Personality disorders

Personality disorders are encompassing all spheres of life and stable behavioral features that cause pronounced distress and disruption of functioning. There are 10 separate personality disorders that are grouped into three clusters. The diagnosis is based on clinical data. The treatment uses psychotherapy and sometimes medical therapy.

Personal traits are features of thinking, perception, response and attitude, which are relatively stable in time and in different situations. Personal traits usually become apparent from late adolescence to an early adult, and although many traits remain unchanged throughout life, some may fade or change with age. The presence of personality disorder can be said in the event that these traits become so stiff and disadaptive that they disrupt the functioning. Psychological coping mechanisms with stress (psychological defense), which unconsciously use everything from time to time, people with personality disorders are often immature and inadequate.

People with personality disorders are often in a state of frustration and may even disrupt their anger at others (including doctors). Most are concerned about their lives, have problems with work and in dealing with people. Personality disorders are often combined with mood disorders, anxiety, substance abuse and eating disorders. Patients with severe personality disorders have a high risk of hypochondria, violence and autodestructive behavior. In the family, they can lead a contradictory, disconnected, overly emotional, cruel or irresponsible education leading to the development of physical and somatic problems in their children.

About 13% of the general population have personality disorders. Antisocial personality disorder occurs in about 2% of the population, with a high prevalence among men than among women (6: 1). Borderline personality disorder occurs in about 2% of the population, among women more than among men (3: 1).

[1], [2], [3]

Diagnosis and classification of personality disorders

Emotional reactions of the patient, his view on the causes of his problems, the attitude of others to him - all this can give information about the disorder. The diagnosis is based on observation of repetitive behaviors or perceptions that cause distress and disturbances in social functioning. The patient is usually not sufficiently critical of these behaviors, therefore it is better to start with the initial evaluation with information from people who are in contact with the patient. Often the suspicion of having a personality disorder comes from a feeling of discomfort in the doctor, usually if the doctor begins to feel anger or tension.

According to the general criteria (DSM-IV) of the Manual on Statistics and Diagnosis of Mental Disorders, the fourth edition, the emphasis is on considering the possible impact of other mental or physical disorders (eg, depression, substance abuse, hyperthyroidism) on the characteristics of the patient's behavior. In DSM-IV, 10 different personality disorders are distinguished, which are divided into 3 clusters: A - unusual / eccentric; B - Impressive / changeable and C - anxious / fearful.

Copying mechanisms 

Mechanism	Definition	Result	Personality disorders
Projection	Attributing your own unconscious feelings to others	It leads to prejudice, the rejection of close relations because of paranoid suspicions, excessive alertness to external danger and collecting injustices	Typical for paranoid and schizotypic personality, occurs in people with a borderline, antisocial or narcissistic personality in a situation of acute stress
Split	Perception or thinking is black and white, all or nothing, when all people are divided into good rescuers and terrible scoundrels	It avoids discomfort from a sense of ambivalence (for example, to experience love and dislike for one and the same person), uncertainty and helplessness	Typical for the borderline personality
Action outside	Immediate behavioral manifestations of unconscious desires or motives, which allows a person to avoid awareness of the concomitant painful or pleasant affect	It leads to many delinquent, ill-considered, disorderly and substance-related actions that can become so common that the actor remains ignorant and free from the feeling that the action was initiated by himself	Very common in people with an antisocial, cyclothymic or borderline personality
Direction of aggression against oneself	The direction of anger is not on others, but on oneself; if directly, it is called self-harm, if indirectly, then by passive aggression	Internalization of feelings about other people's failures; involvement in a silly, provocative clownery	Lies in the basis of a passive-aggressive and depressed person; is dramatic in patients with a borderline personality who show anger on others in the form of self-harm
Fantasy	The tendency to use imaginary relationships and one's own belief system in resolving conflicts and freeing oneself from loneliness	Leads to eccentricity and avoidance of intimacy	Used by people with an avoidant or schizoid personality who, unlike patients in psychosis, are not sure of reality and do not act in accordance with their fantasies
Hypochondria	Use somatic complaints to attract attention	They can get the attention of others; can show anger at others who do not suspect this	Used by people with dependent, hysteroid or borderline personality

[4], [5], [6], [7], [8],

Cluster A

Patients belonging to cluster A tend to be detached and suspicious.

The paranoid personality has such characteristics as coldness and distancing in relationships, with the need to control the situation and a tendency to jealousy, if attachment is formed.

People with this disorder are often secretive and distrustful. They tend to be suspicious of change, they often see hostile and evil motives in the actions of others. Usually these unfriendly motives are a projection of their own hostility to other people. Their reactions sometimes surprise or frighten others. They can use the resulting anger of others and rejection of them (ie, projective identification) to confirm their own perception. Paranoid people tend to experience fair indignation and often take legal action against others. These people can be highly qualified and conscientious, although they usually need relative isolation for work. This disorder must be differentiated from paranoid schizophrenia.

The schizoid personality is characterized by introversion, social detachment, isolation, emotional coldness and distancing. Such people are usually absorbed in their own thoughts and feelings and avoid close, intimate relationships with other people. They are silent, prone to dreaminess, prefer theoretical reasoning to practical actions.

The schizotypic personality, like the schizoid personality, includes social detachment and emotional coldness, but also unusual thinking, perception and communication, such as magical thinking, clairvoyance, relationship ideas or paranoid thinking. These oddities suggest schizophrenia, but not so pronounced as to meet its criteria. It is believed that people with a schizotypic personality have a latent expression of genes that cause schizophrenia.

Cluster B

These patients tend to be emotionally unstable, impulsive, impressionable.

The borderline personality is characterized by unstable self-perception, mood, behavior and relations with others. Such people tend to think that they did not receive adequate care in childhood, and as a consequence, feel emptiness, anger and complain about upbringing. As a result, they are constantly looking for cares and are sensitive to the sense of her absence. Their relationship with people is prone to drama and saturation. When they feel care, they look like lonely vagabonds seeking help from depression, substance abuse, eating disorders, past ill-treatment. When they are afraid of losing a person caring for them, they often display inadequate, expressed anger. Such mood swings are usually accompanied by extreme changes in their views on the world, themselves and others, for example, from bad to good, from hatred to love. When they feel alone, dissociation or pronounced impulsiveness is observed. Their concept of reality is so weak that they can develop short episodes with psychotic disorders, such as paranoid delusions or hallucinations. They often become autodestructive and can cause self-harm and attempt suicide attempts. They are initially inclined to demand special attention, but after repeated crises, vague unjustified complaints and inability to follow therapeutic recommendations, they are perceived as complainants who avoid assistance. Borderline personality disorder tends to become less pronounced and stabilize with age.

The antisocial personality is characterized by a gross disregard for the rights and feelings of others. People with an antisocial personality disorder exploit other people for material gain or personal pleasure. They easily frustrate and do not tolerate the state of stress. They are characterized by impulsive and irresponsible external manifestations of their conflicts, sometimes accompanied by aggression and violence. They can not foresee the consequences of their behavior and usually do not subsequently experience guilt and remorse. Many of them have a well developed ability to actively rationalize their behavior and blame it on other people. Fraud and deception impregnate their relationship with others. Punishment rarely leads to a change in their behavior and improved law-abiding behavior. Antisocial personality disorder often leads to alcoholism, drug use, promiscuity, failure to fulfill obligations, frequent displacements, difficulties in observing the law. Life expectancy is reduced, but the disorder becomes less intense and can stabilize with age.

Narcissistic personality is characterized by majesty. Such people have an exaggerated sense of their own superiority and expect a respectful attitude. Their relationship is characterized by the need for admiration from others, they are extremely sensitive to criticism, failure and loss. If such people face an inability to conform to a high opinion of themselves, they can become furious or deeply depressed and suicidal. They often believe that those around them envy. They can exploit others, because they believe that their superiority justifies it.

Hystrionic (hysteroid) personality is characterized by a conspicuous search for attention. Such people also attach excessive importance to their appearance and behave theatrically. Manifestations of emotions in them often seem exaggerated, immature and superficial. In addition, they often require benevolent and erotic attention from others. Relations with other people are usually easy to establish, too much importance is attached to sexuality, but there is a tendency to superficiality and short-term contacts. For their seductive behavior and tendency to exaggerate somatic problems [v. E. Hypochondria] often hide the basic desires of dependence and protection.

[9], [10], [11], [12], [13], [14]

Cluster C

Such patients are prone to nervousness and passivity or rigidity and concern.

The dependent person is characterized by shifting responsibility to others. Such people can obey others in order to enlist their support. For example, they allow the needs of the people on whom they depend to dominate their own. They lack self-confidence and expressed a feeling that they themselves can not adequately take care of themselves. They believe that other people are more capable and reluctant to express their fear that their entrepreneurship will offend the people on whom they depend. Dependence in other personality disorders can be hidden behind obvious behavioral disorders; for example, hysteroid or borderline behavior masks the underlying dependence.

Avoiding personality is characterized by hypersensitivity to rejection and fear of starting a new relationship or something new because of the risk of failure or disappointment. Because of the expressed conscious desire for affection and approval, such people often experience distress due to isolation and inability to maintain comfortable relationships with others. They react with distance even on small hints of rejection.

Obsessive-compulsive personality is characterized by conscientiousness, accuracy and reliability, but the lack of flexibility often makes such people unable to adapt to change. They take responsibility seriously, but since such people hate mistakes and incompleteness, they get bogged down in details and forget the goal. As a result, they have problems with making a decision and completing the assignment. Such problems make responsibility a source of anxiety, and such patients rarely receive much satisfaction from their successes. Most obsessive-compulsive traits are adaptive if expressed moderately. People with such personal traits can achieve a lot, especially in the sciences and other academic fields, where order, perfectionism and perseverance are desirable. However, they may feel uncomfortable when feelings, interpersonal relationships and the situation go out of control, or when one must rely on other people, or when events are unpredictable.

Other types of personality. Some types of personality are described, but not classified as a disorder in DSM-IV.

Passive-aggressive (negativistic) personality usually gives the impression of stupidity or passivity, but behind such behavior lies the desire to avoid responsibility, control or punishment by others. Passive-aggressive behavior is confirmed by procrastination, inability, unrealistic statements about his helplessness. Often such people, agreeing to carry out the task, do not want to carry it out, and then they sneak out the completion of the task imperceptibly. This behavior usually indicates a denial, or latent hostility, or disagreement.

Cyclotimic personality fluctuates between fervent cheerfulness and despondency and pessimism; each mood lasts a week or more. It is characteristic that rhythmic mood changes are regular and are observed without a reliable external cause. If these characteristics do not violate social adaptation, cyclothymia is considered as a temperament and is present in many gifted and creative people.

Depressive personality is characterized by constant sullenness, anxiety and shyness. Such people have a pessimistic outlook that breaks their initiative and disheartens others. Self-satisfaction seems undeserved and sinful. They unconsciously consider their suffering as the emblem of virtue necessary to earn the love or favor of others.

[15], [16], [17], [18], [19]

Treatment of personality disorders

Although the treatment varies depending on the type of personality disorder, there are some general principles. Family and friends can act in such a way as to either enhance or reduce the problem behavior or thoughts of the patient, so their involvement is useful and often key. It is necessary to make early attempts to help the patient to see that the problem lies in himself. Another principle is that the treatment of personality disorders takes a long time. In order for a person to realize his psychological defenses, beliefs and the characteristics of maladaptive behavior, it is usually necessary to repeat confrontation in long-term psychotherapy or in a collision with other people.

Since personality disorders are extremely difficult to heal, it is important that the therapist has experience, enthusiasm and understanding of the expected areas of emotional sensitivity and habitual coping mechanisms in the patient. Friendly attitude and recommendations in isolation do not affect personal disorders. Treatment of personality disorders may include a combination of psychotherapy and drug therapy. However, the symptoms are usually not very amenable to drug correction.

Relieving anxiety and depression is a priority, as can drug therapy. Reducing external stress can also quickly reduce these symptoms. Disadaptive behavior, characterized by recklessness, social isolation, lack of confidence, emotional outbursts, can change over the months. Sometimes group therapy and behavior correction, conducted at home or in a day hospital, is effective. Participation in self-help groups or family therapy can also help in changing socially undesirable behavior. Changes in behavior are most important for patients with borderline, antisocial or avoiding personality disorder. Dialectic behavioral therapy (DPT) has proven effective in borderline personality disorder. DPT, which includes weekly individual psychotherapy and group therapy, as well as telephone contacts with the physician between the scheduled sessions, helps the patient to seek an understanding of his behavior and teaches him how to deal with problems and adaptive behavior. Psychodynamic therapy is also highly effective in patients with borderline and avoiding personality disorders. An important component of such therapy is to help a patient with a personality disorder to transform their emotional state and think about the influence of their behavior on others.

Solving problems of interpersonal relationships, such as dependence, distrust, arrogance, manipulative, usually takes more than 1 year. The basis of effective changes in interpersonal relations is individual psychotherapy, which helps the patient understand the sources of his problems in relationships with people. The physician should repeatedly point out the undesirable consequences of the patient's thoughts and behaviors, and also periodically establish a framework in the patient's behavior. Such therapy is necessary for patients with an hysteroid, dependent or passive-aggressive personality disorder. Some patients with personality disorders, including various preferences, expectations and beliefs (i.e. Narcissistic or obsessive-compulsive type), are recommended psychoanalysis, usually for 3 years or more.