Ch12 Dissociative and Somatoform Disorders

DISSOCIATIVE AND SOMATOFORM DISORDERS I What is stress? • Stress is a process of adjusting to circumstances that disrupt or threaten to disrupt person’s equilibrium. • Scientists define stress as any challenging event that requires physiological, cognitive, or behavioral adaptation. • Stress is an unavoidable, and in some cases a desirable, fact of everyday life. • Some stressors, however, are so catastrophic and horrifying that they can cause serious psychological harm. • Such traumatic stress is defined in DSM-IV-TR as an event that involves actual or threatened death or serious injury to self or others and creates intense feelings of fear, helplessness, or horror. 1-Acute stress disorder (ASD) occurs within 4 weeks after exposure to traumatic stress and is characterized by dissociative symptoms, re-experiencing of the event, avoidance of reminders of the trauma, and marked anxiety or arousal. 2-Posttraumatic stress disorder (PTSD) is also defined by symptoms of re-experiencing, avoidance, and arousal, but in PTSD the symptoms either are longer lasting or have a delayed onset. Symptoms of ASD and PTSD 1-People who have been confronted with a traumatic stressor re-experience the event in a number of different ways. 2-Many people with ASD or PTSD have repeated and intrusive flashbacks, sudden memories during which the trauma is replayed in images or thoughts—often at full emotional intensity. 3-In rare cases, re-experiencing occurs as a dissociative state, and the person feels and acts as if the trauma actually were recurring in the moment. 4-Marked or persistent avoidance of stimuli associated with the trauma is another symptom of ASD and PTSD. Example 1- December 2004 tsunami trauma 2- September 11th 2001 trauma 3- October 8th trauma Trauma victims may attempt to avoid thoughts or feelings related to the event, or they may avoid people, places, or activities that remind them of the trauma. 5-In PTSD, the avoidance also may manifest itself as a general numbing of responsiveness. People suffering from PTSD often complain that they suffer from “emotional anesthesia”—their feelings seem dampened or even nonexistent. 6- People with ASD and PTSD also experience increased arousal and anxiety following the trauma, a symptom which predicts a worse prognosis when it is more severe. 7-A number of people with PTSD or ASD also have an exaggerated startle response, excessive fear reactions to unexpected stimuli, such as loud noises. 8-Other people experience depersonalization, feeling cut off from themselves or their environment. People with this symptom may report feeling like a robot or as if they were sleepwalking. 9-Derealization is characterized by a marked sense of unreality about yourself or the world around you. ASD also may be characterized by features of dissociative amnesia, specifically the inability to recall important aspects of the traumatic experience. DSM-IV-TR lists a sense of numbing or detachment from others as dissociative symptoms that characterize acute stress disorder. Diagnosis of ASD and PTSD Maladaptive reactions to traumatic stress have long been of interest to the military. Historically, most of the military’s concern has focused on men who leave the field of action as a result of what has been called “shell shock” or “combat neurosis.” The basic diagnostic criteria for PTSD—re-experiencing, avoidance, and arousal—have remained more or less the same in revisions of the DSM. However, two significant changes in the classification of traumatic stress disorders were made with the publication of DSM-IV in 1994: Acute stress disorder was included as a separate diagnostic category, and the definition of trauma was altered. Prevention and Treatment of ASD and PTSD Mounting evidence supports the effectiveness of various cognitive behavioral treatments. A recent consensus statement on the treatment of PTSD concluded that antidepressant medication and psychotherapy involving therapeutic re-exposure are the two “first-line” therapies for PTSD. Let us talk about dissociative disorders. • Is it possible to forget who are you? • It is really possible to forget your past? • Can you have no recollection of your family at all? • Is it actually possible to have no memory of your personal identity or family or work role? • And is it true that there are more cases today than even before? Dissociative Disorders Individuals with a dissociative disorder experience a severe disruption or alteration of their identity, memory, or consciousness. It is based on the unbelievable. Example A housewife forgets her name her entire past life has dissociative disorder. A policeman, who abandoned his family, has dissociative disorder. They are characterized by persistent, maladaptive disruptions in the integration of memory, consciousness, or identity the person with a dissociative disorder may be unable to remember many details about the past; he or she may wander far from home and perhaps assume a new identity; or two or more personalities may coexist within the same person. Dissociative disorders once were viewed as expressions of hysteria. In Greek, hysteria means “uterus,” and the term hysteria reflects ancient speculation that these disorders were caused by frustrated sexual desires, particularly the desire to have a baby. Janet was a French philosophy professor who conducted psychological experiments on dissociation and both Janet and Freud were eager to explain and treat hysteria, and the problem led both of them to develop theories about unconscious mental processes. Janet saw dissociation as an abnormal process. In contrast, Freud considered dissociation as a normal process, a routine means through which the ego defended itself against unacceptable unconscious thoughts. Freud saw dissociation and repression as similar processes, and in fact, he often used the two terms interchangeably. Hypnosis is in which subjects experience loss of control over their actions in response to suggestions from the hypnotist, is a topic of historical importance and contemporary debate about the unconscious mind. All agree that demonstrations of the power of hypnotic suggestion are impressive. However, some experts assert that hypnosis is the dissociative experience of an altered state of consciousness. Symptoms of Dissociative Disorders 1-The symptoms of dissociative disorders apparently involve mental processes that occur outside of conscious awareness. 2-Extreme cases of dissociation include a split in the functioning of the individual’s some researchers and clinicians argue that DID is linked with a past trauma, particularly with child’s physical or sexual abuse. A related issue is very controversial topic of recovered memories, dramatic recollections of long-ago traumatic experiences supposedly blocked from the conscious mind by dissociation. 3-Depersonalization is a form of dissociation wherein people feel detached from themselves or their social or physical environment. 4-Amnesia—the partial or complete loss of recall for particular events or for a particular period of time. 5-Brain injury or disease can cause amnesia. 6-But Psychogenic Amnesia (psychologically caused amnesia) results from traumatic stress or other emotional distress. • Psychogenic amnesia may occur alone or in conjunction with other dissociative experiences. 7-It is widely accepted that fugue and psychogenic amnesia are usually precipitated by trauma, thus providing another link between dissociation and traumatic stress disorders. • Much more controversial is the role that trauma might play in dissociative identity disorder (DID). Diagnosis of Dissociative Disorders For centuries, theorists considered dissociative and somatoform disorders as alternative forms of hysteria. • However, the descriptive approach to classification introduced in DSM-III (1980) led to the separation of dissociative and somatoform disorders into discrete diagnostic categories. • The distinction is preserved in DSM-IV-TR (2000), because the symptoms of the two disorders differ greatly. • The types of dissociative disorders discussed in this lecture are dissociative amnesia, dissociative fugue, dissociative identity disorder and depersonalized disorder. Although dissociative disorders typically involve disruption of identity, dissociative amnesia can involve loss of memory without loss of identity. • The term psychogenic was used in the names of these disorders- as in psychogenic amnesia and psychogenic fugue - to indicate that the fugue or memory loss is not physically caused. 1- Dissociative Amnesia • Each of us, throughout our lives, has forgotten certain things- a person’s name, a friend’s birthday, the need to stop at a store on the way home. Forgetfulness, however, is not yet the same as memory loss. The person with memory loss is unable to recall important personal information too extensive to be viewed in terms of forgetfulness. When there is actual damage to the brain, from injury or disease, the information that isn’t recalled is lost forever. • But in dissociative (psychogenic) amnesia, the memory system is not physically damaged, yet there is selective psychologically motivated forgetting. Often, what has been forgotten is traumatic for the individual. It can sometimes be retrieved from memory. • There are two main types of amnesia: selective and generalized. In cases of selective dissociative amnesia, a person forgets some but not of what happened during a certain period of time. • In contrast to the selective dissociative amnesia, the person who is suffering from generalized dissociative amnesia forgets one’s entire life history. • What did you eat for breakfast today? When is your birthday? These questions do not tax our memory system and appear easy to answer. When you read a textbook but struggle to answer exam questions, you might complain that just “can’t remember.” Why? 1- Forgetting happens as a routine part of life, and there are several explanations for why you forget. Decay theory maintains that loss of memory is a result of disuse and the passage of time; if information is not used or rehearsed it fades over time. 2- Interference theory suggests that memory has a limited capacity; when its capacity is reached; you are susceptible to confusion and forgetting. 3- Another theory suggests that forgetting occurs when there is failure in the process of retrieving information. The information is there, stored away, but it appears to have been forgotten because you cannot retrieve it. • Repression, then, is motivated forgetting, or the burying of unwanted memories in the unconscious where they stay largely unreachable. 2- Dissociative fugue The fugue state involves physical retreat; during a fugue, the individual suddenly and unexpectedly departs. Two important features for diagnosing dissociative (psychogenic) fugue are listed in DSM- IV: a sudden unexpected travel away from home or work with an inability to recall one’s past, and confusion about personal identity. Marked confusion about personal identity interferes with routine daily activities, so, in an effort to adjust and relate to others, the person assumes a new identity. Despite the new assumed identity, characteristics of the “old self” are recognizable. Often, complicated behaviors are carried out during the fugue. A victim may drive a long distance, find a place to live, obtain employment, and begin a new life. Who is Affected with Dissociative Amnesia and Fugue? Both dissociative amnesia and fugue are rare. Reports of case suggest that these disorders can appear at any point in the life span, though less among the elderly. Amnesia is most frequent among adolescent and young women, but its incidence increases slightly among men. Treating Dissociative Amnesia and Fugue Not surprisingly, a person in an amnesic or in a fugue state who is unaware of important facts about his or her own identity is often equally uninformed about the need for therapy. Typically, dissociative amnesic and fugue patients do not seek treatment themselves but, rather, are referred to a therapist after an episode has occurred. The therapy itself often addresses clients’ need for more adaptive ways to manage personal distress and conflict. • Stress management programs, may be used to treat dissociative amnesia and fugue. 3- Dissociative Identity Disorder (DID) • Also known as multiple personality disorder, is characterized by the existence of two or more distinct personalities in a single individual. • At least two of these personalities repeatedly take control of the person’s behavior, and the individual’s inability to recall information is too extensive to be explained by ordinary forgetfulness. • The original personality especially is likely to have amnesia for subsequent personalities, which may or may not be aware of the “alternates.” • DID has received considerable public attention, but where does it fit among the many different types of psychological disorders? Readers may wonder whether it is related to the personality disorders. It is not: Unlike DID, personality disorders involve clusters of behavioral traits that are excessive, maladaptive, lifelong, and pervasive. Also, although DID may resemble a “split mind,” which is the literal translation of the word schizophrenia. Examples 1-“Sybil,” a girl with sixteen personalities, DID is characterized by the presence of two or more distinct personalities of personality states within one individual patterns. 2-The Three Faces of Eve, who describes a client, whose three different personalities virtual opposites in terms of their emotional and behavioral patterns. Eve White was the quiet, polite, hard-working, and conservative mother of a young daughter; Eve Black was seductive, impulsive, risk-taking, and adventure-seeking. Jane, the third personality, was a confident and capable woman. Who Is Affected with DID? DID has been found to occur many time more often in women than in men (estimated rates are three to nine times higher in women). The most common explanations offered for this variance are that women are typically more exposed to sexual abuse, women may handle their psychological traumas in “internal” ways and finally women tend to seek help more than men do. Treating DID Antidepressants and anti-anxiety drugs would be the medications commonly used in these circumstances. Once DID is detected, however, the typical treatment involves psychotherapy aimed at helping replace the patients’ internal division with a unity of personalities (Putnam, 1989). 4- Depersonalization disorder • Depersonalization disorder is a less dramatic problem that is characterized by severe and persistent feelings of being detached from oneself. • Depersonalization experiences include such sensations as feeling as though you were in a dream or were floating above your body and observing yourself acted. Diagnosis of Dissociative Disorders (continued) Occasional depersonalization experiences are normal and are reported by about half of the population. Causes of Dissociative Disorders The onset of dissociative amnesia and fugue usually can be traced to a specific traumatic experience. DISSOCIATIVE and SOMATOFORM DISORDERS II Individuals with a dissociative disorder experience a severe disruption or alteration of their identity, memory, or consciousness. It is based on the unbelievable things. Example A housewife forgets her name her entire past life she has dissociative disorder. Kinds of Dissociative disorders The types of dissociative disorders discussed in this lecture are dissociative amnesia, dissociative fugue, dissociative identity disorder and depersonalized disorder. Although dissociative disorders typically involve disruption of identity, dissociative amnesia can involve loss of memory without loss of identity. Diagnosis of Dissociative Disorders • For centuries, theorists considered dissociative and somatoform disorders as alternative forms of hysteria. • However, the descriptive approach to classification introduced in DSM-III (1980) led to the separation of dissociative and somatoform disorders into discrete diagnostic categories. • The distinction is preserved in DSM-IV-TR (2000), because the symptoms of the two disorders differ greatly. 1- The symptoms of dissociative disorders apparently involve mental processes that occur outside of conscious awareness. 2- Extreme cases of dissociation include a split in the functioning of individual’s sense of self. 3- Depersonalization is a form of dissociation wherein people feel detached from themselves or their social or physical environment. 4- Amnesia—the partial or complete loss of recall for particular events or for a particular period of time. 5- Brain injury or disease can cause amnesia. 6- But Psychogenic Amnesia (psychologically caused) results from traumatic stress or other emotional distress. Psychogenic amnesia may occur alone or in conjunction with other dissociative experiences. 7- It is widely accepted that psychogenic fugue and psychogenic amnesia are usually precipitated by trauma, thus providing another link between dissociation and traumatic stress disorders. Some researchers and clinicians argue that DID is linked with a past trauma, particularly with child’s physical or sexual abuse. The term psychogenic was used in the names of these disorders- as in psychogenic amnesia and psychogenic fugue - to indicate that the fugue or memory loss is not physically caused. 1-Dissociative Amnesia each of us, throughout our lives, has forgotten certain things- a person’s name, a friend’s birthday, the need to stop at a store on the way home. Forgetfulness, however, is not yet the same as memory loss. The person with memory loss is unable to recall important personal information too extensive to be viewed in terms of forgetfulness. When there is actual damage to the brain, from injury or disease, the information that isn’t recalled is lost forever. • But in dissociative (psychogenic) amnesia, the memory system is not physically damaged, yet there is selective psychologically motivated forgetting. Often, what has been forgotten is traumatic for the individual. It can sometimes be retrieved from memory. • There are two main types of amnesia: selective and generalized. In cases of selective dissociative amnesia, a person forgets some but not of what happened during a certain period of time. • In contrast to the selective dissociative amnesia, the person who is suffering from generalized dissociative amnesia forgets one’s entire life history. 2-Dissociative fugue the fugue state involves physical retreat; during a fugue, the individual suddenly and unexpectedly departs. Two important features for diagnosing dissociative (psychogenic) fugue are listed in DSM-IV: a sudden unexpected travel away from home or work with an inability to recall one’s past, and confusion about personal identity. Marked confusion about personal identity interferes with routine daily activities, so in an effort to adjust and relate to others, the person assumes a new identity. Despite the new assumed identity, characteristics of the “old self” are recognizable. Often, complicated behaviors are carried out during the fugue. A victim may drive a long distance, find a place to live, obtain employment, and begin a new life. 3-Dissociative identity disorder (DID), also known as multiple personality disorder, is characterized by the existence of two or more distinct personalities in a single individual. • At least two of these personalities repeatedly take control of the person’s behavior, and the individual’s inability to recall information is too extensive to be explained by ordinary forgetfulness. • The original personality especially is likely to have amnesia for subsequent personalities, which may or may not be aware of the “alternates.” • Examples 1-“Sybil,” a girl with sixteen personalities, DID is characterized by the presence of two or more distinct personalities of personality states within one individual patterns. 2-The Three Faces of Eve, who describe a client, whose three different personalities virtual opposites in terms of their emotional and behavioral patterns. Eve White was the quiet, polite, hard-working, and conservative mother of a young daughter; Eve Black was seductive, impulsive, risk-taking, and adventure-seeking. Jane, the third personality was a confident and capable woman. 4-Depersonalization disorder is a less dramatic problem that is characterized by severe and persistent feelings of being detached from oneself. • Depersonalization experiences include such sensations as feeling as though you were in a dream or were floating above your body and observing yourself as acting. Somatoform Disorders • Do some individuals really need a cabinet full of medicines to deal with their many ailments, or they might benefit more from psychological counseling? • Do we sometimes respond physically- for example, by becoming paralyzed- to psychological stress? • When mind-body interactions are maladaptive, a somatoform disorder may result. Somatoform disorders involve physical symptoms, in the absence of physical illness for which there is no adequate explanation. (Soma means body, and somatoform means “bodylike.” One patient with a somatoform disorder may report being blind but according to medical tests, have normal functioning eyes. Somatoform disorders are problems characterized by unusual physical symptoms that occur in the absence of a known physical illness. 1-There is no demonstrable physical cause for the symptoms of somatoform disorders. They are somatic (physical) in form only— their name. 2-All somatoform disorders involve complaints about physical symptoms, but not caused by physical impairments. There is nothing physically wrong with the patient. 3-The physical problem is very real in the mind, though not the body, of the person with a somatoform disorder. 4-The physical symptoms can take a number of different forms substantial impairment of a somatic system, particularly a sensory or muscular system. The patient will be unable to see, for example, or will report a paralysis in one arm. 5-In other types of somatoform disorder, patients experience multiple physical symptoms usually numerous, complaints about such problems as chronic pain, upset stomach, and dizziness. 6-Finally, some types of somatoform disorder are defined by a preoccupation A- With a particular part of the body say eyes or stomach or B- With fears about a particular illness. The patient may constantly worry that he or she has contracted some deadly disease, for example, and the anxiety persists despite negative medical tests and clear reassurance by a physician. 7-People with somatoform disorders typically do not bring their problems to the attention of a mental health professional. Instead, they repeatedly consult their physicians about their “physical” problems. This often leads to unnecessary medical treatment. Kinds of Somatoform Disorders DSM-IV-TR lists five major subcategories of somatoform disorders: (1) Conversion disorder (2) Somatization disorder (3) Hypochondriasis (4) Pain disorder (5) Body Dysmorphic disorder 1- Conversion Disorder • The symptoms of conversion disorder often mimic those found in neurological diseases, and they can be dramatic. • “Hysterical” blindness or “hysterical” paralysis are examples of conversion symptoms. Although conversion disorders often resemble neurological impairments, they sometimes can be distinguished from these disorders because they make no anatomic sense. The term conversion disorder accurately conveys the central assumption of the diagnosis—the idea that psychological conflicts are converted into physical symptoms. • One or more symptoms or deficits affecting voluntary sensory or motor functioning that cannot be explained by a neurological or general medical condition (after appropriate investigation) and is not a culturally sanctioned behavior. Psychological factors (though not intentional) are judged to be involved because symptoms are exacerbated under stress and the symptoms are useful for the patient’s avoidance of stress. The symptoms or deficits cause clinically significant distress or impairment in social, occupational, other important areas of functioning. 2-Somatization disorder • Somatization disorder is characterized by a history of multiple somatic complaints in the absence of organic impairments. • In order to be diagnosed with somatization disorder, the patient must complain of at least eight physical symptoms and must involve multiple somatic systems. • Patients with somatization disorders sometimes present their symptoms in a histrionic manner—a vague but dramatic, self-centered, and seductive style. Patients also may exhibit la belle indifference (“beautiful indifference”), a flippant lack of concern about the physical symptoms. 72136073660000 3-Hypochondriasis • Hypochondriasis is a problem characterized by a fear or belief that one is suffering from a physical illness. • Hypochondriasis is much more serious than normal and fleeting worries. • The preoccupation with fears of disease extends over long periods of time. • In addition, in hypochondriasis, a thorough medical evaluation or examination does not alleviate the fear of the disease. • Based on misinterpretations of bodily reactions, the sufferer is preoccupied with fears of having a serious disease. Though not a delusion, the fear persists despite medical evaluations. The preoccupation causes clinical distress of at least six months duration. 4-Pain disorder • Pain disorder is characterized by preoccupation with pain. • Complaints seem excessive and apparently are motivated at least in part by psychological factors. • As with hypochondriasis and somatization disorder, pain disorder can lead to the repeated, unnecessary use of medical treatments. 5-Body dysmorphic disorder • Body dysmorphic disorder is a somatoform disorder in which the patient is preoccupied with some imagined defect in appearance. • The preoccupation typically focuses on some facial feature, such as the nose or mouth, and in some cases may lead to repeated visits to a plastic surgeon. • Preoccupation with the body part far exceeds normal worries about physical imperfections. • Preoccupation with and imagined defect in appearance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. 5-Somatoform disorders must be distinguished from malingering, pretending to have a somatoform disorder in order to achieve some external gain, such as a disability payment. 6-A related diagnostic concern is factitious disorder, a fake condition that, unlike malingering, is motivated primarily by a desire to assume the sick role rather than a desire for external gain. 7-A rare, repetitive pattern of factitious disorder is sometimes called Munchausen syndrome, named after Baron Karl Friedrich Hieronymus von Munchausen, an eighteenth-century writer known for his tendency to embellish the details of his life. Frequency of Somatoform Disorders Conversion disorders are rare, perhaps as infrequent as 50 cases per 100,000 population. Most other somatoform disorders also appear to be relatively rare. For example, one study found a 0.7 percent prevalence of body dysmorphic disorder. Hypochondriasis is also quite rare, although less severe worrying about physical illness is quite common. The lifetime prevalence of somatization disorder in the United States is only 0.13 percent. With the exception of hypochondriasis, all other forms of somatoform disorder are more common among women. This is particularly true of somatization disorder, which may be as much as10 times more common among women than men. In addition to gender, socioeconomic status and culture are thought to contribute to somatization disorder. In the United States, somatization is more common among lower socioeconomic groups and people with less than a high school education. It is four times more common among African Americans. Somatoform disorders typically occur with other psychological problems, particularly depression and anxiety. Finally, somatization disorder has frequently been linked with antisocial personality disorder, a lifelong pattern of irresponsible behavior that involves habitual violations of social rules. The two disorders do not typically co-occur in the same individual, but they often are found in different members of the same family. An obvious—and potentially critical —biological consideration in somatoform disorders is the possibility of misdiagnosis. A patient may be incorrectly diagnosed as suffering from a somatoform disorder when, in fact, he or she actually has a real physical illness that is undetected or is perhaps unknown. Because mental health professionals cannot demonstrate psychological causes of physical symptoms objectively and unequivocally, the identification of somatoform disorders involves a process called diagnosis by exclusion. The physical complaint is assumed to be a part of a somatoform disorder only when various known physical causes are excluded or ruled out. Initially, both Freud and Janet assumed that conversion disorders were caused by a traumatic experience. Freud later came to believe that dissociation and other intrapsychic defenses protected individuals from their unacceptable sexual impulses, not from their intolerable memories. In Freud’s view, conversion symptoms were expressions of intolerable unconscious psychological conflicts. In Freudian terminology, this is the primary gain of the symptom. Freud also suggested that hysterical symptoms could produce secondary gain, for example, avoiding work or responsibility or to gain attention and sympathy. Social and cultural theorists offer a straightforward explanation of the physical symptoms of somatization disorder, hypochondriasis, and pain disorder. Patients with these disorders are experiencing some sort of underlying psychological distress. However, they describe their problems as physical symptoms and, to some extent, experience them that way because of limited insight and/or the lack of social tolerance of psychological complaints. Treatment of Somatoform Disorders 1- Cognitive behavior therapy is effective in reducing physical symptoms in somatization disorder, hypochondriasis, and body dysmorphic disorder. 2-Recent evidence also indicates that antidepressants may be helpful in treating somatoform disorders. PERSONALITY DISORDERS I We often hear remarks that some people have a pleasing personality while others have charming and fascinating personality. Some political leaders have charismatic personality while others have repulsive and annoying personality. So the question comes to your mind that What is personality? Personality refers to characteristic ways a person behaves and thinks. Example • A is shy and timid. • B is sensitive and gets upset easily. • C is suspicious of friends and family. • D is confident and successful. Definition of Personality Personality refers to enduring patterns of thinking and behavior that define the person and distinguish him or her from other people. These patterns are ways of expressing emotion as well as patterns of thinking about ourselves and other people. When enduring patterns of behavior and emotion bring the person into repeated conflicts with others, and when they prevent the person from maintaining close relationships with others, an individual’s personality may be considered disordered. All of the personality disorders are based on exaggerated personality traits that are frequently disturbing or annoying to other people. In order to qualify for a personality disorder diagnosis in DSM-IV-TR, a person must fit the general definition of personality disorder (which applies to all 10 subtypes) and must also meet the specific criteria for a particular type of personality disorder. The specific criteria consist of a list of traits and behaviors that characterize the disorder. The general definition of personality disorder presented in DSM-IV-TR emphasizes the duration of the pattern and the social impairment associated with the traits in question. The pattern must be evident in two or more of the following domains: 1- Cognition (such as ways of thinking about the self and other people) 2- Emotional responses 3- Interpersonal functioning 4- Impulse control. This pattern of maladaptive experience and behavior must also be: 1- Inflexible and pervasive across a broad range of personal and social situations, 2- The source of clinically significant distress or impairment in social, occupational, or other important areas of functioning, 3- Stable and of long duration, with an onset that can be traced back at least to adolescence or early adulthood. The concept of social dysfunction plays an important role in the definition of personality disorders. It provides a large part of the justification for defining these problems as mental disorders. Personality disorders are among the most controversial categories in diagnostic system for mental disorders. 1- They are difficult to identify reliably, their etiology is poorly understood, and there is relatively little evidence to indicate that they can be treated successfully. 2- Although they are difficult to define and measure, but personality disorders are also important in the field of psychopathology. Several observations support this argument. • First, personality disorders are associated with significant social and occupational impairment. • Second, the presence of pathological personality traits during adolescence is associated with an increased risk for the subsequent development of other mental disorders. • Third, in some cases, personality disorders actually represent the beginning stages of the onset of a more serious form of psychopathology. • Finally, the presence of a comorbid personality disorder can interfere with the treatment of a disorder such as depression. Most other forms of mental disorder, such as anxiety disorders and mood disorders, are ego-dystonic; that is, people with these disorders are distressed by their symptoms and uncomfortable with their situations. Personality disorders are usually ego-syntonic—the ideas or impulses with which they are associated are acceptable to the person. People with personality disorders frequently do not see themselves as being disturbed. We might also say that they do not have insight into the nature of their own problems. The ego-syntonic nature of many forms of personality disorder raises important questions about the limitations of self-report measures—interviews and questionnaires—for their assessment. Many people with personality disorders are unable to view themselves realistically and are unaware of the effect that their behavior has on others. The specific symptoms that are used to define personality disorders represent maladaptive variations in several of the building blocks of personality. Causes of Personality Disorders These causes include motives, cognitive perspectives regarding the self and others temperament and personality traits. 1- Motive • The concept of a motive refers to a person’s desires and goals. • Motives (either conscious or unconscious) describe the way that the person would like things to be, and they help to explain why people behave in a particular fashion. • The most important motives in understanding human personality are affiliation—the desire for close relationships with other people —and power—the desire for impact, prestige, or dominance. • Individual differences with regard to these motives have an important influence on a person’s health and adjustment. • Many of the symptoms of personality disorders can be described in terms of maladaptive variations with regard to needs for affiliation and power. 2- Cognitive Perspectives • Our social world also depends on mental processes that determine knowledge about us and other people which includes the mental process of perception. When distortions take place in these mechanisms we come across personality disorders. • When we misperceive the intentions and motives and abilities of other people, our relationships can be severely disturbed. • Many elements of social interaction also depend on being able to evaluate the nature of our relationships with other people and then to make accurate judgments about appropriate and inappropriate behaviors. 3- Temperament and Personality Traits • Temperament refers to a person’s most basic, characteristic styles of relating to the world, especially those styles that are evident during the first year of life. • Experts disagree about the basic dimensions of temperament and personality. Some theories are relatively simple, using only three or four dimensions. While others are more complicated and consider as many as 30 or 40 traits. • One point of view that has come to be widely accepted is known as the five factor model of personality. • The basic traits (also known as domains) included in this model are neuroticism, extraversion, openness to experience, agreeableness, and conscientiousness. • Taken as a whole, the five-factor model provides a relatively comprehensive description of any person’s behavior. • The authors of DSM-IV-TR have organized ten specific forms of personality disorder into three clusters on the basis of broadly defined characteristics. • The behavior of people who fit the subtypes in cluster A is typically odd, eccentric, or asocial. All three types share similarity with the symptoms of schizophrenia. • One implicit assumption in the DSM-IV-TR system is that these types of personality disorder may represent behavioral traits or interpersonal styles that precede the onset of full-blown psychosis. • Because of their close association with schizophrenia, they are sometimes called schizophrenia spectrum disorders. 1- Paranoid Personality Paranoid personality disorder is characterized by the pervasive tendency to be inappropriately suspicious of other people’s motives and behaviors. Because paranoid people do not trust anyone, they have trouble maintaining relationships with friends and family members. 2- Schizoid Personality Schizoid personality disorder is defined in terms of a pervasive pattern of indifference to other people, coupled with a diminished range of emotional experience and expression. These people are loners; they prefer social isolation to interactions with friends or family. 3- Schizotypal Personality Schizotypal personality disorder centers on peculiar patterns of behavior rather than on the emotional restriction and social withdrawal that are associated with schizoid personality disorder. People with this disorder may report bizarre fantasies and unusual perceptual experiences. Their speech may be slightly difficult to follow because they use words in an odd way or because they express themselves in a vague or disjointed manner. In spite of their odd or unusual behaviors, people with schizotypal personality disorder are not psychotic or out of touch with reality. According to DSM-IV-TR, these disorders are characterized by dramatic, emotional, or erratic behavior, and all are associated with marked difficulty in sustaining interpersonal relationships. 4- Antisocial Personality Antisocial personality disorder is defined in terms of a persistent pattern of irresponsible and antisocial behavior that begins during childhood or adolescence and continues into the adult years. The DSM-IV- TR definition is based on features that, beginning in childhood, indicate a pervasive pattern of disregard for, and violation of, the rights of others. Once the person has become an adult, these difficulties include persistent failure to perform responsibilities that are associated with occupational and family roles. 5- Borderline Personality Borderline personality disorder is a diffuse category whose essential feature is a pervasive pattern of instability in mood and interpersonal relationships. People with this disorder find it very difficult to be alone. They form intense, unstable relationships with other people and are often seen by others as being manipulative. Many clinicians consider identity disturbance to be the diagnostic hallmark of borderline personality disorder. People with this disturbance presumably have great difficulty maintaining an integrated image of them that simultaneously incorporates their positive and negative features. 6- Histrionic Personality Histrionic personality disorder is characterized by a pervasive pattern of excessive emotionality and attention seeking behavior. People with this disorder thrive on being the center of attention and they want the spotlight on them at all times. They are self-centered, vain, and demanding, and they constantly seek approval from others. The concept of histrionic personality disorder overlaps extensively with other types of personality disorder, especially borderline personality disorder. There may also be an etiological link between histrionic and antisocial personality disorders. Both may reflect a common, underlying tendency toward lack of inhibition. People with both types of disorder form shallow, intense relationships with others, and they can be extremely manipulative. 7- Narcissistic Personality The essential feature of narcissistic personality disorder is a pervasive pattern of grandiosity, need for admiration, and inability to empathize with other people. • Narcissistic people have a greatly exaggerated sense of their own importance. • They are preoccupied with their own achievements and abilities. • There is a considerable amount of overlap between narcissistic personality disorder and borderline personality disorder. • Both types of people feel that other people should recognize their needs and do special favors for them. • They may also react with anger if they are criticized. • The distinction between these disorders hinges on the inflated sense of self-importance that is found in narcissistic personality disorder and the deflated or devalued sense of self found in borderline personality disorder. • The common element in all three disorders is presumably anxiety or fearfulness. • This description fits most easily with the avoidant and dependent types. • In contrast, obsessive–compulsive personality disorder is more accurately described in terms of preoccupation with rules and with lack of emotional warmth than in terms of anxiety. 8- Avoidant Personality • Avoidant personality disorder is characterized by a pervasive pattern of social discomfort, fear of negative evaluation, and timidity. • People with this disorder tend to be socially isolated when outside their own family circles because they are afraid of criticism. • Unlike people with schizoid personality disorder, they want to be liked by others, but they are extremely shy—easily hurt by even minimal signs of disapproval from other people. • Thus they avoid social and occupational activities that require significant contact with other people. • Avoidant personality disorder is often indistinguishable from generalized social phobia. • Some experts have argued that they are probably two different ways of defining the same condition. • Others have argued that people with avoidant personality disorder have more trouble than people with social phobia in relating to other people. 9-Dependent Personality • The essential feature of dependent personality disorder is a pervasive pattern of submissive and clinging behavior. • People with this disorder are afraid of separating from other people on whom they are dependent for advice and reassurance. • Often unable to make everyday decisions on their own, they feel anxious and helpless when they are alone. 10- Obsessive–Compulsive Personality Disorder (OCPD • Obsessive–compulsive personality disorder (OCPD) is defined by a pervasive pattern of orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness, and efficiency. • People with this disorder set ambitious standards for their own performance that frequently are so high as to be unattainable. • The central features of this disorder may involve a marked need for control and lack of tolerance for uncertainty. PERSONALITY DISORDERS II Personality refers to enduring patterns of thinking and behavior that define the person and distinguish him or her from other people. These enduring patterns are ways of expressing emotion as well as patterns of thinking about ourselves and other people. When enduring patterns of behavior and emotion bring the person into repeated conflicts with others, and when they prevent the person from maintaining close relationships with others, an individual’s personality may be considered disordered. Personality disorders are among the most controversial categories in the diagnostic system for mental disorders. 1- They are difficult to identify reliably, their etiology is poorly understood, and there is relatively little evidence to indicate that they can be treated successfully. 2- Although they are difficult to define and measure, but personality disorders are important in the field of psychopathology. Several observations support this argument. • First, personality disorders are associated with significant social and occupational impairment. • Second, the presence of pathological personality traits during adolescence is associated with an increased risk for the subsequent development of other mental disorders. • Third, in some cases, personality disorders actually represent the beginning stages of the onset of a more serious form of psychopathology. • Fourth, the presence of a co-morbid personality disorder can interfere with the treatment of a disorder such as depression. • The specific symptoms that are used to define personality disorders represent maladaptive variations in several of the building blocks of personality. • These include 1- Motives 2- Cognitive perspectives regarding the self and others 3- Temperament and personality traits. • The authors of DSM-IV-TR have organized ten specific forms of personality disorder into three clusters on the basis of broadly defined characteristics. • The behavior of people who fit the subtypes in cluster A is typically odd, eccentric, or asocial. All three types share similarity with the symptoms of schizophrenia. • The close association with schizophrenia, they are sometimes called schizophrenia spectrum disorders. 1- Paranoid Personality • Paranoid personality disorder is characterized by the pervasive tendency to be inappropriately suspicious of other people’s motives and behaviors. • Paranoid people do not trust anyone; they have trouble maintaining relationships with friends and family members. Example Client A was frequently complaining about her boss, co-workers, teachers, father and friends. She watched everyone closely, did not accept food or medicine from anyone for the fear that it would contain poison. She did not go out with friends and co-workers that they might kill her. 2- Schizoid Personality • Schizoid personality disorder is defined in terms of a pervasive pattern of indifference to other people, coupled with a diminished range of emotional experience and expression. • These people are loners; they prefer social isolation to interactions with friends or family. Example Client B would follow her class mates to school but would hurry back to her hostel room where she would stay alone most of the time and was completely uninterested in others. 3- Schizotypal Personality Schizotypal personality disorder centers on peculiar patterns of behavior rather than on the emotional restriction and social withdrawal that are associated with schizoid personality disorder. People with this disorder may report bizarre fantasies and unusual perceptual experiences. Example Client A was a young man with vague complaints of stuttering, feeling of indifference towards one’s self and wanted to study stars. He had peculiar, odd language and perceptual experiences. • The cluster B includes Antisocial, Borderline, Histrionic, and Narcissistic Personality disorders. • According to DSM-IV-TR, the cluster B disorders are characterized by dramatic, emotional, or erratic behavior, and all are associated with marked difficulty in sustaining interpersonal relationships. 4- Antisocial Personality Antisocial personality disorder is defined in terms of a persistent pattern of irresponsible and antisocial behavior that begins during childhood or adolescence and continues into the adult years. The pattern shows disregard for, and violation of the rights of others. Once the person has become an adult, these difficulties include persistent failure to perform responsibilities that are associated with occupational and family roles. Example Client D is a young man who has just knocked out a man with his beer bottle because he thinks that he was insulted. The same client has history of being kicked out of school, fighting with neighbors and he does what pleases him not what is right or wrong. 5- Borderline Personality • Borderline personality disorder is a diffuse category whose essential feature is a pervasive pattern of instability in mood and interpersonal relationships. • People with this disorder find it very difficult to be alone. • They form intense, unstable relationships with other people and are often seen by others as being manipulative. Example Client C is a man who has been thrown out of his father’s house because of bad temper and undependability. He is depressed to the point of suicidal feelings. 6- Histrionic personality • Histrionic personality disorder is characterized by a pervasive pattern of excessive emotionality and attention seeking behavior. • People with this disorder thrive on being the center of attention and they want the spotlight on them at all times. • They are self-centered, vain, and demanding, and they constantly seek approval from others. Example Client C is an attractive woman with a lovely smile used by her to get the attention of people. Her habit of trying to be the centre of attention is annoying to others. She is moody and seemed to over- dramatize minor problems. 7- Narcissistic Personality • The essential feature of narcissistic personality disorder is a pervasive pattern of grandiosity, need for admiration, and inability to empathize with other people. • Narcissistic people have a greatly exaggerated sense of their own importance. • They are preoccupied with their own achievements and abilities. Example Client D is a lawyer of outward charm and good looks who has won the bar elections. He has written books and has a media following. He is a man preoccupied by appearance, wealth, power and fame. 8- Avoidant Personality • Avoidant personality disorder is characterized by a pervasive pattern of social discomfort, fear of negative evaluation, and timidity. • People with this disorder tend to be socially isolated when they are outside their own family circle because they are afraid of criticism. Example Client D is a woman who has taken a job in night shift where she can have minimal contact. Off duty she spends time alone, worrying less that she may behave stupidly. 9- Dependent Personality • The essential feature of dependent personality disorder is a pervasive pattern of submissive and clinging behavior. • People with this disorder are afraid of separating from other people on whom they are dependent for advice and reassurance. • Often unable to make everyday decisions on their own, they feel anxious and helpless when they are alone. Example Client A has lacked self confidence since childhood, relying on her mother to choose what to wear, what friends to have, which courses and classes to study. 10- Obsessive–Compulsive Personality • Obsessive–compulsive personality disorder (OCPD) is defined by a pervasive pattern of orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness, and efficiency. • People with this disorder set ambitious standards for their own performance that frequently are so high as to be unattainable. • The central features of this disorder may involve a marked need for control and lack of tolerance for uncertainty. • Obsessive–compulsive personality disorder should not be confused with obsessive–compulsive disorder (OCD), a type of anxiety disorder. A pattern of intrusive, unwanted thoughts accompanied by ritualistic behaviors is used to define OCD. The definition of obsessive– compulsive personality disorder, in contrast, is concerned with personality traits, such as excessively high levels of conscientiousness. Example Client A has a reputation of being careful and conscientious and careful. He works long hours and brings a lot of money to the firm but he is humorless but takes a lot time in procedural details in staff meetings. The common element in all three disorders is presumably anxiety or fearfulness. This description fits most easily with the avoidant and dependent types. In contrast, obsessive–compulsive personality disorder is more accurately described in terms of preoccupation with rules and with lack of emotional warmth than in terms of anxiety. Like people with avoidant personality disorder, they are easily hurt by criticism, extremely sensitive to disapproval, and lacking in self confidence. One difference between them is that people who are avoidant have trouble initiating a relationship (because they are fearful). People who are dependent have trouble being alone or separating from other people with whom they already have a close relationship. The Diagnosis The diagnosis of Personality Disorders is not an easy and simple task because 1-There are a lot of people with serious personality problems who do not fit the official DSM-IV-TR subtypes. 2-Another frequent complaint about the description of personality disorders is the considerable overlap among categories. 3-Many patients meet the criteria for more than one type. Thus, for diagnosis of personality disorders many experts favor the proposal to use the five-factor model of personality as the basic structure for a comprehensive description of personality problems. 4-There is also extensive overlap between personality disorders and disorders that are diagnosed on Axis I of DSM-IV-TR. Approximately 75 percent of people who qualify for a diagnosis on Axis II also meet criteria for a syndrome such as major depression, substance dependence, or an anxiety disorder. Gender Differences The overall prevalence of personality disorders is approximately equal in men and women. Antisocial personality disorder is unquestionably much more common among men than among women. Almost nothing is known about the extent of potential gender differences for the other types of personality disorder. Borderline personality disorder and dependent personality disorder may be somewhat more prevalent among women than men, but the evidence is not strong. Stability of Personality Disorders over Time Temporal stability is one of the most important assumptions about personality disorders. Evidence for the assumption that personality disorders appear during adolescence and persist into adulthood has, until recently, been limited primarily to antisocial personality disorder. The rate of personality disorders was relatively high in this sample: Seventeen percent of the adolescents received a diagnosis of at least one personality disorder. Viewed from a dimensional perspective, the maladaptive traits that represent the core features of the disorders remained relatively stable between adolescence and young adulthood. Several studies have examined the stability of personality disorders among people who have received professional treatment for their problems, especially those who have been hospitalized for schizotypal or borderline disorders. Recovery rates are relatively high among patients with a diagnosis of borderline personality disorder.