Theatrical personality disorder. Drama Queen

In Somerset Maugham's novel The Theater, the brilliant stage actress Julia Lambert increasingly blurs the boundaries between play and reality. She also “acts out” experiences in real life, including in relationships with those closest to her, constantly thinking about how she looks from the outside. And she doesn’t even realize this until her grown son throws a bitter accusation in her face: “I would love you if I could find you. But where are you? If you peel away your exhibitionism, take away your skill, peel away, like peeling the skin from an onion, layer upon layer of pretense, insincerity, hackneyed quotes from old roles and scraps of fake feelings, will you finally get to your soul?

Histrionic personality disorder should not be confused with the outdated medical diagnosis of hysteria (it was previously used to describe a range of mood and behavioral disorders, and then split into several modern diagnoses), especially since it carries strong negative connotations.

“The term “hysteria” has been devalued,” explains psychotherapist Tatyana Salakhieva-Talal, “it arose at the end of the 18th - beginning of the 19th centuries within the framework of a rather chauvinistic paradigm: it was believed that only women suffer from hysteria. In society at that time there were strict requirements for behavior; direct expression of desires and emotions was considered wrong and indecent. And this led to “crooked” expression - for example, through affective breakdowns or various somatic symptoms. Most of Freud's research clients were women, and he attributed these problems to repressed sexuality, but in fact the problem was the taboo on the expression of genuine emotionality. Now demonstrative behavior is considered closer to the norm than before, because the entire postmodern society, which requires people to have an attractive image, is essentially hysterical in some sense; we are all often “in character.”

Recently, they prefer to call this disorder histrionic (from the Latin histrio - “actor”). It’s funny that in American psychiatry there is a mnemonic rule for remembering the symptoms of a disorder - the first letters of the symptoms form the acronym PRAISE ME - “praise me,” which very accurately conveys the main motivation of hysteroids. This phonetic game, alas, is untranslatable into Russian, so let’s just name the main signs by which you can identify a person with such a disorder.

• He feels uncomfortable in situations where he is not the center of attention. It is important to emphasize here that, unlike a narcissist, being noticeable for a hysteroid is much more important than being the best. Let them adore, or hate, or be perplexed, as long as they think and talk about him.
• Interactions with others are often characterized by inappropriate seductiveness or provocative behavior. That is, almost any act of communication is a reason to conquer, hook, or at least irritate the interlocutor, to squeeze out of him some emotions towards himself.
• The hysterical also often uses his appearance to attract attention; he knows how to do it and loves it. If he is handsome, he will polish and emphasize his advantages; if he is not very handsome, he will come up with an eccentric image for himself.
• This person behaves very dramatically and displays exaggerated emotions. If it’s love, then it’s to death; if it’s disappointment, then it’s fatal; if you’re unwell, then it’s a fever. No restraint or halftones - everything should be about aortic rupture.
• This may sound paradoxical, but the emotions of a hysteroid are not that deep. He is very lively, bright and reverent, and next to him it may seem to people that they have never met a more sensitive person, but here one must always make allowances for artistic exaggeration.
• For the hysteroid, reality is essentially raw material. He extracts from it subjectively significant events from which he can make a “drama”, while others may simply not notice or not attach much importance to them. This perception also affects speech: it is characterized by colorful descriptions that omit details that would be quite significant for another person. In general, such an eyewitness is a nightmare for any investigator, and in personal relationships this feature creates various “difficulties of translation.”
• People with histrionic disorder are easily suggestible and may act impulsively under the influence of a belief or situation. This again stems from a lack of deep internal content.
• Hysteroids often consider relationships with other people to be closer than they actually are. They tend to invent fiery love for themselves where there is only sympathy.

Of course, without hysterics, the world would be much more boring, because they provide those around them with a continuous stream of fresh impressions and vivid emotions. But at the same time, people with a pronounced histrionic disorder have little ability for systematic and purposeful activity, they do not like to work, they are restless, their knowledge is shallow (although sometimes, for the sake of a beautiful image, they can show off, here and there dropping relevant remarks about art and philosophy, but if you dig deeper, it turns out that they have little understanding of the topic), and desires and goals are changeable. Ideally, they would like to lead a “relaxed” lifestyle, have prestigious acquaintances and move in society, show off and have fun. But this is not laziness (in professional psychology the concept of “laziness” does not exist at all), but excessive sensitivity to failures.

“Such people have low tolerance to tension,” explains Tatyana Salakhieva-Talal. “They avoid frustration, although it is learning from mistakes and failures that forms a healthy personality. Therefore, it is difficult for them to withstand long distances without receiving immediate rewards - they immediately need to find an excuse for the fact that something did not work out for them. In addition, people with a demonstrative personality type often have narcissistic traits. So no matter how much attention they get, they always remain unsatisfied.”

Personal relationships with hysterics can also be difficult: despite their outward warmth and ardor, they are quite self-centered, and it is not so easy to achieve true emotional intimacy with them. They often make their partners jealous without meaning to, because they are accustomed to using their sexuality as a tool to attract attention. Such people are also impulsive and often commit rash acts, and then blame others and circumstances for everything.

But, as in the case of other disorders, it all depends on the abilities of each individual and on the severity of his “bugs.” After all, between the norm and a serious illness there is a whole range of intermediate options. If a person with a hysterical personality is talented and able to work on himself, and his specificity does not go to extremes (remains at the level of accentuation, that is, character traits that are within the clinical norm), his “distortions” are compensated, and his strengths allow him to achieve social success, especially in art, media and show business. You can also build happy family relationships if your partner is patient and helps his dramatic half to take everything more calmly and commit fewer impulsive actions. In more severe cases, the help of a psychotherapist is needed.

How to treat

As with other personality disorders, medications only help with underlying problems such as depression, but do not treat the disorder itself. Therefore, the best option is to work with a psychotherapist, during which the patient will be able to form a more stable self-esteem, cope with excessive impulsiveness and solve other problems.

“Such a “skew” in personality occurs if at an early age a person did not feel that he was noticed and accepted,” says Tatyana Salakhieva-Talal. “The parents were busy with hard work and paid attention to the child only when he was sick with something. He felt lonely, unwanted, and felt that his true desires were not being listened to. Therefore, such people may sometimes report feeling unwell just to attract attention to themselves (but do not think that they are pretenders, this is an unconscious manipulation). Even if an adult hysterical person manages to attract a lot of attention and positive evaluations, he still remains “hungry” because he knows that it is not his true self that receives attention, but his stage image. And when the experience of unsatisfactory emotional contacts accumulates, the hysterical begins to accuse loved ones of disrespect and constantly demand proof of love from them. Psychotherapists teach such patients to gradually become aware of their real feelings and needs and speak directly about them, rather than making a scene over minor issues. Talk openly about what doesn’t suit you, and not fall into silent resentment according to the principle “guess for yourself what’s wrong.” And to develop greater independence from other people’s attention and assessments.”

Histrionic personality disorder is one of a group of conditions called dramatic personality disorder. People with these disorders have intense, unstable emotions and distorted self-images. For people with histrionic personality disorder, self-esteem depends on the approval of others and is not based on a true sense of self-worth. They have an overwhelming desire to be noticed and often behave in dramatic or inappropriate ways in order to gain attention. The word histrionic means “dramatic or theatrical.”

This disorder is more common in women than men and usually becomes evident in early childhood.

What are the symptoms of theatrical personality disorder?

In many cases, people with theatrical personality disorder have good social skills; however, they use these skills to manipulate other people so that they can be the center of attention.

A person with this disorder may also:

Feeling uncomfortable until he or they are the center of attention

Dress provocatively and/or exhibit inappropriate seductive or flirtatious behavior

Change emotions quickly

Behave very dramatically, as if performing a performance in front of an audience, with exaggerated emotions and expressions, and lack of sincerity

Being too concerned about your appearance

Constantly asking for reassurance or approval

Be gullible and easily influenced by others

Being overly sensitive to criticism or disapproval

Have little tolerance for dissatisfaction and are easily bored by routine, often starting projects without finishing them, or jumping from one event to another

Don't think before you act

Be focused on yourself and very rarely interested in others

Find it difficult to maintain relationships and often appear deceitful or superficial in your interactions with others

Scare or attempt suicide to get attention

What causes theatrical personality disorder?

The exact cause of theatrical personality disorder is not known, but most mental health professionals believe that both inherited and learned factors play a role in its development. For example, the existence of a family history of theatrical behavior disorder suggests that there may be a genetic component and that the disorder may be inherited. However, a child of a parent with this disorder may simply be repeating learned behavior. Other environmental factors that may have an influence are a lack of criticism or punishment in childhood, positive reinforcement that is given only when the child behaves only in approved ways, and unpredictable attention given to the child by his or her parent(s).

How is theatrical personality disorder diagnosed?

If symptoms are present, the doctor will begin the evaluation by reviewing the patient's complete medical history and physical examination. Although there are no laboratory tests to specifically diagnose personality disorders with a specific diagnosis, a doctor may use various diagnostic methods, such as x-rays and blood tests, to rule out physical illness or medication side effects as the cause of symptoms.

If no physical illness is found, the patient may be referred to a psychiatrist or psychologist, health care professionals who are specially trained to diagnose and treat mental illness. Psychiatrists and psychologists use specially designed interviews and assessment tools to determine whether a person has a personality disorder.

How is theatrical personality disorder treated?

In general, people with theatrical personality disorder do not believe that they need treatment. They also tend to exaggerate their feelings, which makes it difficult to follow the treatment plan.

Psychotherapy (a type of counseling) is used to treat theatrical personality disorder. The goal of treatment is to help the person uncover the motivations and fears associated with his or her thoughts and behavior and to help that person learn to relate to other people in the most positive way.

Medicines may be used to treat symptoms of distress that may occur with the disorder, such as depression and anxiety.

What complications are associated with theater disorder?

Histrionic personality disorder can affect a person's social or romantic relationships, as well as how the person reacts to loss. People with this disorder also have a higher risk of developing depression than the general population.

What is the prognosis for people with theatrical personality disorder?

Many of these people are able to function well socially and at work. Patients with severe cases may face significant problems in their daily lives.

Can theatrical personality disorder be prevented?

Although there is no known way to prevent this disorder, treatment may allow people who are susceptible to this disorder to learn more productive ways to adapt to different situations.

Tested by doctors at the Cleveland Clinical Department of Psychiatry and Psychology

Not everyone knows about the existence of such a disease as dependent personality disorder. In our lives we have to meet different characters, aggressive and timid, active and passive, dominant and passive. In most cases, these are individual personality traits, but sometimes such character traits become painful and develop into the stage of mental illness. Dependent personality disorder is one such case where it is difficult to draw the line between personality traits and illness.

What is dependent personality disorder?

Dependent personality disorder is a mental illness associated with a personality disorder that manifests itself as:

• constant and voluntary dependence of the patient on another person or group of persons,
• inability to act independently,
• feelings of inferiority and incompetence
• helplessness when it comes to making decisions
• constant need for approval, support, protection.

All of the listed feelings and conditions can be observed in any person, but in a normal state they are temporary and depend on the situation that has arisen. If they are permanent and the person seeks to maintain them in the future, this is evidence of a painful personality disorder.

Main symptoms and behavioral reactions

The presence of dependent personality disorder can be judged by a number of symptoms that are expressed in a person’s behavior in everyday life.

All signs can be divided into two groups, expressed in attitude towards oneself and relationships with other people.

In relation to his own personality, the patient experiences:

• low self-esteem
• helplessness
• incompetence
• inability to make decisions independently
• fear of being rejected
• pessimistic attitude towards the present and future
• refusal to assume adult responsibilities

In relation to other people, including the dominant partner:

• feeling of subordination
• constant need for care, protection and support
• waiting for all problems to be resolved
• desire to meet the expectations of others
• willingness to take on secondary roles
• emotional dependence, i.e. feelings and moods do not arise on their own, but in response to the behavior of other people
• fulfilling the wishes of others to the detriment of one's own interests
• conscious limitation of relationships with outsiders, so-called social contacts

According to the American Diagnostic Manual of Mental Disorders (DSM-IV), the main features are as follows:

1. regular difficulties when making the simplest daily decisions and the inability to make them without recommendations, advice and confirmation from others
2. the need for the constant presence of a person who will take responsibility for making decisions in all life issues
3. impossibility or significant difficulties when trying to express disagreement with partners, associated not with fear of punishment, but with the possibility of losing support and good attitude
4. inability to perform independent work due to constant doubts about one’s own abilities and uncertainty in decisions made
5. willingness to follow all instructions, even if these are unpleasant or humiliating things, just so as not to lose support
6. when thinking that the person or people who care about him will no longer exist, a feeling of discomfort, fear and helplessness appears
7. the emergence of a strong, to the point of inadequacy, feeling of fear at the prospect of independent existence without outside care
8. a persistent desire, upon the loss of an existing relationship, to enter into a new relationship in search of help and care.

Externally, the disease manifests itself in general “nervous weakness”, rapid fatigue, acute impressionability, the habit of introspection and constant worry. The patient is characterized by anxiety, fear of possible difficulties and expectation of trouble.

These manifestations become obvious in extreme situations in which a person does not make any decisions, does not act, and does not even look for a patron, but passively waits for someone who can take care of him.

• In family relationships, such a patient, regardless of age, remains in the position of a child who is completely subordinate to family members and does not strive for independence, receiving care and guardianship in exchange.
• At work, he is completely dependent on the manager, needs constant care, guidance, approving or critical comments. Tries to please others, is humble about insults and insults, just to remain in the team.
• Women in the family voluntarily remain in a dependent position; for many years they endure cruelty, drunkenness, and neglect from their spouses for fear of ruining the relationship and losing the person who dominates them and on whom they depend.
• Men with similar psychological disorders may exhibit hypercompensatory behavior patterns, i.e. develop opposite qualities. In this case, feeling the need for support and care, they hide it for fear of disapproval by society and outwardly strive for dominance, which leads to a deep conflict between internal feelings and external behavior.
• When dealing with doctors, they show a willingness to obey and follow all recommendations and instructions, but do not show their own initiative.

In medicine, there is a concept - a pattern (i.e., a stable repetition of the same behavior) of anxiety addiction. This is one of the main symptoms of dependent personality disorder, which is expressed in the fact that the patient constantly doubts his partner, his reciprocity, and availability. To get rid of these doubts, patients strive to show even greater helpfulness and humility in order to avoid any possibility of a break in the relationship.

Diseases with similar symptoms

Dependent personality disorder is a disorder that must be differentiated from other diagnoses with similar symptoms.

The closest diseases are:

• An asthenic type of psychopathy, which is characterized by symptoms of indecision, timidity, inferiority, and increased impressionability. The difference is that there is no attachment and dependence on a specific dominant personality

• Dramatic personality disorder, expressed in vivid, unstable emotions, intense relationships with other people. The difference is that all emotions and relationships are superficial and are more designed for the public’s reaction.
• Schizoid psychopathy, which manifests itself in isolation, unsociability, reduced need for social contacts, and lack of empathy.
• Phobic disorders are the presence of constant, unfounded fears that arise about circumstances, phenomena, situations, objects, living beings. Accompanied by constant anxiety.
• Borderline personality disorder, in which a person is unstable and experiences frequent changes in mood, self-esteem, feelings and relationships with other people.

Despite the coincidence of a number of symptoms, each of these diseases has its own motivating reasons that affect behavior and relationships with other people.

Thus, individuals with dramatic or borderline disorders are characterized by regular breaks with people around them, as well as attempts to manipulate others with the help of feelings. For “addicts” such behavior is impossible, since they experience dependence not only physical and economic, but also emotional, i.e. They value their partner, obey him and are afraid of relationship breakdowns.

Patients diagnosed with schizoid psychopathy not only avoid expanding social contacts, but also avoid them in every possible way, even to the point of complete self-isolation.

Phobic disorders are manifested by increased anxiety and fears, as well as in dependent disorder, but there is no desire for a subordinate and dependent position.

Causes

Medicine has not yet precisely established the causes of dependent personality disorder. It is generally accepted that the disease is formed under the influence of personality characteristics when external factors are imposed.

Among the most likely reasons are:

• temperamental characteristics, such as indecisiveness, high emotional sensitivity, increased susceptibility to stress
• excessive care from adults in childhood
• deprivation of the opportunity to satisfy one's needs at a young age
• suppressive authoritarian parenting style
• the prevalence of social stereotypes about the subordinate position of women in the family and society.

All of these reasons are superimposed on personal life circumstances, for example, the emergence of a relationship with an overwhelming dominant, and lead to the emergence of dependent personality disorder.

Classification in medical science

Different schools of psychologists have their own approaches to the classification of mental disorders of various types.

Thus, in old Russian and Soviet psychiatry, the disease “dependent personality disorder” is not mentioned.

The German founders of classical psychiatry did not diagnose it either.

This disorder was identified as a separate type of disease in the United States and included in the Diagnostic and Statistical Manual of Mental Disorders (DSM), which was published from 1994 to 2000.

Scientists explain this discrepancy by the fact that the symptoms of a dependent disorder can manifest themselves throughout life only as character traits and do not reach painful manifestations. This is most likely in the following cases:

• when a person prone to addiction is in a stable relationship with a socially adequate person who understands and supports his partner;
• in the presence of a patriarchal family, when a man takes on the role of protector, and a woman traditionally occupies a subordinate position
• under totalitarian regimes with a strictly established order of life.

Since Russia and Germany existed for a very long time on similar principles, there were no factors for the transition of a dependent position into a painful state, i.e. there was no danger or fear of couples breaking up and partners leaving.

Possible consequences and complications

Dependent personality disorder may not manifest itself throughout life if external factors do not contribute to it. Under “favorable” circumstances, the following consequences are possible:

• Living for many years with a cruel person with constant insults and beatings does not lead to the desire to change the situation. As a result, most dependent participants in such relationships end up in the hospital with trauma as victims of domestic violence.
• In normal relationships, a break with a partner leads to severe depression.
• It is possible to develop somatophoric disorders, in which psychological problems become the source of somatic (bodily, physical as opposed to mental) symptoms. A person may experience difficulty breathing, pain, and weakness in the absence of obvious reasons.
• Against the background of addictive disorders, a craving for unhealthy habits arises, i.e. a person tries to hide from problems with the help of food, smoking, medications, and alcoholism.
• Dependent disorders create the basis for the emergence of various phobias, which at first glance are not related to the person’s condition.

The main goal of treatment is not to cure the underlying disease, which is practically impossible, but to prevent its further development and transition to more severe stages.

At-risk groups

There are certain categories of the population that are most vulnerable to mental illness, including dependent personality disorder.

First of all, age is taken into account. Scientists call the most vulnerable age periods, such as:

• Oral development period (from birth to 1.5 years), in conditions of complete dependence of the child on others. Children with chronic somatic diseases who do not have the strength to develop an active attitude towards the surrounding reality suffer more often.

• Junior school age, when the child finds himself in conditions of strict discipline and constant tension. The first signs are increased fatigue, loss of self-confidence, decreased academic performance, the appearance of shyness and feelings of inferiority.
• The next stage is the puberty period, during which a break in the psyche occurs, a change in authority and a change in relationships with others.

Among those diagnosed with addictive disorders, the majority are women. In men, this disease is rarely detected.

Among the total number of mental illnesses, 2.5 percent are dependent mental disorder.

Diagnostic methods

Diagnosis of the disease is carried out during a conversation with the patient, special tests and anamnesis of his life.

The diagnosis is made if several basic criteria are met:

• a conscious or subconscious desire to delegate the making of any decisions to others;
• subordinate position and constant concessions in personal relationships;
• lack of demands on others or inability to express them;
• fear of loneliness due to lack of ability to live independently;
• exaggerated fear of losing a partner;
• inability to make independent decisions even in ordinary everyday matters without outside instructions or advice.

If at least 4 of the listed signs are present, then we can talk about a developed dependent personality disorder.

Treatment

Psychotherapeutic methods are used as treatment. The patient is invited to participate in individual or group psychotherapy sessions. Groups are formed separately for women and men.

The goal of group therapy is to teach a person to care for others and provide support to people in similar situations. As a result, an atmosphere of equal relations is created and self-confidence appears.

In severe cases, when the disease is accompanied by depression, medications are used. The peculiarity of medical prescriptions is that the patient easily becomes dependent on the medications and the doctor himself. Patients, seeking attention and care, exaggerate symptoms.

Doctors admit that it is impossible to completely recover from an addictive condition, but it is necessary to reduce tension in a person’s condition, reduce his fears and prevent him from slipping into depression.

– a personality disorder characterized by intense but superficial interpersonal relationships, intense, unstable emotions, and distorted self-image. Patients with dramatic personality disorder try to lead an overactive life, dramatize events that happen to them, constantly try to attract the attention of others, and quickly change beliefs. Manipulative behavior and sexual provocations are possible. The disorder occurs in childhood. The diagnosis is made based on medical history, conversation with the patient and test results. Treatment is psychotherapy.

General information

Dramatic personality disorder is one of the most common personality disorders. Along with dissocial, borderline and narcissistic disorders, it is included in the group of disorders with unpredictable or dramatic behavior (group B personality disorders). Traditionally, it was believed that dramatic personality disorder is more common in women, but studies conducted by American psychologists and psychotherapists at the end of the last century showed some bias in diagnosing “dramatic personality disorder” in male and female patients.

It turned out that when both histrionic and antisocial traits were present, women were often diagnosed with dramatic personality disorder, and men were often diagnosed with dissocial personality disorder. Modern Western experts claim that theatrical disorder is detected in 2-3% of the population and is equally common in men and women. Occurs in childhood and persists throughout life. Treatment is carried out by specialists in the field of psychotherapy and clinical psychology.

Causes of dramatic personality disorder

There are several concepts of the development of theatrical personality disorder. Proponents of the psychoanalytic school place family relationships at the forefront, pointing out that patients with dramatic personality disorder are often raised by domineering parents who constantly convey hidden double messages to children (especially often in matters of gender relations). Fear of rejection pushes children with dramatic personality disorder to dramatize ordinary life situations and causes provocative sexual behavior in combination with the perception of their gender as weak and inferior, and the opposite gender as strong and dangerous.

Representatives of the cognitive school point to the extreme suggestibility and lack of internal content in the thinking of patients with dramatic personality disorder. Experts believe that the cause of the development of the disorder is increased emotionality and progressive egocentrism. Patients with dramatic personality disorder are so immersed in their own emotions and experiences that they have little opportunity to get acquainted with the real world and the events taking place in it. They compensate for the lack of deep knowledge with the opinions of other people or their own intuitive insights.

Experts in the field of sociology hypothesize that dramatic personality disorder is related to social norms and public expectations in relation to the fairer sex. They believe that this disorder may be a reflection of excessive femininity, internal immaturity and dependence on other people - one of the gender stereotypes that denies the self-sufficiency and internal maturity of a woman. A number of psychologists believe that dramatic personality disorder develops under the influence of all of the above factors in combination with hereditary predisposition, as well as stereotypes of thinking and behavior learned through constant contact with older family members suffering from the same disorder.

Symptoms of Dramatic Personality Disorder

Histrionic personality disorder is characterized by demonstrative behavior, pretentious speech, constant change, and an insatiable need to be the center of attention. Patients with dramatic personality disorder usually have good social skills but have difficulty forming stable, harmonious, close relationships. They are charming, easily make contact and are able to quickly charm their interlocutor, but their interest in other people is superficial and unstable. They are impulsive, often act under the influence of emotions, without thinking about the consequences. They quickly change their opinions and beliefs and need attention, support and approval.

Patients with dramatic personality disorder seem to be constantly “in the limelight.” They put on performances in front of any audience, wear overly sexy clothes, and often flirt when contacting members of the opposite sex. Patients with dramatic personality disorder are very sensitive to any criticism and at the same time very suggestible, easily manipulate others and are just as easily manipulated by more calculating people, which is why they sometimes find themselves in difficult situations. Another hallmark of dramatic personality disorder is boredom intolerance. When faced with a routine, patients with this disorder very quickly “fade out”, not finishing the things they started and “jumping” from one event to another.

When interacting with sick people, other people may feel a lack of attention to their own interests and personality. Patients with dramatic personality disorder may appear shallow, deceitful, vain, and pushy. To attract attention, any techniques are used - from seduction and emotional stories about the events that took place to an exaggerated demonstration of one’s own weakness and helplessness. Sometimes patients with dramatic personality disorder exaggerate their own physical suffering from some existing or imagined illness, or attempt suicide in an effort to get what they want.

People with dramatic personality disorder tend to be preoccupied with their appearance. They follow fashion trends and wear bright, extravagant, eye-catching outfits. Provocative behavior and ease of getting close to other people lead to numerous romances, which, however, do not always develop into serious relationships due to the superficiality and fickleness of the patients. At the same time, patients often inadequately evaluate their relationships with other people, considering themselves a friend in the case of a simple acquaintance or a permanent partner in the case of a fleeting love affair.

Diagnosis and treatment of dramatic personality disorder

Patients with theatrical personality disorder, as a rule, do not understand the reason for their difficulties in life and look for this reason in social conditions, characteristics of relationships with loved ones, etc. According to Western researchers, only about 20% of patients seek professional help with dramatic personality disorder, with many leaving treatment after little improvement or stopping seeing a specialist, feeling frustrated by the lack of immediate results.

The diagnosis is established on the basis of a life history, a conversation with the patient and the results of special psychological testing. When diagnosing dramatic personality disorder, specialists take into account the criteria specified in ICD-10 and DSM-IV. To make a diagnosis according to ICD-10, three or more criteria are required from a list that includes theatricality and self-dramatization, easy suggestibility, rapidly changing surface emotions, constant need to be the center of attention, inappropriate seductiveness, and excessive preoccupation with one's own attractiveness.

The main treatment for dramatic personality disorder is psychotherapy. Individual and group techniques are used. There are two main approaches to treating such disorders. Representatives of classical psychodynamic therapy focus on identifying the patient’s painful experiences hidden in the unconscious. Supporters of the behavioral approach help a patient with dramatic personality disorder to see the ineffectiveness of his own lifestyle, identify erroneous ideas about the world around him, correct thinking errors and learn new, more adaptive behavior.

To achieve a state of stable compensation, long-term (often several years) joint work of a specialist and a patient with a dramatic personality disorder is required. In the presence of concomitant depression, neuroses and other mental disorders, appropriate medications are prescribed. The prognosis depends on the patient’s level of motivation and his readiness for constant active work. Dramatic personality disorder cannot be cured; the personal characteristics of patients remain throughout life, however, with compensation for this disorder, patients can successfully function in society.

I. Grant

Understanding personality includes the individual's individual way of thinking, feeling, behaving, and responding to the environment. When this “psychological definition” reflects an appropriate balance between consistency and adaptive flexibility, then we are talking about character traits. We talk about personality disorders in cases where a given person constantly uses certain, the same mechanisms of responding to situations of everyday life in a completely inadequate, poorly adapted, stereotypical way.

Diagnosis of personality disorders. American Psychiatric Association Diagnostic and Statistical Manual ( DSM-III ) identifies eleven fairly clearly distinguishable personality disorders, which can be grouped into three thematic subgroups. Paranoid, schizoid and schizoid personality disorders are characterized by strange and eccentric behavior.

“Theatrical, narcissistic, antisocial and borderline personality disorders are characterized by dramatic presentation along with self-centeredness, extreme emotionality and abnormal behavior. Irritability and fear underlie the dependent, compulsive, evasive, and passive-aggressive personality.

In the classification scheme ( DSM-III ) specific exclusion and inclusion criteria are provided for the diagnosis of each of the listed personality disorders. Since the number of criteria for each personality disorder ranges from 3 to 24, the description of these disorders in this chapter is rather just a “light reflection” of their full text. And to get acquainted with a detailed list of symptoms and signs necessary for diagnosis, you need to contact DSM-III.

Paranoid personality disorder . Individuals with this disorder are very suspicious and hypersensitive to slights or interpersonal conflicts. They are usually hypervigilant about the possibility of harm or deception from others, so they are always on guard, secretive and often unkind to others. They can be jealous and, as a rule, are concerned about the evil intentions of others. They tend to exaggerate difficulties, are very touchy, and easily become hostile towards their interlocutor. Their emotional palette is very poor, so most people perceive them as cold, unemotional and humorless people.

Schizoid personality disorder . Schizoid individuals are usually loners and seem to have little need for the company of other people. They give the impression of being very cold and withdrawn, indifferent to praise or criticism; They tend not to have close friends, so they are often socially reclusive. In earlier nomenclatural descriptions, they were sometimes also credited with eccentric thinking. IN DSM-III However, secondary categories are not taken into account, they are considered schizotypal and related to difficulties in cognitive function of the brain, rather than difficulties in interpersonal relationships.

Personality disorder of the schizophrenic type (schizotypal). Schizotypal personalities are similar to those with schizophrenia in the eccentricity of thinking, perception of the environment, speech and the nature of interpersonal relationships, however, the degree of expression of these features and their coverage of the individual does not reach the extent when a diagnosis of schizophrenia can be made. They have strange speech (e.g., metaphorical, evasive, detailed), referential ideas (i.e., ideas with the inappropriate inference that some neutral events have a special relationship to their personality), magical (unrealistic) thinking, and marked suspicion. Many schizotypal individuals are also often socially withdrawn, which makes them similar to schizoid individuals.

Borderline personality disorder . Individuals with this personality disorder have been described as "stable-unstable". They experience constant difficulties in maintaining a stable mood, interpersonal attachments, and also in maintaining a stable self-image. Borderline personality may manifest itself through impulsive behavior, sometimes of a self-harmful nature (for example, self-harm, suicidal behavior). The mood of such persons is usually unpredictable. Some of them have seemingly spontaneous “explosions” of anger, irritability, “severe grief,” and fear. Others, on the contrary, suffer from chronic spiritual emptiness. Despite the chaotic nature of their interpersonal relationships, in which immeasurable love is replaced by immeasurable hatred, borderline individuals cannot tolerate loneliness. The protective mechanism of “splitting” (of other persons or events into “exceptionally good” and “exceptionally bad”) around them can be expressed quite sharply.

“Theatrical” (ostentatious, hysterical) personality disorder . People with a "theatrical" personality type are characterized by very "intense" but actually superficial interpersonal relationships. They usually come across as very busy people, the events around them are dramatized, and they, of course, are the center of these events. As a rule, they exaggerately express their emotions, want to attract attention to themselves, seek emotional excitement, and have a tendency to be overactive. Although on the surface they are warm and charming, theatrical personalities are perceived as shallow, thoughtless, fussy, demanding, dependent on others, easily self-forgiving and adventurous. Some of them often attempt or threaten to commit suicide.

Narcissistic personality disorder . Narcissistic individuals typically have a heightened sense of self-worth and often view themselves as unique, gifted, and possessing incredible potential. Such a patient usually greatly exaggerates his talents and capabilities, therefore he expects admiration from others and often uses them to achieve a better position in society, while remaining indifferent to their feelings and needs. Refusal by others to help them can make them feel angry, humiliated, ashamed, or resigned. Narcissistic individuals find it difficult to see others in a real light; they either over-idealize them or immediately devalue them.

Antisocial personality disorder . Antisocial behavior is characterized by non-compliance with generally accepted rules of behavior for an individual; he commits actions that are not expected of him, repeatedly violates the rights of others. This diagnosis can only apply to adults (in patients under 18 years of age, traits of antisocial behavior are classified as behavioral disorders) in whom the traits of antisocial behavior appeared before the age of 15 years. Such behavior includes skimping on school and work, various offenses, running away from home, lying, premature sexuality, violations of generally established legality, and abuse of alcohol and certain medications. In addition to the listed anamnestic data, a person who is diagnosed with antisocial personality disorder must, at the time of diagnosis, be guilty of certain behavioral deviations characterized by irresponsibility at work, violation of parental responsibilities, financial irresponsibility and antisocial personal behavior (for example,reckless behavior, driving while intoxicated). In addition, antisocial individuals tend to engage in various illegal activities, lie and deceive, and demonstrate an inability to maintain long-term attachment to a sexual partner, while being aggressive and irritable. They usually abuse alcohol and other toxic chemicals.

A personality disorder with a tendency to avoid relationships with another person. This personality disorder is characterized by the patient’s inability to respond correctly to rejection or impolite treatment. Therefore, patients often avoid close communication with anyone altogether. However, secretly they still want to communicate with other people. Unlike individuals of the narcissistic type, their self-esteem is often low, and they tend to exaggerate their shortcomings.

Personality disorder involving dependence on others . “Dependent” individuals easily allow others to solve many of their life problems for them. Due to the fact that they feel helpless and unable to resolve any issue on their own, they strive to subordinate their needs and desires to others, so as not to be responsible for themselves.

Passive-aggressive personality disorder . Individuals with passive-aggressive personality disorder typically reject all responsibility, both social and professional. Instead of expressing this directly, they tend to procrastinate and procrastinate, resulting in slacking or ineffective work; their frequent reference is the word “forgot”. Thus, they ruin their potential in work and life.

Compulsive personality disorder . This condition is characterized by the presence of irresistible urges and is equivalently designated by the term “obsessive-compulsive” personality. Such individuals usually overload themselves with various rules, rituals and details of behavior. They often stubbornly insist that this or that activity be carried out in exactly this way, but at the same time they show indecisiveness at the most crucial moment of carrying out this or that activity. These individuals value their work and their property much more highly than interpersonal relationships. They have difficulty expressing warm and affectionate feelings towards others and at times appear cold, awkward (in terms of relationships) and tense.

Atypical, mixed and other personality disorders . This last category of personality disorders DSM-III include those that do not exactly fit into any of the above categories. The term “mixed personality disorder” is most often used. This means that the behavior of a given individual simultaneously corresponds to several categories of personality disorders, for example, a given person is both passive-aggressive and dependent. People speak of an atypical personality disorder when it seems to undoubtedly exist, but the doctor clearly does not have enough anamnestic information to classify this disorder into a certain category in accordance with the classification. Other personality disorders cover conditions not mentioned in DSM-III , for example, masochistic, impulsive, infantile personality disorders, included in other classification schemes. The so-called attention disorder in adults is increasingly being diagnosed ( ADD ) - residual form of children's ADD (hyperkinesis). At the same time, adults are often distinguished by absent-mindedness, inattention, unstable mood, they are often quick-tempered, impulsive, do not tolerate stress well, and are often unable to fully complete one or another task. Sometimes they can paradoxically calmly react to this or that stress for the central nervous system.

Reliability of personality disorder diagnosis . Despite ongoing attempts to unify specific diagnostic criteria for diagnosing personality disorders, this problem is far from resolved. While experienced clinicians seem to agree that some forms of personality disorders undoubtedly exist, this confidence disappears when they try to make the diagnosis nosologically specific. The greatest agreement has been achieved in this regard in the diagnosis of antisocial and paranoid personality disorders.

Differential diagnosis . Major mental disorders. In the early stages, schizophrenia can easily be confused with schizoid, schizotypal, paranoid and borderline personality disorders. Affective disorders can be mistaken for borderline, “theatrical” and compulsive personality disorders. Anxious and suspicious states have something in common with compulsive, “theatrical” and “evasive” personality disorders. Abuse of alcohol and other toxic-chemical agents must be differentiated from antisocial, borderline and “theatrical” personality disorders. Paranoid disorders can sometimes be difficult to distinguish from schizotypal and borderline personality disorders. The following guidelines help in differential diagnosis: the main mental diseases often still have a fairly clear onset, their symptoms are usually more severe and significantly disrupt a person’s daily life, and some of their characteristics go far beyond the diagnostic criteria for personality disorders.

Additional personality disorders . Criteria for categories of personality disorders given in DSM-III , often seem to overlap each other. Thus, “schizophrenia-like” phenomena, including eccentric behavior and elements of psychosis, may resemble the clinical picture of paranoid, schizoid, schizotypal and borderline personality disorders. Dramatic behavior, emotional outbursts, and inappropriate behavior may be confused with antisocial, borderline, narcissistic, and theatrical personality disorders. Impulsivity of behavior is noted in antisocial, borderline and theatrical types of personality disorders, while irritability and fears can be a manifestation of evasive, passive-aggressive, dependent and compulsive behavior.

Behavioral disorders associated with other (non-mental) illnesses . Non-psychiatric and neurological diseases can sometimes mimic personality disorders. So, for example, people with complex-partial epilepsy in the presence of lesions in the left temporal lobe may exhibit an extraordinary passion for order, religiosity, sometimes they are somewhat “sticky”, which can be mistaken for compulsiveness. On the other hand, they may have a paranoid “flying to pieces” mentality, which brings them closer to paranoid or schizotypal personalities. Strictly correct, once and for all established and full of ritualistic minutiae, behavior characteristic of a compulsive personality may be a manifestation of the development of dementia or a consequence of a head injury, while irritability, incontinence of emotions, and inadequate interpersonal relationships in such individuals may be mixed with borderline personality disorder . Apart from these specific examples, almost every disease that affects the brain in one way or another can cause behavioral disorders that suggest a personality disorder. The differential diagnostic key in such cases may be a relatively sudden onset and the presence of certain neuropsychological abnormalities indicating a violation of brain functions.

Etiology and pathopsychology . It was generally accepted that personality disorders reflected the disfiguring influence of an unfavorable social environment in childhood. At present, there are many facts indicating the leading role of purely biological factors. Constitutional and genetic characteristics are also of great importance.

Genetic factors. Although studies have not been conducted on all types of personality disorders, for most of them it has been established that the risk of developing them is many times higher in monozygotic twins compared to dizygotic twins. Antisocial personality disorders have been the best studied in this regard. It was found that this pathology occurs in men 3-4 times more often than in women; among the primary relatives of these patients, persons with antisocial personality disorder, alcoholism and psychosomatic disorders (Briequet syndrome) are also more common. The latter is characterized by persistent multi-organ systemic complaints in women with a “theatrical” personality type. The combination of these two personality disorders in people of the same ancestry suggests that Briquet syndrome and antisocial personality disorder are expressions of a common biogenetic substrate that manifests itself differently in men and women. The influence of genetic factors in persons with antisocial personality disorder also proves that children of parents suffering from antisocial personality disorder and alcoholism also have an increased risk of developing this pathology, even if they are raised by adoptive parents who do not suffer from any antisocial tendencies . And, on the other hand, children taken in by foster parents suffering from antisocial behavioral tendencies do not become antisocial individuals if there are no alcoholics or antisocial individuals among their blood relatives. It has been suggested that the development of antisocial personality disorder may be due to a chromosomal disorder XYY . More recent studies indicate that although this disorder is very often detected in persons serving prison sentences, the majority of men with a karyotype XYY do not suffer from antisocial personality disorder. The diagnoses of schizotypal, borderline, and schizoid personality disorders initially arose from the assumption that there must be some “preclinical” forms of schizophrenia, which would be characterized by milder symptoms and fewer symptoms indicating disordered thinking or abnormal interpersonal relationships. Thus, a person with schizotypal personality disorder could theoretically be a carrier of early disorders of thinking, perception and attention that later characterize schizophrenia. Schizoid personality disorder includes difficulties in building interpersonal relationships, so characteristic of schizophrenia. Genetic studies have confirmed that schizotypal, but not schizoid, personality disorder is quite common among relatives of people diagnosed with schizophrenia.

Borderlines are genetically theatrical. In almost 50% of cases, borderline individuals have a family history of some kind of affective deviation. Borderline personality disorder, like other personality disorders, tends to be more common in first-degree relatives, “borderline” parents, but is not consistently associated with schizophrenia.

Schizophrenia is more common in families of patients suffering from paranoid personality disorder. Twin studies of compulsive personality traits indicate increased concordance for obsessive traits in monozygotic rather than dizygotic twins. There are also facts confirming the family inheritance of a painful commitment to order and a strict regimen of life.

Other personality disorders have not been studied thoroughly from a biogenetic perspective.

Constitutional factors. Although it is clear that infants are born with certain temperamental characteristics (e.g., high or low activity levels; the ability to attend for longer or shorter periods of time), there is little evidence that these characteristics persist into adolescence. So, infant temperament does not in any way predict the development of a particular personality disorder at a later age, except that a “difficult child” (irritable, difficult to calm down, with a disturbed rhythm of life) is undoubtedly more likely to later display certain behavioral disorders. difficulties. In the anamnesis of persons with personality disorders, one can often find indications of insufficient physical and mental development.

Combination of personality disorders with neurophysiological and neuroendocrine disorders. Several neurophysiological and biochemical changes in the body are associated with personality disorders. Thus, the electroencephalograms of patients with antisocial personality disorder often show pathologically low waves and low peaks, and in people with borderline personality disorder, the EEG pattern indicates the presence of periodic limbic epileptiform discharges. Some researchers believe that a common neurophysiological feature of individuals with antisocial and histrionic personality disorder is reduced cortical arousal in response to cortical stimuli, which occurs secondarily in response to increased inhibitory impulses coming from “lower” (in terms of location) parts of the brain. This is precisely combined with motor disinhibition observed in individuals with antisocial personality disorder and autonomic disinhibition in hysterics. In schizotypal personality disorders, an impairment in the ability to calmly follow a directional gaze has been noted. Since many schizophrenics also perform this task quite poorly, it can be assumed that in schizotypal individuals, like in patients with schizophrenia, neural efficiency in relation to “centering” is reduced. Some schizophrenics and patients with schizotypal personality disorder have decreased platelet monoamine oxidase (MAO) activity, and it has been suggested that decreased MAO activity may be related to insufficient degradation of certain biologically active amines, leading to the accumulation of certain psychotomimetic substances. properties. Cortisol's ability to evade dexamethasone suppression and shortened rapid eye movement (REM) latency (REM latency is the time between falling asleep and the first REM episode) have been associated with mood disorders. Both of these phenomena are also observed in individuals with borderline and obsessive-compulsive disorder, which suggests some connection between affective, borderline and obsessive-compulsive personality disorder. No specific biological correlations have yet been established for other personality disorders.

Environmental factors. Based on the nature of the social environment in early childhood, it turned out to be impossible to predict the later development of personality pathology. For example, there is evidence that 30% of men suffering from one or another personality disorder indicated a lack of maternal warmth in childhood, but in the control group 24% of respondents mentioned this. Various difficult psychological situations in early childhood were indicated by 16% of people with personality disorders and 10% of healthy respondents. If a child was mistreated as a child, then in adulthood he often displays behavior with a tendency to commit violence. The relative "weakness" of temperamental and environmental factors as "predictors" of future personality disorder development has led to the emergence of the "goodness of fit" theory. According to this theory, personality disorders in children develop more often in subsequent years, then there is a clear discrepancy between the child’s temperament, childhood upbringing and the psychosocial environment around him.

Epidemiology. The incidence of personality disorders in the population ranges from 5 to 23%. Antisocial personality disorder is diagnosed more often in men than in women, while borderline and theatrical personality disorders tend to be diagnosed in women. Much more often, prisoners suffer from personality disorders, as well as residents of provincial cities and areas with social disintegration. Among the population with a low standard of living, these violations occur 3 times more often than among wealthier citizens. This socio-demographic feature is most characteristic of antisocial personality development.

Course of the disease and prognosis. Compared with controls, individuals with personality disorders are much more likely to have a variety of emotional problems in childhood. The incidence of most personality disorders decreases with age, with peak incidence occurring between ages 20 and 29. This trend is most characteristic of antisocial personality disorder, which is apparently due to the slower maturation of such individuals. Although no more than 20% of such patients usually seek medical help, most of them encounter insurmountable difficulties in creating a family, stable friendships, and getting a job. With regard to psychiatric complications, it should be noted that approximately 30% of people with personality disorders have quite clearly defined depression or a state of anxiety and fear. Patients with personality disorders are prone to alcohol abuse, which is especially typical for men, so that alcoholism among them reaches 50%.

Treatment. Patients with personality disorders usually do not understand the reason for their difficulties in life. They often look for this reason in others, in the social environment around them, which makes people close to them feel very uncomfortable. Only 20% of such patients, as already mentioned, seek psychiatric help.

Treatment consists mainly of psychotherapy, used in one form or another. Only in some cases psychopharmacological agents are used. Various types of psychotherapeutic interventions have proven successful - individual, group, couples and family psychotherapy. Despite the different techniques and target orientation of psychotherapeutic influences, most psychotherapists emphasize that the most important point (and the most difficult) in treatment is the establishment of a trusting relationship with the patient, which allows one to identify the internal sources of behavior that is poorly adapted to life. From a psychodynamic point of view, this means that it is necessary first of all to identify those basic painful experiences of the patient that need to be eliminated, but for this purpose their causes must be found. Cognitive-behavioral therapists typically try to identify patients' misconceptions about life, teach them to always look ahead, especially with regard to their unusual behavior, draw patients' attention to the ineffectiveness of their lifestyle, and teach them more appropriate behavior. As a rule, patients with “dramatic” manifestations of the disease (borderline, antisocial, “theatrical”, narcissistic personality disorders) require a more active, sometimes forced, strictly prohibitive approach on the part of the psychotherapist. In some cases, individuals with antisocial personality disorder apparently should not and cannot be treated in an outpatient setting, but require forcible detention either in a correctional facility or in an appropriate treatment facility. When it comes to treating people with borderline personality disorder, psychotherapists are divided into two camps: some believe in the psychotherapeutic effects of occupational therapy, others adhere to tactics of supporting the patient “here and now.” In both cases, treatment for these patients is often interrupted for long periods when the patient becomes disliked by his therapist, attempts suicide, or experiences psychotic decompensation and requires hospitalization.

In contrast to these active and aggressive tactics, it may be advisable to take a more cautious, understanding and “light” approach to patients with episodes of “terrible” and “more than strange” behavior.

Psychotherapy in such cases should be long-term, i.e., lasting for several years. In such cases, the psychotherapist often experiences a feeling of dissatisfaction, anger, helplessness and inability to help the patient. There are quite a lot of clinical reports about significant improvement in the condition of such scores, but there is practically no controlled data. This reflects ongoing unresolved issues regarding diagnostic reliability and general methodological approaches to treatment, as well as the determination of disease outcomes. Therefore, further research is needed. At the same time, there is growing evidence in favor of psychopharmacological interventions for some personality disorders. Thus, in persons with borderline disorder, especially with simultaneous impairment of self-regulation of mood, tricyclic antidepressants and MAO inhibitors are effective. Other groups of “borderline” individuals, in whom mood regulation disorders and impulsive behavior were particularly pronounced, responded well to the use of lithium. Patients with explosive behavior responded well to carbamazepine. In some of them, according to EEG data, the presence of epileptic foci in the limbic structures was assumed. Both “borderline” and schizotypal individuals with disorganized cognitive processes can respond well to small doses of antipsychotic drugs. People with compulsive personality disorder who are prone to obsessive thoughts may find relief from the tricyclic drug clomipramine (not manufactured in the United States). In addition to its antidepressant effect, clomipramine has a specific anti-obsessive effect. The effectiveness of other antidepressants for personality disorders has not been established, although MAO inhibitors have shown promise in compulsive individuals who simultaneously experience fears or “panic” attacks.

Meridil can reduce absent-mindedness and increased motor activity, as well as affective lability and impulsivity in patients whose personal difficulties are associated precisely with lack of attention.

T.P. Harrison.Principles of internal medicine.Translation by Doctor of Medical Sciences A. V. Suchkova, Ph.D. N. N. Zavadenko, Ph.D. D. G. Katkovsky