Augustina

Norieta D. Abelardo, MD,

Calma-Balderrama, MD Patho 1
FPSP, MIAC 3
211
OS 215 Integration, Coordination,
Reproduction and Hormonal and Behavior
Regulation

Identifying Personality
Lec 2A: Pathology of theDisorders
Female Genital Tract (Vulva and Vagina)

Lecture Outline: 2. Preoccupied with unjustified doubts

I. Objectives about loyalty or trustworthiness of friends
II. Introduction  Cannot talk about secrets
III. Cluster A
3. Reluctant to confide in others because
A. Paranoid Personality Disorder of unwarranted fear
B. Schizoid Personality Disorder 4. Reads hidden, demeaning, or
C. Schizotypal Personality Disorder threatening meanings into benign remarks or
IV. Cluster B events
A. Antisocial Personality Disorder 5. Persistently bears grudges (i.e.,
unforgiving of insults, injuries)
B. Borderline Personality Disorder
6. Perceives attacks on character that are
C. Histrionic Personality Disorder not apparent to others and is quick to react
D. Narcissistic Personality Disorder angrily
V. Cluster C 7. Recurrent suspicions, without
A. Avoidant Personality Disorder justification, regarding fidelity of spouse or
B. Dependent Personality Disorder sexual partner
C. Obsessive-Compulsive Personality Disorder
• Associated features – socially isolated, brief
D. Personality Disorder Not Otherwise Specified psychosis, persecutory delusions (false +
unshakeable + cannot be explained by patient’s
Transers’ Note: Those in smaller font size were lifted from Kaplan background), sensory impairment
& Sadock's Synopsis of Psychiatry, 10th Ed. (We believe in
Block A transers notes so we left them here ) • Their defense mechanism is projection because
they are paranoid! (Possible Exam Question)
• The hallmarks of paranoid personality disorder are
OBJECTIVES excessive suspiciousness and distrust of others
expressed as a pervasive tendency to interpret actions
Why the need to identify personality disorders? of others as deliberately demeaning, malevolent,
1. Discuss the criteria for personality disorders. threatening, exploiting, or deceiving.
2. Identify the personality disorder given a case.
3. Increase ability to diagnose personality disorders. B. Schizoid Personality Disorder
• Pervasive pattern of detachment from social
INTRODUCTION relationships
• 4 or more of the following:
Personality 1. Neither desires nor enjoys close
- person’s characteristic totality of emotional relationships, including being part of a family
and behavioral traits apparent in ordinary 2. Almost always chooses solitary activities
life, a totality that is usually stable and 3. Has little if any interest in having sexual
predictable. experiences with another person
Personality disorder  Their sexual lives may exist exclusively
in fantasy, and they may postpone
- traits are excessive, rigid, maladaptive and
mature sexuality indefinitely
produce functional impairment of
subjective distress.  Men may not marry because they are
unable to achieve intimacy; women may
Three Clusters of Personality Disorders passively agree to marry an aggressive
1. Cluster A (odd and eccentric) man who wants the marriage
4. Takes pleasure in few, if any, activities
• Paranoid, schizoid, schizotypal 5. Lacks close friends or confidants other
(“magical thinking”) than first degree relatives
• Prone to have schizophrenia 6. Appears indifferent to praise or criticism
of others
2. Cluster B (dramatic, emotional, and erratic) 7. Shows emotional coldness, detachment,
• Antisocial, borderline, histrionic, or flattened affectivity (no facial expression)
narcissistic
• Although persons with schizoid personality disorder
appear self-absorbed and lost in daydreams, they have
3. Cluster C (anxious or fearful; preoccupied with a normal capacity to recognize reality. Because
criticisms and rigidity) aggressive acts are rarely included in their repertoire of
• Avoidant, dependent, obsessive- usual responses, most threats, real or imagined, are
compulsive, personality disorder NOS dealt with by fantasized omnipotence or resignation.
• Fantasy: Many persons who are often labeled schizoid
CLUSTER A: Odd/Eccentric seek solace and satisfaction within themselves by
creating imaginary lives, especially imaginary friends. In
their extensive dependence on fantasy, these persons
A. Paranoid Personality Disorder often seem to be strikingly aloof.
• Pervasive distrust and suspiciousness
• “They don’t tell secrets because others might tell C. Schizotypal Personality Disorder
their secrets.”
• Left out by caregiver/loved ones, not taken care • Persons with schizotypal personality disorder are
strikingly odd or strange, even to laypersons. Magical
of when young
thinking, peculiar notions, ideas of reference
• 4 or more of the following: (feeling nya pinag-uusapan sya palagi), illusions,
1. Suspects without basis that others are and derealization are part of a schizotypal person's
exploiting harming or deceiving him everyday world.

JC Tayag. Clare Toledo. Angel. Pot Torres. WED, 16 Feb 2011 Page 1 of 4

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OS 215 Integration, Coordination,
Reproduction and Hormonal and Behavior
Regulation
Identifying Personality
Lec 2A: Pathology of theDisorders
Female Genital Tract (Vulva and Vagina)
• 5 or more of the following:
1. Ideas of reference – the Px feels like he
is constanty talked about by people around
him
2. Odd beliefs or magical thinking
 Magical thinking – culture-related,
disappears by 6-7 years old
3. Unusual perceptual disturbances
4. Odd thinking and speech
 E.g. you’re topic is about Robinson’s, but he/she’s
talking about outerspace.
5. Suspiciousness or paranoid ideation
6. Inappropriate or constricted affect
7. Behavior or appearance that is odd,
eccentric or peculiar
8. Lack of close friends or confidants other
than first degree relatives
9. Excessive social anxiety that does not
diminish with familiarity and tends to be
associated with paranoid fears
• Retrospective studies have shown that many patients
thought to have had schizophrenia actually had
schizotypal personality disorder and, according to
current clinical thinking, the schizotype is the
premorbid personality of the patient with
schizophrenia.
CLUSTER B: Dramatic/Emotional
A. Antisocial Personality Disorder
• Inability to conform to the social norms that ordinarily
govern many aspects of a person's adolescent and
adult behavior. Although characterized by continual
antisocial or criminal acts, the disorder is not
synonymous with criminality.
• Although characteristics are similar, antisocial
personality among adults is not synonymous to
conduct disorder in children. Having conduct
disorder does not mean a child will develop an
antisocial personality disorder as an adult.
• However, if a person had a lot misbehavior during
childhood and there is a pattern, more likely than
not, they will develop antisocial personality
disorder.
• Disregard for and violation of rights of others
since age 15
• 3 or more of the following:
1. Failure to conform to social norms with
respect to lawful behaviors (performs acts
grounds for arrest)
2. Deceitfulness, repeated lying, use of
aliases, or conning others for personal profit
or pleasure
3. Impulsivity or failure to plan ahead
4. Irritability and aggressiveness (repeated
physical fights or assaults)
 Differential for irritability: Bipolar
Disorder
5. Reckless disregard for safety of self or
others
6. Consistent irresponsibility (failure to
sustain consistent work behavior)
7. Lack of remorse (indifferent to having
hurt, mistreated or stolen)
 Most important when assessing an
individual with this personality disorder.
 Patient’s superego was not developed
(should be developed by 10 years of
age).
JC Tayag. Clare Toledo. Angel. Pot Torres. WED, 16 Feb 2011
Augustina
Norieta D. Abelardo, MD,
Calma-Balderrama, MD Patho 1
FPSP, MIAC 3
• Once an antisocial personality disorder
develops, it runs an unremitting course, with the height
of antisocial behavior usually occurring in late
adolescence. The prognosis varies. Some reports
indicate that symptoms decrease as persons grow
older. Many patients have somatization disorder and
multiple physical complaints. Depressive disorders,
alcohol use disorders, and other substance abuse are
common.
B. Borderline Personality Disorder
• Patients with borderline personality disorder stand on
the border between neurosis and psychosis and they
are characterized by extraordinarily unstable affect,
mood, behavior, object relations, and self-image.
• These patients are very manipulative. They are
those who threaten their partners that they would
commit suicide if their partner leaves them.
• 5 or more of the following:
1. Frantic efforts to avoid real or imagined
abandonment
 One of the more difficult cases that you
can have as physicians. They go to the
ER because of history of repeated
slashing of the wrist.
 According to mothers, they have
problems early on in their life during the
separation individuation phase. They
have no object relationships. Lesson:
Attachment figures should be present
and constant (at least for the first 7
years).
2. Unstable and intense interpersonal
relationships
3. Identity disturbance (unstable self
image)
4. Impulsivity in two areas (impulsive when
it comes to different things; e.g. having sex,
shopping, etc)
5. Recurrent suicidal behavior or threats or
self mutilating behavior
6. Affective instability due to marked
reactivity to mood
7. Chronic feelings of emptiness
8. Inappropriate intense anger or difficulty
controlling anger
9. Transient, stress-related paranoid
ideation or severe dissociative symptoms
• The defense mechanism of a person with
borderline personality disorder is splitting: the
patient will look at you as either good or bad. “It’s
not because of you but because of the way the
patient looks at you.”
 Example: Dr. Balderrama’s patient who
thinks of her as a motherly figure; she uses
this relationship to understand and help her
patient.
• In splitting, persons toward whom patients'
feelings are, or have been, ambivalent are
divided into good and bad. For example, in an
inpatient setting, a patient may idealize some
staff members and uniformly disparage others.
• Borderline personality disorder is fairly stable; patients
change little over time. Longitudinal studies show no
progression toward schizophrenia, but patients have a
high incidence of major depressive disorder
episodes. The diagnosis is usually made before the
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OS 215 Integration, Coordination,
Reproduction and Hormonal and Behavior
Regulation
Identifying Personality
Lec 2A: Pathology of theDisorders
Female Genital Tract (Vulva and Vagina)
age of 40, when patients are attempting to make
occupational, marital, and other choices and are unable
to deal with the normal stages of the life cycle.
C. Histrionic Personality Disorder
• Persons with histrionic personality disorder are
excitable and emotional and behave in a colorful,
dramatic, extroverted fashion. Accompanying their
flamboyant aspects, however, is often an inability to
maintain deep, long-lasting attachments.
• Excessive emotionality and attention seeking;
“KSP”
• 5 or more of the following:
1. Uncomfortable in situations where
he/she is not the center of attention
2. Inappropriate sexually or provocative
behavior (wears plunging necklines, etc.)
3. Rapidly shifting and shallow expression
of emotions
4. Uses physical appearance to draw
attention to self
5. Has a style of speech that is excessively
impressionistic and lacking in detail
6. Self dramatization, theatricality, and
exaggerated expression of emotion
7. Suggestible, easily influenced by others
or circumstances
8. Considers relationships to be more
intimate than they actually are
• The major defenses of patients with histrionic
personality disorder are repression and
dissociation. Accordingly, such patients are unaware
of their true feelings and cannot explain their
motivations. Under stress, reality testing easily
becomes impaired.
D. Narcissistic Personality Disorder
• Grandiosity, need for admiration, lack of empathy
• 5 or more of the following:
1. Grandiose sense of self importance
2. Preoccupied with fantasies of unlimited
success, power, brilliance, beauty or love
3. Believes he is “special” and unique and
can only be understood by, should associate
with special or high status
4. Requires excessive admiration
5. Sense of entitlement
6. Interpersonally exploitative (takes
advantage of others to achieve own end)
7. Lacks empathy
8. Envious of others or feels that others are
envious of him
9. Shows arrogant, haughty behavior
• Narcissistic personality disorder is chronic and difficult
to treat. Patients with the disorder must constantly deal
with blows to their narcissism resulting from their own
behavior or from life experience.
• Aging is handled poorly; patients value beauty,
strength, and youthful attributes, to which they
cling inappropriately. They may be more vulnerable,
therefore, to midlife crises than are other groups.
CLUSTER C: Anxious/Fearful
A. Avoidant Personality Disorder
• Persons with avoidant personality disorder show
extreme sensitivity to rejection and may lead a socially
withdrawn life. Although shy, they are not asocial and
show a great desire for companionship, but they need
unusually strong guarantees of uncritical acceptance.
JC Tayag. Clare Toledo. Angel. Pot Torres. WED, 16 Feb 2011
Augustina
Norieta D. Abelardo, MD,
Calma-Balderrama, MD Patho 1
FPSP, MIAC 3
Such persons are commonly described as having an
inferiority complex.
• Social inhibition, feelings of inadequacy
• 4 or more of the following:
1. Avoids activities with interpersonal
contact due to fears of rejection, criticism
2. Unwilling to get involved unless certain
of being liked
3. Restraint within intimate relationships
because of fear of being shamed
4. Preoccupied with being criticized or
rejected
5. Inhibited in new interpersonal situations
6. Views self as socially inept,
unappealing, or inferior to others
7. Unusually reluctant or take personal
risks or to engage in new activities because
it may be embarrassing
• Criteria similar to schizoid (but unlike schizoid
which is total withdrawal from socialization)
• Avoidant: they want to, but they can’t; schizoid: no want at all
• Socially inept – opposite of narcissistic
From 2013:
• Hypersensitive to criticism, wants to socialize but finds it
hard to do so, low self-esteem
• Shy away or avoid almost all occupational or social
relationships because of fears of rejection that are
based on feelings of inadequacy
• Perceive self as substandard, preoccupied with
rejection, avoiding activities because of fear of failure,
lonely and seek human contact when acceptance is
certain
• Associated with social phobia, panic disorder,
agoraphobia
B. Dependent Personality Disorder
• Persons with dependent personality disorder
subordinate their own needs to those of others, get
others to assume responsibility for major areas of their
lives, lack self-confidence, and may experience intense
discomfort when alone for more than a brief period.
• 5 or more of the following:
1. Difficulty making everyday decisions
without reassurance or advice
2. Needs others to assume responsibility
for most major areas of his or her life
3. Difficulty expressing disagreement with
others because of fear of loss of support
4. Difficulty initiating projects
5. Goes to excessive lengths to obtain
nurturance and support
6. Feels uncomfortable or helpless when
alone
7. Urgently seeks another relationship as a
source of care
8. Unrealistically preoccupied with fears of
being left to take care of himself
• Most common cause of annulment
• Similar to avoidant: low self-esteem
C. Obsessive-Compulsive Personality Disorder
• Obsessive-compulsive personality disorder is
characterized by emotional constriction, orderliness,
perseverance, stubbornness, and indecisiveness. The
essential feature of the disorder is a pervasive pattern
of perfectionism and inflexibility.
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OS 215 Integration, Coordination,
Reproduction and Hormonal and Behavior
Regulation
Identifying Personality
Lec 2A: Pathology of theDisorders
Female Genital Tract (Vulva and Vagina)
• Preoccupation with orderliness, perfectionism,
control at the expense of flexibility openness and
efficiency
• 4 or more of the following:
1. Preoccupied with details, rules, lists,
order to the point of the activity being lost
2. Perfectionism that interferes with task
completion
3. Excessive devotion to work to the
exclusion of leisure activities and friendships
4. Over conscientious, scrupulous, and
inflexible about matters of morality ethics and
values
5. Unable to discard worn-out or worthless
objects even without any sentimental value
6. Reluctant to delegate task
7. Adopts a miserly spending style
8. Shows rigidity and stubbornness
• Treatment: Psychotherapy
• Unlike patients with the other personality disorders,
those with obsessive-compulsive personality disorder
are often aware of their suffering, and they seek
treatment on their own. Overtrained and oversocialized,
these patients value free association and no-directive
therapy highly. Treatment, however, is often long and
complex, and countertransference problems are
common.
• Group therapy and behavior therapy occasionally offer
certain advantages. In both contexts, it is easy to
interrupt the patients in the midst of their maladaptive
interactions or explanations. Preventing the completion
of their habitual behavior raises patients' anxiety and
leaves them susceptible to learning new coping
strategies. Patients can also receive direct rewards for
change in group therapy, something less often possible
in individual psychotherapies.
• Treatment: Pharmacotherapy
 Antipsychotics
 For those agitated
 Stabilizers
 For Borderline – give mood stabilizers
 Atypical antipsychotics
• Risperidone
o Give to a limited number of days
depending on the presentation
o But has a lot of side effects after 4 mg
 First mood stabilizer = lithium
 Other examples:
Anticonvulsants
o Valproics
 For manics
o Lamotrigine
 For depressed
o Quetiapine
 For antipsychotic mood stabilizer
 For depression
 For bipolar
 For psychosis
o Olanzepine
 For mood problems
 With side effects of metabolic
problems so contraindicated for
diabetics, etc.
*Basically for personality disorders
• Give antipsychotic mood stabilizers (Lithium)
• Anticonvulsant Antipsychotics
*For aggressive patients
• Antipsychotics
• Anticonvulsants
JC Tayag. Clare Toledo. Angel. Pot Torres. WED, 16 Feb 2011
Augustina
Norieta D. Abelardo, MD,
Calma-Balderrama, MD Patho 1
FPSP, MIAC 3
*We used to give antipsychotics only but now we also give
anticonvulsants as mood stabilizers
• Clonazepam (Klonopin), a benzodiazepine with
anticonvulsant use, has reduced symptoms in patients
with severe obsessive-compulsive disorder. Whether it
is of use in the personality disorder is unknown.
D. Personality Disorder Not Otherwise Specified
• From 2013: waste basket of PD
1. Passive aggressive
 Resists routine tasks, complains of
being misunderstood and unfortunate, sullen
and argumentative, unreasonably scorns
authority, envy for those fortunate, alternate
contrition and hostile defiance
 Not common
2. Depressive
 Pessimistic, anhedonic, duty bound,
self-doubt, chronically unhappy
3. Sadomasochistic
 (Not official in DSM-IV)
 Sadism - Desire to cause others pain
 Masochism - inflicting pain on self
SUMMARY
• THREE clusters
 Odd/eccentric
 Dramatic/ emotional
 Anxious/ fearful
• Sample Cases
• Diagnosis
TIPS FOR THE EXAM FROM BLOCK A
Dr. Balderrama did not give any tips for our exam but here
are her tips for block A.
She only gave key statements from her list of 15 questions
(i.e., cases) for the exam.
1. “Easy”
2. How do you describe a person with avoidant
personality?
3. Why are people with histrionic personality
disorder unusual?
4. “Childhood patterns”
5. Lack of interest in sexual behavior - what is the
indication?
6. What is the personality disorder of a patient who
uses dissociation or denial as a defense mechanism?
7. Very difficult cases, usually referred to other
doctors
8. Patients who are odd or strange: schizoid vs.
schizotypal (“Basta makita niyo magic, schizotypal
'yun”)
9. Dramatic, extroverted, flamboyant
10. More vulnerable to midlife crisis; handle aging
poorly; value beauty, strength, and youthful attributes
to which they cling inappropriately
11. Can fool even the more experienced physicians;
"They appear ganyan, pero beneath..."
12. The best way to deal with a patient who has
obsessive-compulsive personality disorder
13. Borderline personality has a high incidence of?
Answer is another disorder
14. Reads hidden meaning and hostile intentions
Page 4 of 4
 Augustina
Norieta D. Abelardo, MD,
Calma-Balderrama, MD Patho 1
FPSP, MIAC 3
211
OS 215 Integration, Coordination,
Reproduction and Hormonal and Behavior
Regulation

Identifying Personality
Lec 2A: Pathology of theDisorders
Female Genital Tract (Vulva and Vagina)

15. Defense mechanism of patients with schizoid

personality

*We decided not to answer the questions because Dr.

Balderrama only hinted on the topics which are to be given in the
exam. Sa ibang items, hindi clear kung ano talaga ‘yung tanong
kasi cases naman ang ibibigay. Tsaka, baka magkamali pa kayo
pag sinagutan namin. Hehe.

Questions?
For Block B transers, text
GREETINGS

JC:

Clare: Happy Valentines’ Day 2014! <super delayed> Happy Summer-ing!

<super advanced>

Angel: hello 2014! Everyday is love’s day if we put our hearts in everything
we do and share the love that we have to others <3
Thank you ulit sa 2014 boys. HI wheaters, seatmates, MSU-mates, atbp!
 special hi kay nico, scott and bry na nakasama kong magAI marathon. 
God bless us all 2014!

Pot: Good Job 2014 Basketball! First win is oh so sweet! Hello 2014! Good
luck sa exam sa Friday! Hello sa ever dependable seatmates, Bea, Angel,
Nico, Jhing! Sa Wheaters (malapit na bakasyon!)! Sa UP Meridian (Belated
Happy New Year!)! Sa MDP! Sa 14J! Sa 11G! Sa 25A! At sa 19B11! At sa
mga naka-date ko nung Feb 14, Rog, KB at Jay! Sa uulitin! Nalaman na
ngayon kung sino ang mga totoong adik at emo dyan.hahaha. Peace sa
lahat!

JC Tayag. Clare Toledo. Angel. Pot Torres. WED, 16 Feb 2011 Page 5 of 4