Personality disorders: Pathology review

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Case study0:00–1:27

28 year old Anna is brought to the emergency department by her roommate, who found her in the bathroom about to cut her wrists.
Anna tells you that her boyfriend of two weeks broke up with her today. When asked how she feels, she just utters “empty”.
She also discloses that she’s been in several intimate relationships that are always amazing in the beginning, but they all end up being disappointing.
Upon physical examination, you notice that Anna has multiple scars over her forearms and wrists. Next, 35 year old Luis presents to the clinic with his girlfriend, who thinks that he is too shy and he would benefit from getting professional help.
Luis mentions that since childhood, he’s always been the “silent” one. He has very few friends, and he avoids hanging out with new people, since he is afraid they will not like him.
Finally, you see Bella, a 41 year old woman, who comes to the emergency department because she thinks she’s been poisoned by her fiancé.
She is certain that he’s been planning to kill her before they get married. When you ask her why she suspects this or if she has any proof, Bella says that her fiancé has frequently offered to prepare her meals.
She also mentions that she’s afraid she’ll lose her job, because her coworkers have been trying to sabotage her. In addition, Bella doesn’t talk to any of her relatives, because four years ago they forgot her birthday.
Okay, based on the initial presentation, Anna, Luis, and Bella all seem to have a personality disorder. Now, each of us has a set of personal traits, which are repetitive patterns involving the way we think, feel, act or behave, and perceive ourselves and what surrounds us.

Pathology1:27–3:01

This combined is what makes up a person’s personality. Despite that, we should normally be able to cope with daily circumstances and adapt our personality accordingly.
Now, sometimes these personal traits can interfere with someone’s day-to-day functioning in their personal life, at work, or in social settings.
If this were the case, we would say that the individual has a personality disorder. Generally, personality disorders are characterized by personality traits that can be rigidly pervasive, meaning that they are stable and of long duration, inflexible, meaning that individuals act in a certain way in most situations, and maladaptive, meaning that they have a hard time adjusting to new or different circumstances.
However, what’s high yield is that these traits remain ego-syntonic, meaning that they stay consistent with the individuals’ values, beliefs, and self-image, also known as ego.
And sometimes, this keeps individuals affected by a personality disorder from viewing their behaviors as problematic. Now, for your exams, you need to know that personality disorders typically arise in adolescence or early adulthood, and there are ten personality disorders that are classified into clusters A, B, and C, each with its own specific patterns of thought and behaviors.
All right, so cluster A personality disorders are characterized by odd or eccentric thinking or behavior, and include paranoid personality disorder, schizoid personality disorder, and schizotypal personality disorder.

Cluster A personality disorders3:01–3:32

What’s extremely high yield for your exams is that cluster A personality disorders are linked to higher rates of schizophrenia, and vice versa, individuals that have a genetic association with schizophrenia are more likely to develop a cluster A personality disorder.
Okay, starting with paranoid personality disorder, this describes someone who is accusatory or generally distrustful and suspicious of other people without really having any reason or proof.

Paranoid personality disorder3:32–4:21

They also assume that others will disappoint them, manipulate them, or talk about them behind their back. Because of this, they are constantly hypervigilant or excessively alert, and are quick to get angry and counterattack or hold grudges.
And that’s a high yield fact! In many ways, this behavior can totally affect the individual’s work, social life and the way they relate to those around them, creating a cycle that leads to even more paranoid behaviors, and ultimately, to social withdrawal or awkward behaviors.
So, remember that these people tend to have superficial relationships. Next there’s schizoid personality disorder.
That’s where individuals avoid social interaction because they simply aren’t interested in getting to know others. In a test question, look for someone who lacks close friends and almost always chooses solitary activities because they don’t enjoy company.

Schizoid personality disorder4:21–5:01

These people even have anhedonia, meaning that they enjoy few, if any activities, and don’t find pleasure in physical contact, from sexual activity to holding hands.
Another important thing to keep in mind is that these individuals tend to have a flat affect and emotional blunting, meaning that they don’t show positive or negative emotions.
The last cluster A personality disorder is schizotypal personality disorder, which is where an individual comes across as being quirky or eccentric.

Schizotypal personality disorder5:01–6:33

People with schizotypal personality disorder can be overly superstitious or might engage in excessive magical thinking, like believing in clairvoyance or telepathy.
Related to this would be ideas of reference, which are the false belief that real and irrelevant occurrences or details directly relate to oneself.
Like thinking that it’s raining because the world is sending them a specific signal. Make sure not to confuse these with delusions, which are beliefs that are not based in reality.
And that’s important because it can help you set schizotypal personality disorder apart from schizophrenia, where delusions are characteristically present!
Now, like those with schizoid personality disorder, individuals with schizotypal personality disorder tend to be socially awkward and have few close people.
Unlike schizoid, though, they usually have a strong desire to have them, but are often unable to maintain them. That’s because these people have a self-centered way of speaking, dressing or acting that is socially inappropriate and can turn people off.
A way to remember this is that those with schizoid are distant with a “D”, and those with schizotypal have odd thoughts with a “T”.
Finally, another thing to keep in mind is that individuals with schizotypal personality disorder have an inappropriate or constricted affect, which might cause them to laugh at a funeral or smile at the news of a tragedy.
Okay, let’s switch gears and discuss cluster B personality disorders, which are characterized by overly emotional, dramatic or unpredictable thinking or behavior and include antisocial personality disorder, borderline personality disorder, histrionic personality disorder, and narcissistic personality disorder.

Cluster B personality disorders6:33–7:03

For your exams, keep in mind that all four of these have a genetic association with mood disorders like depression and bipolar disorder, as well as substance misuse.
All right, let’s start with antisocial personality disorder. This sounds like individuals don’t get along well with others, but don’t let this confuse you.

Antisocial personality disorder7:03–8:25

In fact, it’s the opposite, they can be really charming, and often use that to manipulate others for their personal gain.
For your exams, remember that individuals with antisocial personality disorder show little empathy, meaning they are unwilling to recognize the feelings and needs of others, as well as a lack of remorse or guilt, as shown by the indifference when hurting, mistreating, or stealing from others.
They also disregard moral values and societal norms, and have poor impulse control. This combination makes them willing to hurt others if it helps them, lie repeatedly and use aliases, making them prone to aggressive and unlawful behavior, at times earning the label sociopath or psychopath.
For your test, remember that individuals with this disorder tend to be overrepresented in prison populations. Another unique thing about antisocial personality disorder is that it’s most common in males, and to meet the diagnosis, individuals must be over 18 years old and have a history of conduct disorder with onset before age 15.
So if the individual is under the age of 18, the diagnosis is conduct disorder instead. And that’s a high yield fact!
Next up is borderline personality disorder, which instead is more common in females. Now, individuals with borderline personality disorder tend to have unstable moods.

Borderline personality disorder8:25–9:46

So, they can go from being happy one minute to rage or sadness the next; this leads to a pattern of intense and unstable relationships, which alternate between extremes of idealization and disappointment.
For example, one might think his or her partner is the love of their lives, and the next day think that the same person is totally worthless.
Remember that this pattern is sometimes called stable instability because the only consistent thing is instability. And it can cause people with a borderline personality disorder to feel "empty" and "lost".
What’s high yield here is that these people often use a defense mechanism called splitting where people and important things, like a job, are seen as either completely good or completely bad.
In addition, people with borderline personality disorder are often terrified of abandonment and might even do extreme things, including suicidal behavior, threats, or self-mutilating behavior like deliberately cutting or burning themselves.
This can be associated with a lack of impulse control, which may lead to potentially self-damaging behavior like spending money they don’t have or abusing certain substances.
Next, there’s histrionic personality disorder, where the key features are excessive emotionality, meaning that emotions are labile or rapidly shifting and shallow, as well as attention-seeking.

Histrionic personality disorder9:46–10:43

In fact, individuals are uncomfortable in situations where they’re not the center of attention, and often manipulate situations to draw more attention to themselves.
An important clue is that they have a special style of speech as well as exaggerated expressions that are overly dramatic and theatrical.
They often also use their physical appearance or act inappropriately flirtatious or in a sexually seductive or provocative way.
In addition, people with histrionic personality disorder are constantly seeking for approval or reassurance, which can make them very gullible or easily influenced by others.
These behaviors result in superficial relationships with lots of acquaintances, and they tend to have few, if any, deep connections with others.
All right so the last one in cluster B is narcissistic personality disorder, which is characterized by grandiosity, where individuals think that they are more attractive, more intelligent, or more talented than they actually are.

Narcissistic personality disorder10:43–11:40

Since they believe they’re so special, they expect to be treated as such, demanding excessive admiration from others. They may also think that they can only be understood by other special or high-status people or institutions.These people typically come across to others as being arrogant, self-centered, and entitled.
This is made worse by the fact that they lack empathy, and don’t hesitate to take advantage of others to achieve their own purposes.
But what you need to remember is that behind this mask of ultra-confidence lies a fragile self-esteem that's vulnerable to the slightest criticism, with them lashing out if they feel slighted.
In addition, they’re often envious of others, and hide a feeling of resentment or deprivation. inally, there’s cluster C personality disorders, which include avoidant personality disorder, obsessive compulsive personality disorder, and dependent personality disorder.

Cluster C personality disorders11:40–12:04

To help you remember them, think of the 3Cs in cluster C for “Cowardly,” “Compulsive,” and “Clingy”. Another thing to note is that they all have a genetic association with anxiety disorders.
Okay, so let’s start with avoidant personality disorder, associated with the word “cowardly.” These individuals are classically shy, have an extremely low self-esteem, and see themselves as incapable, inadequate, and undesirable.

Avoidant personality disorder12:04–13:16

Similarly to schizoid personality disorder, these people often have very few close relationships. However, unlike schizoid individuals, those with avoidant personality disorder are unhappy with social isolation, and they actually desire close relationships.
The reason why they choose to be socially inhibited and avoid any type of social interaction is due to fear of criticism, disapproval, or embarrassment.
In fact, people with this disorder are hypersensitive to rejection and negative feedback, becoming even more withdrawn. Now, in a test question, it might be hard to set avoidant personality disorders apart from social phobias.
One key difference is that social phobias tend to be focused on anxiety of specific situations that put them in the spotlight, like speaking or dancing in public, while avoidant personality disorder is defined by an anxiety of social situations in general.
Then there's obsessive compulsive personality disorder, hence the word “compulsive”. These individuals are obsessed with orderliness, perfectionism, and having complete control, as well as rules, details, and schedules.

Obsessive compulsive personality disorder13:16–14:45

People with this disorder are often being surprisingly unproductive because they spend so much extra time planning and worrying about tasks, rather than just getting them done.
For example, one might be unable to complete a project because their own overly strict standards aren’t met. In addition, they’re excessively devoted to work and productivity, to the point where they neglect pleasurable activities and friendships.
They also tend to be very inflexible and rigid when it comes to beliefs and moral issues, which leads them to be perceived as very stubborn.
Now, it’s important not to confuse obsessive compulsive personality disorder with obsessive compulsive disorder or OCD, which is a different disorder with some overlap in symptoms.
OCD is an anxiety disorder where there is a repetition of ritualistic actions, like checking the door over and over again to make sure that it is locked.
The key difference is that OCD is an ego-dystonic condition because individuals affected wish that they could stop their behavior.
In contrast, just like all personality disorders, obsessive compulsive personality disorder is ego-syntonic, meaning that individuals affected see their behavior as correct, and don’t want to change anything about themselves.
Finally, there’s dependent personality disorder, which is associated with the word “clingy.” These people have an intense fear of separation and rejection, so they tend to become overly dependent or ‘cling’ to the relationships they do have.

Dependent personality disorder14:45–15:32

For your exams, remember that they have feelings of discomfort and helplessness when they’re alone, because they lack self-confidence and believe they can’t adequately care for themselves.
They find it nearly impossible to make even simple decisions like what to eat for lunch, and become desperate to hold on to someone who can completely support and take care of them.
Remember that this makes them prone to getting trapped in an abusive relationship. Another high yield fact is that, when a close relationship ends, they urgently seek a new one to replace it.
All, right, now treatment for personality disorders can include lifestyle changes, like creating a regular daily routine that involves frequent physical activity, deep-breathing exercises, yoga, and a healthy diet.

Treatment15:32–16:56

In addition, individuals with a personality disorder may benefit from psychotherapy. Remember though that traditional psychoanalytic treatments tend to be ineffective and might even be counter-productive, since remember that their behaviors are ego-syntonic, so these individuals don’t view them as problematic.
More effective forms of therapy seek to try to support the individual instead of challenging them, for example, by helping them to improve their understanding of social activities or the consequences of their actions.
Personality disorders can also benefit from group therapy since it provides them with a safe space through which they can practice engaging in different social interactions.
Now, what you need to keep in mind for your exams is that dialectical behavioral therapy is a type of psychotherapy that aims at helping individuals accept themselves and deal with their emotions, thoughts, and behaviors, and can be particularly helpful for individuals with borderline personality disorder.
Finally, some individuals with personality disorders may also benefit from medical therapy with antidepressants, mood stabilizers, or antipsychotic medications.
All right, as a quick recap... Personality disorders can be grouped into three clusters: A, B, and C.

Review16:56–19:01

There are 3 cluster A personality disorders. Paranoid personality disorder is characterized by feelings of distrust, suspiciousness, and hypervigilance towards others.
In schizoid personality disorder there’s a pattern of voluntary withdrawal and isolation from social relationships, as well as a limited range of emotional expression.
Finally, schizotypal personality disorder presents with eccentric and inappropriate behaviors, as well as odd beliefs and magical thinking, which cause social and interpersonal awkwardness.
Next, there are 4 cluster B personality disorders. Antisocial personality disorder is where individuals show little empathy and disregard for the rights of others, associated with impulsivity, aggressiveness, and even criminality.
Borderline personality disorder is characterized by stable instability in relationships, self-image, and emotions, as well as impulsivity, self-mutilation, and suicidal behavior.
Histrionic personality disorder features dramatic expressions and attention-seeking, associated with labile and shallow emotions.
Finally, narcissistic personality disorder is where there’s grandiosity, need for admiration, and lack of empathy to hide their fragile self-esteem and envy of others.
Finally, there are 3 cluster C personality disorders. Avoidant personality disorder is where there’s social inhibition due to feelings of inadequacy and hypersensitivity to criticism.
Obsessive compulsive personality disorder is characterized by an obsession with orderliness, perfectionism, and control, at the expense of flexibility and productivity.
Lastly, dependent personality disorder is when there’s an excessive need to be supported and taken care of due to a lack of self-confidence and fear of separation and rejection.
Okay, back to our cases. Anna is a 28 year old girl that is brought in because of a suicide attempt after a breakup.

Summary19:01–20:07

In fact, she frequently engages in self-mutilation, as evidenced by the multiple scars on her forearms and wrists.All of this, along with her feelings of “emptiness” and the fact that she’s been in several unstable relationships, points to borderline personality disorder.
So, Anna gets started on dialectical behavioral therapy. After Anna, you see Luis, a 35 year old man, that’s shy and has an extremely low self-esteem.
The most important clue here is that he is socially inhibited and avoids social interaction because he fears criticism and disapproval.
So, that’s a classic case of avoidant personality disorder. Last comes 41 year old Bella, who suspects her fiancé is trying to poison her, and the only proof she has is that he has frequently offered to prepare her meals.
At the same time, she’s extremely distrustful of her coworkers. This combined with the fact that Bella has been holding a grudge against her family members for four years now, makes us think of paranoid personality disorder.