identity than are people with a histrionic personality. Borderline personality becomes evident in early adulthood but becomes less common in older age groups.

People with a borderline personality often report being neglected or abused as children. Consequently, they feel empty, angry, and deserving of nurturing. They have far more dramatic and intense interpersonal relationships than people with cluster A personality disorders. When they fear being abandoned by a caring person, they tend to express inappropriate and intense anger. People with a borderline personality tend to see events and relationships as black or white, good or evil, but never neutral.

When people with a borderline personality feel abandoned and alone, they may wonder whether they actually exist (that is, they do not feel real). They can become desperately impulsive, engaging in reckless promiscuity , substance abuse, or self-mutilation. At times they are so out of touch with reality that they have brief episodes of psychotic thinking, paranoia, and hallucinations.

People with a borderline personality commonly visit primary care doctors. Borderline personality is also the most common personality disorder treated by therapists, because people with the disorder relentlessly seek someone to care for them. However, after repeated crises, vague unfounded complaints, and failures to comply with therapeutic recommendations, caretakers—including doctors—often become very frustrated with them and view them erroneously as people who prefer complaining to helping themselves.

Cluster C: Anxious or Inhibited Behavior

Avoidant Personality: People with an avoidant personality are overly sensitive to rejection, and they fear starting relationships or anything new. They have a strong desire for affection and acceptance but avoid intimate relationships and social situations for fear of disappointment and criticism. Unlike those with a schizoid personality, they are openly distressed by their isolation and inability to relate comfortably to others. Unlike those with a borderline personality, they do not respond to rejection with anger; instead, they withdraw and appear shy and timid. Avoidant personality is similar to generalized social phobia (see Anxiety Disorders: Social Phobia).

Dependent Personality: People with a dependent personality routinely surrender major decisions and responsibilities to others and permit the needs of those they depend on to supersede their own. They lack self-confidence and feel intensely insecure about their ability to take care of themselves. They often protest that they cannot make decisions and do not know what to do or how to do it. This behavior is due partly to a reluctance to express their views for fear of offending the people they need and partly to a belief that others are more capable. People with other personality disorders often have traits of a dependent personality, but the dependent traits are usually hidden by the more dominant traits of the other disorder. Sometimes adults with a prolonged illness or physical handicap develop a dependent personality.

Obsessive-Compulsive Personality: People with an obsessive-compulsive personality are preoccupied with orderliness, perfectionism, and control. They are reliable, dependable, orderly, and methodical, but their inflexibility makes them unable to adapt to change. Because they are cautious and weigh all aspects of a problem, they have difficulty making decisions. They take their responsibilities seriously, but because they cannot tolerate mistakes or imperfection, they often have trouble completing tasks. Unlike the mental health disorder called obsessive-compulsive disorder (see Anxiety Disorders: Obsessive-Compulsive Disorder (OCD)), obsessive-compulsive personality does not involve repeated, unwanted obsessions and ritualistic behavior.

People with an obsessive-compulsive personality are often high achievers, especially in the sciences and other intellectually demanding fields that require order and attention to detail. However, their responsibilities make them so anxious that they can rarely enjoy their successes. They are uncomfortable with their feelings, with relationships, and with situations in which they lack control or must rely on others or in which events are unpredictable.

Other Personality Types

Some personality types are not classified as disorders.

Passive-Aggressive (Negativistic) Personality: People with a passive-aggressive personality behave in ways that appear inept or passive. However, these behaviors are actually ways to avoid responsibility or to control or punish others. People with a passive-aggressive personality often procrastinate, perform tasks inefficiently, or claim an implausible disability. Frequently, they agree to perform tasks they do not want to perform and then subtly undermine completion of the tasks. Such behavior usually enables them to deny or conceal hostility or disagreements.

Cyclothymic Personality: People with cyclothymic personality alternate between high-spirited buoyancy and gloomy pessimism. Each mood lasts weeks or longer. Mood changes occur regularly and without any identifiable external cause. Many gifted and creative people have this personality type (Depression and Mania: Symptoms and Diagnosis).

Depressive Personality: This personality type is characterized by chronic moroseness, worry, and self-consciousness. People have a pessimistic outlook, which impairs their initiative and disheartens others. To them, satisfaction seems undeserved and sinful. They may unconsciously believe their suffering is a badge of merit needed to earn the love or admiration of others.

John Gunderson, MD, is a Professor of Psychiatry at Harvard Medical School. He chaired the DSM IV work group on personality disorders, and currently chairs a major NIMH-funded collaborative study on the longitudinal stability of personality disorders.

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