Avoidant Personality Disorder Resources

by Aunt Becky | May 9, 2019

What Is Personality?

Personality is a particular set of behaviors, traits, emotions, and patterns that make up a person, his character, and their individuality. Personality includes how we see the world, our thoughts, attitudes, and feelings. Personality is strongly influenced by our values, attitudes, perception of ourselves, and predicts our reactions to people, the world, stress, and problems.

While there are many different definitions of personality, most focus on the pattern of behaviors and characteristics that can help predict and explain a person’s behavior.

What Is A Personality Disorder?

A person’s personality may be influenced by experiences, environment (surroundings, life situations) and inherited – genetic – characteristics. A person’s personality typically stays the same over time.

While personality disorders differ from mental disorders, like schizophrenia and bipolar disorder, they do, by definition, lead to significant impairment. Personality disorders are estimated to affect about 10 percent of people, although this figure ultimately depends on where clinicians draw the line between a “normal” personality and one that leads to significant impairment.

A personality disorder is a way of thinking, feeling, and behaving that is different from the expectations of the culture, causes distress, problems functioning, and lasts over time. Personality disorders are almost always associated with marked social and personal disruption and are both pervasive and inflexible. While these behaviors can produce poor coping skills, leading to personal issues including anger, anxiety, depression, and distress, they are considered appropriate by the person with the disorder.

There are 10 specific types of personality disorders. Personality disorders are long-term patterns of behavior and inner experiences that differs significantly from what is expected. The pattern of experience and behavior begins by late adolescence or early adulthood and causes distress or problems in functioning.

Without treatment, personality disorders can be long-lasting. Personality disorders must affect at least two of the following areas:

• Way of thinking about oneself and others
• Way of responding emotionally
• Way of relating to other people
• Way of controlling one’s behavior

What Is Avoidant Personality Disorder?

No one enjoys criticism, rejection, or embarrassment, but sometimes certain people spend their entire life avoiding these situations altogether, by in part, avoiding situations that could produce such situations. They may avoid confrontations, not take credit for work that is theirs, distance themselves from others, and try to avoid any interactions with other people. Sometimes, these socially-challenged people who have a over-the-top reaction to rejection while feeling consistent feelings of inadequacy are diagnosed with a personality disorder, a mental illness known as avoidant personality disorder (AVPD).

Avoidant personality disorder is one of a group of mental illnesses called personality disorders, which are characterized by feelings of nervousness and fear. People with avoidant personality disorder have poor self-esteem and feel very down about themselves and the ways in which they relate to others. Often. people who have AvPD have an intense fear of rejection and being negatively judged by others. These feelings make them very uncomfortable in social situations, leading them to avoid group activities and contact with others.

AVPD (also called Anxious Personality Disorder or Anxious (Avoidant) Personality Disorder) is a personality disorder that is characterized by a pattern of withdrawal, self-loathing and an extremely heightened sensitivity to criticism. People who have AVPD usually consider themselves socially unsuccessful and socially awkward tend to remove themselves from social situations (whenever possible) in the hopes of avoiding the feeling – or risk – of feeling rejected by others. They spend a lot of time focusing on their shortcomings and are very hesitant to form relationships in which rejection is possible, which naturally often results in feelings of loneliness, becoming disengaged from relationships at work, and having few people they truly feel safe with. People with AVPD might also refuse a promotion, make excuses to miss meetings, or be too fearful to engage in events where they might make friends.

Those who live in a relationship with a person who suffers from avoidant personality disorder often recognize that something is not quite right with the behavior of their family member or loved-one but often don’t have any idea what the “not quite right” bit is. Partners and loved ones of those who have AvPD may feel trapped in the relationship and frustrated by their loved-one’s tendency to pull them away from family, friends, and other “everyday” social settings.

People who are in a relationship with a person who suffers from AVPD may also experience pressure to isolate themselves along with them or pressure to protect them from criticism or to create an artificial or dysfunctional “bubble” or ideal environment around them in which they can escape the risk of negative self-thought.

Avoidant personality disorder (AvPD) is a Cluster C personality disorder; cluster C personality disorders are those in which the affected exhibit a notable pattern of severe social anxiety, social inhibition, feelings of inadequacy and inferiority, extreme sensitivity to negative evaluation and rejection, as well as avoidance of social interaction despite a strong desire for intimacy. The behavior is usually noticed by early adulthood and occurs in most situations.

People with AvPD often consider themselves to be socially inept,  personally unappealing, and avoid social interaction for fear of being ridiculed, humiliated, rejected, or disliked. They generally avoid becoming involved with others unless they are certain they will be liked. As the name suggests, the main coping mechanism of those with AvPD is avoidance of feared situations. Childhood emotional neglect (in particular, the rejection of a child by one or both parents) and peer group rejection are associated with an increased risk for its development; however, it is possible for AvPD to occur without any notable history of abuse or neglect.

Is Avoidant Personality Disorder The Same As Social Anxiety?

There remains much controversy over the notion that social anxiety disorder is simply an advanced form of AvPD. Researchers and clinicians used to believe that avoidant personality disorder only occurred in conjunction with social anxiety disorder (SAD). However, more recent research has shown that there is a significant percentage of people with AVPD who do not meet the criteria for social anxiety disorder.

Let’s examine this further:

Social anxiety disorder (SAD) is, naturally, very distressing for those who must cope with it in their daily lives. Typically, people with SAD understand that their fears of rejection and criticism are out of proportion with reality, though these reactive thought patterns persist. They may give a lot of energy to imagining worst-case scenarios but do not venture out of the house to face these possibilities. These habits make forming and maintaining friendships and relationships extremely challenging, and people with advanced social anxiety disorder may live very isolated lives. The resulting stress of SAD may also cause nervous physical symptoms, such as sweating, dizziness, trembling, difficulty breathing, upset stomach, increased heart rate, and tension within the body.

The overwhelming symptoms of social anxiety can contribute to the trauma of social situations in the end, generating more fear and anxiety in the future.

Symptoms of avoidant personality do disorder mirror those of social anxiety disorder but reach further into a person’s understanding of their own identity and their dysfunction in everyday life.

People with avoidant personality disorder:

• Have extremely low self-esteem because they believe that they are inferior, incompetent, and entirely deserving of the rejections they anticipate from others.
• Are incredibly sensitive to criticism –  real or imagined – to such point that it is so crippling that they have very few, or even no, social interactions on a regular basis.
• May not be able to succeed in a job because of the socialization it requires and opt for jobs in which they can work at home
• Are often without friendships and romantic relationships, if they want these connections in their lives. Looking for real connections with people raises the stakes, and people with avoidant personality disorder may feel extreme anxiety about interacting with these people.

Those with social anxiety disorder may have low self-esteem in social situations but do not actually believe they are inferior or worthy of the outside judgments they fear, while those with avoidant personality disorder internalize this criticism so completely that they believe the pending hostile perspective is justified. Their perception is distorted so much so that they do not even see themselves as they are in reality—let alone how the world and the people around them really are. It is as if avoiding others and social situations is a way of avoiding themselves, however. they continue to live with these fears and distress, withdrawing further and becoming severely isolated. They may develop overwhelming anxiety in anticipation of going to the grocery store, simply walking out to the mailbox, or having an unexpected visitor show up at the door.

Sometimes it may be difficult to distinguish whether a person has social anxiety disorder or avoidant personality disorder, or both conditions. Typically, a person with AVPD will experience anxiety and avoidance in all arenas of life, whereas a person with social anxiety may only have fears specific to certain situations, such as public speaking or performing.

What is a Cluster C Personality Disorder?

Different personality disorder diagnoses are organized by cluster,” and those who have Cluster C personality disorders experience characteristics and feelings that involve being particularly anxious or fearful. Avoidant personality disorder is a Cluster C personality disorder, as are dependent personality disorder, and obsessive-compulsive personality disorder.

How Common Is Avoidant Personality Disorder?

It is estimated that about 2.5 percent of the population has avoidant personality disorder and seems to affect men and women equally. It generally begins in infancy and childhood and continues into adulthood. As with most personality disorders, avoidant personality disorder usually is not diagnosed in people younger than 18 years of age.

New information has found that in several separate clinical studies, Avoidant Personality Disorder may actually affect anywhere from 1.8% to 5.2% of the general population. Remember this, people who are diagnosed with Avoidant Personality Disorder also frequently meet the criteria for other personality disorders.

This table below shows how statistically likely it is that a person who is diagnosed with AVPD will also meet the criteria for another personality disorder. The more positive the number, the more likely it is that a person will be diagnosed with the second personality disorder listed. The more negative the number, the less likely it is that a person will be diagnosed with the second personality disorder in the table.

What Causes Avoidant Personality Disorder?

Researchers don’t completely understand what causes avoidance personality disorder, but they believe it is a combination of genetics and environmental factors, meaning that as of this writing, no single cause is to blame for the development of Avoidant Personality Disorder. The following factors may greatly influence the development of AvPD, but there’s no accepted single root cause for the disorder.

Early Childhood Experiences:

Millon and others considered early interactions with parents as an important etiological factor in AVPD. The likely importance of early caregiver experiences is underscored by adoption studies. Increased odds of PD in adoptees were evident in the National Epidemiological Survey on Alcohol and Related Conditions (NESARC) study, but the odds were highest, about double that of non-adoptees, for paranoid, antisocial, and avoidant PDs.

Early childhood experiences may be linked to the development of AVPD. Research suggests that children who see their caregivers as lacking in affection and encouragement and/or experience rejection from them may be at increased risk. So are children who experience abuse, neglect, and an overall lower level of care. In response to these experiences, children may avoid socializing with others as a coping strategy.

Some studies suggest that patients with AvPD are more likely to see their parents as less affectionate, more rejecting, guilt-engendering, and less encouraging of achievement than matched controls. AvPD has been linked to a recalled history of neglect, abuse, overprotection, and lower care. The CLPS found relatively few differences between AvPD and other PDs on experiences of physical or emotional abuse, or caretaker emotional denial. However, there are some noteworthy differences: those with a primary diagnosis of AvPD reported fewer positive relationships with other adults, poorer parental social ability, less sexual abuse, and physical neglect than a group of persons with other PDs. Research has also discovered associations mediated in part by a maladaptive schema of belief in the need to subjugate personal needs, wants, and desires to avoid negative interpersonal outcomes, although overall few relationships with early maladaptive schemas were evident.

In summary, despite some variability of findings, there seems to be reasonable support for an association between neglect and emotional abuse, and perhaps less encouragement by early caregivers and later AvPD symptomatology. Recall bias influenced by underlying hypersensitivity cannot be excluded as a contributor to these findings, but twin studies point to some role for environmental factors, and negative experiences within the family would appear a likely candidate.

Attachment style:

Attachment provides an explanatory model for the link between temperament, adverse childhood environment, and personality disorders. An attachment style referred to as avoidant, detached, or dismissing (also referred to as an “anxious/avoidant” style) has been proposed to contribute to the development of AvPD. This attachment style may be associated with a negative self-concept and a fear of intimate relationships. A fearful attachment style – involving a desire for intimacy in the presence of interpersonal distrust and fear of rejection – is now thought to be of major relevance to people who have AvPD. Indeed, Bartholomew regarded the fearful style, when extreme, as typical of AVPD.

A number of studies have confirmed the theorized relationship between AvPD and both anxious and avoidant strategies. Using the four-category model of Bartholomew and Horowitz, which posits that attachment is classified into one of four groups determined by positive or negative views of the self and positive or negative views of others, some studies also identified a fearful attachment style in AVPD. In the four-category model, the fearful attachment style may be the most disabling, since it is associated with negative views of both self and other. Research suggests that experiences with critical, demeaning, and neglectful early caregivers may increase the risk of developing a fearful attachment style.

These findings are important because attachment style is highly relevant to assessment and treatment; It is more difficult for a therapist to establish and maintain a relationship with a person who is distrustful of others, is hypersensitive to criticism and rejection, and relies on avoidant coping strategies.

Links between early childhood experiences and core features of AVPD: hypervigilance, avoidance, low self-esteem, and negative self-concept:

It’s been postulated that a child may develop hypervigilance as a coping strategy when a parent is inaccessible or inconsistent and this hypervigilance may then move to other social situations. This might be expected to apply equally to social anxiety disorder. Others suggest that repeated negative experiences with parents might lead the child to expect unpleasant or distressing interactions, and to then employ avoidance as a coping strategy. Over time, this might become the default strategy. The resulting social isolation then predisposes these people to feel greater emotional distress. Millon viewed parental rejection or denigration as a critical factor in the loss of self-esteem in the child.

A role for temperamental factors has also been proposed with some supportive evidence:

• Personality rigidity
• Hypersensitivity
• Major harm avoidance
• Low novelty-seeking
• Overactive behavioral inhibition system

It also seems likely that social anxiety disorder and AVPD share some temperamental vulnerability factors:

• Negative emotionality (neuroticism)
• Behavioral inhibition
• Shyness

Temperamental factors may increase the person’s vulnerability to the effects – and possibly even the risk – of negative childhood experiences. They may also influence the selection of coping strategies, such as avoidance, and the adverse impact of maladaptive strategies. A relationship between attachment and temperament has also been described. For example, the amount and expression of distress an infant experiences upon separation from the early caregiver may be influenced by temperamental traits, and the responsiveness of the caregiver may influence attachment.

Genetic factors:

Genetic studies have the potential to offer insight into the relative contributions of genes and environment, as well as more specifically to inform the question of diagnostic validity. A heritability coefficient for AVPD of 0.64 has been estimated in one study. Initial and 10-year follow-up genetic findings in people who had avoidant personality disorder and social anxiety disorder using data from the Norwegian Twin Registry indicated that genetic influences on AVPD were stable over time, but the genetic risk for SAD was more variable.

The authors concluded that environmental factors contributed to co-occurrence of AVPD and SAD, and that there are potentially distinct factors underlying SAD and AVPD.

In summary, these studies suggest a complex relationship between genes, temperament, early childhood environment, attachment style, and personality in AVPD, which remains to be fully elucidated. The research indicates some shared vulnerability with SAD, but also some points of difference.

What Are Some Of The Characteristics of Avoidant Personality Disorder?

The following is a list of some of the more common characteristics and traits of people who suffer from Avoidant Personality Disorder (AVPD) from Out of The Fog:

These traits are listed as a guideline only and are not intended for actual or diagnosis or as diagnostic criteria. People who suffer from avoidant personality disorder are each unique and so each person will display a different subset of traits. It’s also important to remember that everyone displays “avoidant” behaviors from time to time. Therefore, if a person exhibits one or some of these traits, that does not necessarily qualify them for a diagnosis of AVPD.

Always/Never Statements are declarations containing the words “always” or “never” especially used in arguing in interpersonal relationships, while often used, these statements are usually not true They are commonly used but rarely true.

Avoidance – Purposefully withdrawing from relationships with others as a preemptive defensive measure to help reduce the risk of rejection, accountability, criticism, or exposure.

Blaming – Rather than identifying ways of dealing with a problem together, these people blame other people who “created the problem.”

Catastrophizing – Automatically assuming a “worst case scenario” in absolutely every situation, thus wrongly characterizing minor or moderate problems or issues as catastrophic events.

Circular Conversations – People who engage in circular conversations (generally within the context of an argument) can go on almost endlessly, repeating the same patterns, never coming to an actual conclusion together.

Confirmation Bias – The tendency involves paying much more attention to things that reinforce their already-held beliefs rather than things which contradict them.

“Control-Me” Syndrome – Some people have the tendency to engage in relationships with people who have a controlling narcissistic, antisocial, or “acting-out” nature.

Cruelty to Animals – acts of violence toward helpless animals have been discovered to statistically occur more frequently in those who have a personality disorder rather than the general population more often in people who suffer from personality disorders than in the general population.

Denial – the imagination or belief that some awful, traumatic situation didn’t exist and that they have no memory of the event.

Dependency – far out of normal and appropriate constant reliance by an adult to another adult, allowing the other adult to make decisions about illness, health, and personal and emotional well-being

Depression – Many individuals who have been diagnosed are also diagnosed with depression and depression symptoms

Escape To Fantasy – Instead of dealing with the present crisis or the here and now, a person escapes to a fantasy world

Identity Disturbance – a distorted and/or inconsistent view of themselves

Imposed Isolation – occurs when abuse leads a person becoming isolated from their support network, including friends and family.

Lack of Object Constancy – An inability to remember that people or objects are consistent, trustworthy and reliable, especially when they are out of your immediate field of vision.

Low Self-Esteem – negatively distorted view of self that is disingenuous to reality

Magical Thinking – Looking for supernatural connections between external events and one’s own thoughts, words and actions.

Manipulation – The practice of steering an individual into a desired behavior for the purpose of achieving a hidden personal goal.

Masking – Covering up one’s own natural outward appearance, mannerisms and speech in dramatic and inconsistent ways depending on the situation.

Neglect – A passive form of abuse in which the physical or emotional needs of a dependent are disregarded or ignored by the person responsible for them.

Objectification – The practice of treating a person or a group of people like an object.

Obsessive-Compulsive Behavior – An inflexible adherence to arbitrary rules and systems, or an illogical adherence to cleanliness and orderly structure.

Panic Attacks – Short intense episodes of fear or anxiety, often accompanied by physical symptoms, such as hyperventilating, shaking, sweating and chills.

Parentification – A form of role reversal, in which a child is inappropriately given the role of meeting the emotional or physical needs of the parent or of the family’s other children.

Passive-Aggressive Behavior – Expressing negative feelings in an unassertive, passive way.

Perfectionism – The maladaptive practice of holding oneself or others to an unrealistic, unattainable or unsustainable standard of organization, order, or accomplishment in one particular area of living, while sometimes neglecting common standards of organization, order or accomplishment in other areas of living.

Sabotage – The spontaneous disruption of calm or status quo in order to serve a personal interest, provoke a conflict or draw attention.

Selective Competence – Demonstrating different levels of intelligence, memory, resourcefulness, strength or competence depending on the situation or environment.

Self-Loathing – An extreme hatred of one’s own self, actions or one’s ethnic or demographic background.

Self-Victimization – Casting oneself in the role of a victim.

Splitting – The practice of regarding people and situations as either completely “good” or completely “bad”.

Testing – Repeatedly forcing another individual to demonstrate or prove their love or commitment to a relationship.

Thought Policing – Any process of trying to question, control, or unduly influence another person’s thoughts or feelings.

Tunnel Vision – The habit or tendency to only see or focus on a single priority while neglecting or ignoring other important priorities.

What Are The Symptoms of Avoidant Personality Disorder?

While avoidant personality disorder symptoms include anxiety during social contexts, they also differ sharply from social anxiety in the underlying beliefs and sense of self that drive their anxiety. Fear of social interaction arises from a deeply held sense of insecurity, inferiority, and ineptness. In contrast, many people with social anxiety disorder have healthy self-esteem and do not believe themselves to be inferior to others; social anxiety is not rooted in a particular self-image.

The symptoms of avoidant personality disorder are a highly specific set of beliefs that drive disordered behavior.

To receive a diagnosis, a person must have experienced these components by the time they reach earl adulthood. They also must experience at least four of the following AVPD symptoms, these include:

• Extremely low self-esteem
• Avoidance of activities at work that involve interpersonal contact due to fear of criticism or rejection
• Believing oneself to be inferior, inept, or unappealing to others
• Unwillingness to interact with others unless certain they will receive a positive response
• Highly sensitive to criticism or perceived rejection
• Feeling inadequate and being inhibited in new social situations
• Reluctance to enter social situations or form relationships
• An absence of friendships
• Hesitancy in intimate relationships due to fear of shame
• Preoccupation with criticism in social situations
• Extreme shyness that arises out of fear of doing something wrong
• Unwillingness to try new things for fear of humiliation or embarrassment

Living with avoidant personality disorder can be extremely limiting, as fear and rumination over perceived shortcomings can make even the most simple activities into (possible) emotional minefields.

It is also important to remember that people with this condition do not lack a desire for social contact; in fact, most people with AvPD deeply want to form close relationships and be able to engage in social interactions, but are so restrained by their disruptive thoughts and distorted self-image that they are unable to participate in such activities. If they do have social relationships, they are likely with people considered to be “low-risk” in terms of rejection, humiliation, or judgment, severely restricting social options.

For people with this disorder, the fear of rejection is so strong that they choose isolation rather than risk being rejected in a relationship. The pattern of behavior in people with this disorder can vary from mild to extreme. In addition to their fear of humiliation and rejection, other traits of people with this disorder include the following:

• They are oversensitive and easily hurt by criticism or disapproval.
• They have few, if any, close friends and are reluctant to become involved with others unless certain of being liked.
• They experience extreme anxiety (nervousness) and fear in social settings and in relationships, leading them to avoid activities or jobs that involve being with others.
• They tend to be shy, awkward, and self-conscious in social situations due to a fear of doing something wrong or being embarrassed.
• They tend to exaggerate potential problems.
• They seldom try anything new or take chances.

A diagnosis will require a psychological evaluation by a mental health professional. This evaluation will also rule out other potential diagnoses or determine whether a person has more than one diagnosis.

Psychologist Theodore Millon notes that because most patients present a mixed picture of symptoms, their personality disorder tends to be a blend of a major personality disorder type with one or more secondary personality disorder types. He identified four adult subtypes of avoidant personality disorder:

Lynn E. Alden and Martha J. Capreol, in 1993, proposed two other subtypes of avoidant personality disorder:

How Are General Personality Disorders Diagnosed?

Before a diagnosis of a personality disorder can be made, they must first meet the criteria for a personality disorder.

The two relevant major systems of classification for personality disorders must be met before any type of specific diagnosis (such as Avoidant PD) can be made.

• International Classification of Diseases (11th revision, ICD-11) published by the World Health Organization
• The Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition, DSM-5) by the American Psychiatric Association.

Both have deliberately merged their diagnoses to some extent, however some differences remain. There are accepted diagnostic issues and controversies with regard to distinguishing particular personality disorder categories from each other. Before a specific diagnosis is made, the general criteria put forth by the ICD-11 and DSM-V must be met.

General Criteria For Diagnosing Personal Disorders:

Both diagnostic systems provide a definition and six criteria for a general personality disorder. These criteria should be met by all personality disorder cases before a more specific diagnosis can be made.

The ICD-10 lists these general guideline criteria:

• Markedly disharmonious attitudes and behavior, generally involving several areas of functioning; e.g. affectivity, arousal, impulse control, ways of perceiving and thinking, and style of relating to others;
• The abnormal behavior pattern is enduring, of long standing, and not limited to episodes of mental illness;
• The abnormal behavior pattern is pervasive and clearly maladaptive to a broad range of personal and social situations;
• The above manifestations always appear during childhood or adolescence and continue into adulthood;
• The disorder leads to considerable personal distress but this may only become apparent late in its course;
• The disorder is usually, but not invariably, associated with significant problems in occupational and social performance.

The ICD adds: “For different cultures it may be necessary to develop specific sets of criteria with regard to social norms, rules and obligations.”

Chapter V in the ICD-10 contains the mental and behavioral disorders and includes categories of personality disorder and enduring personality changes which are defined as, “ingrained patterns indicated by inflexible and disabling responses that significantly differ from how the average person in the culture perceives, thinks, and feels, particularly in relating to others.”

The specific personality disorders in the ICD-11: paranoid, schizoid, dissocial, emotionally unstable (borderline type and impulsive type), histrionic, anankastic, anxious (avoidant) and dependent. In addition, there are the following personality disorders:

• Other specific personality disorders (involves PD characterized as eccentric, haltlose, immature, narcissistic, passive–aggressive, or psychoneurotic.)
• Personality disorder, unspecified (includes “character neurosis” and “pathological personality”).
• Mixed and other personality disorders (defined as conditions that are often troublesome but do not demonstrate the specific pattern of symptoms in the named disorders).
• Enduring personality changes, not attributable to brain damage and disease (this is for conditions that seem to arise in adults without a diagnosis of personality disorder, following catastrophic or prolonged stress or other psychiatric illness).

In the proposed revision of ICD-11, all discrete personality disorder diagnoses will be removed and replaced by the single diagnosis “personality disorder.” Instead, there will be specifiers called “prominent personality traits” and the possibility to classify degrees of severity ranging from “mild”, “moderate”, and “severe” based on the dysfunction in interpersonal relationships and everyday life of the patient.[

In DSM-5, any personality disorder diagnosis must meet the following criteria:

• An enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture. This pattern is manifested in two (or more) of the following areas:
• Cognition (i.e., ways of perceiving and interpreting self, other people, and events).
• Affectivity (i.e., the range, intensity, lability, and appropriateness of emotional response).
• Interpersonal functioning.
• Impulse control.
• The enduring pattern is inflexible and pervasive across a broad range of personal and social situations.
• The enduring pattern leads to clinically significant distress or impairment in social, occupational, or other important areas of functioning.
• The pattern is stable and of long duration, and its onset can be traced back at least to adolescence or early adulthood.
• The enduring pattern is not better explained as a manifestation or consequence of another mental disorder.
• The enduring pattern is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., head trauma).

The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) stresses a personality disorder is an enduring and inflexible pattern of long duration that leads to significant distress or impairment and is not due to use of substances or another medical condition. The DSM-5 lists personality disorders in the same way as other mental disorders:

DSM-5 lists ten specific personality disorders: paranoid, schizoid, schizotypal, antisocial, borderline, histrionic, narcissistic, avoidant, dependent and obsessive-compulsive personality disorder.

The DSM-5 also contains three diagnoses for personality patterns not matching these ten disorders, but nevertheless exhibit characteristics of a personality disorder:

• Personality change due to another medical condition – personality disturbance due to the direct effects of a medical condition.
• Other specified personality disorder – general criteria for a personality disorder are met but fails to meet the criteria for a specific disorder, with the reason given.
• Unspecified personality disorder – general criteria for a personality disorder are met but the personality disorder is not included in the DSM-5 classification.

World Health Organization (WHO) Criteria:

If symptoms are present, the doctor will begin an evaluation by performing a complete medical history and physical examination. Although there are no laboratory tests to specifically diagnose personality disorders, the doctor might use various diagnostic tests to rule out physical illness as the cause of the symptoms.

The World Health Organization’s ICD-10 lists avoidant personality disorder as anxious (avoidant) personality disorder. It is a requirement of ICD-10 that all personality disorder diagnoses also satisfy a set of general personality disorder criteria.

AvPD is characterized by at least four of the following symptoms according to the ICD-10:

• Persistent and pervasive feelings of tension and apprehension
• Belief that one is socially inept, personally unappealing, or inferior to others
• Excessive preoccupation with being criticized or rejected in social situations
• Unwillingness to become involved with people unless certain of being liked
• Restrictions in lifestyle because of need to have physical security
• Avoidance of social or occupational activities that involve significant interpersonal contact because of fear of criticism, disapproval, or rejection.

Associated features may include hypersensitivity to rejection and criticism.

The DSM-V criteria for diagnosis of AvPD:

The Diagnostic and Statistical Manual of Mental Disorders (DSM-V) also has an Avoidant Personality Disorder diagnosis that refers to a widespread pattern of inhibition around people, feeling inadequate, and being extremely sensitive to negative evaluation. Symptoms begin by early adulthood and occur in a range of situations. Four of seven specific symptoms should be present, which are the following:

• Avoids occupational activities that involve significant interpersonal contact, because of fears of criticism, disapproval, or rejection
• Is unwilling to get involved with people unless certain of being liked
• Shows restraint within intimate relationships because of the fear of being shamed or ridiculed
• Is preoccupied with being criticized or rejected in social situations
• Is inhibited in new interpersonal situations because of feelings of inadequacy
• Views self as socially inept, personally unappealing, or inferior to others
• Is unusually reluctant to take personal risk or to engage in any new activities because they may prove embarrassing

Differential Diagnosis: 

Avoidant personality disorder must be distinguished from the following 2 disorders:

Social phobia: Differences between social phobia and avoidant personality disorder are hard to spot. Avoidant personality disorder involves more pervasive anxiety and avoidance than social phobia, which is often specific to situations that may result in public embarrassment (eg, public speaking, performing on stage). However, social phobia may involve a broader avoidance pattern and thus may be hard to distinguish. The 2 disorders often occur together.

Schizoid personality disorder: Both disorders are characterized by social isolation. However, patients with schizoid personality disorder become isolated because they are disinterested in others, whereas those with avoidant personality disorder become isolated because they are hypersensitive to possible rejection or criticism by others.

Other personality disorders may be similar in some ways to avoidant personality disorder but can be distinguished by characteristic features (eg, by a need to be cared for in dependent personality disorder vs avoidance of rejection and criticism in avoidant personality disorder).Other personality disorders may be similar in some ways to avoidant personality disorder but can be distinguished by characteristic features (eg, by a need to be cared for in dependent personality disorder vs avoidance of rejection and criticism in avoidant personality disorder).

How Is Avoidant Personality Disorder Treated?

Avoidant personality disorder is a chronic, lifelong condition that will continue to disrupt emotions, thoughts, and behaviors unless treatment is sought. Today, there is a wide variety of interventions that can be used to both alleviate acute symptoms and break through the disordered beliefs that underlie those symptoms. These include psychopharmacological and psychotherapeutic treatment options. Of particular note is cognitive behavioral therapy, which aims to replace damaging patterns of thought and behavior with healthier, reality-based alternatives as well as desensitize patients to those situations that act as triggers for symptoms. Additionally, trauma-focused therapies may help you explore the roots of your disorder and create strategies for processing the pain of traumatic childhood experiences while giving you a framework for creating secure attachments. Due to the intensity of the disorder and its profound impact on functionality, long-term residential treatment is often the best treatment milieu, offering the ability to participate in a broad range of therapies to overcome distress.

Treating personality disorders is difficult, because people with these disorders have deep-rooted patterns of thinking and behavior that have existed for many years. However, people with avoidant personality disorder tend to be good candidates for treatment because their disorder causes them significant distress, and most feel the need to develop relationships with other people and reduce the amount of distress they experience at public or at work. This desire can be a motivating factor for people with avoidant personality disorder to follow their treatment plans.

Symptoms will generally decrease in intensity with age, with the peak level of symptoms displayed in their 40s or 50s. Many people with Avoidant Personality Disorder do not seek out treatment, thinking that they are not good enough or that their symptoms don’t matter, even though the disorder has a significant impact upon their lives. Typically help is sought when life becomes too stressful and they are unable to cope with it.

It is extremely important to understand that treating any personality disorder can be difficult, as many of the symptoms have been experienced for many years. Treatment of avoidant personality disorder can employ various techniques, such as social skills training, psychotherapy, cognitive therapy, and exposure treatment to gradually increase social contacts, group therapy for practicing social skills, and sometimes drug therapy.

Significant improvement in the symptoms of personality disorders is possible, with the help of treatment and individual effort.

However, if you are living with avoidant personality disorder, the condition itself can present unique barriers to treatment. Many people with this condition are highly reluctant to enter into mental health treatment due to the social contact inherent to such care. As such, finding the right treatment environment that will encourage participation and foster feelings of safety is paramount. A key issue in treatment is gaining and keeping the patient’s trust, as people who have avoidant personality disorder may start avoiding treatment sessions if they distrust the therapist or fear rejection. Those with Avoidant Personality Disorder often have low self-esteem about any social interactions, often finding it difficult to see the positive in life. This may be challenging for a therapist, as the person may under-report symptoms, deeming them unimportant. A more thorough, detailed interview may be required.

Being a personality disorder, which are chronic and long-lasting mental conditions, avoidant personality disorder is not expected to improve with time without treatment. Being that it is a poorly studied personality disorder and in light of prevalence rates, societal costs, and the current state of research, AvPD qualifies as a neglected disorder.

The following features may help to make treatment less intimidating and more productive:

• Experienced and compassionate clinicians: It is critical that the treatment you choose is staffed by clinicians who have the experience and compassion necessary to effectively address avoidant personality disorder symptomatology. This includes a deep understanding of individual challenges and how to form strong therapeutic alliance. These will allow you to feel safe and comfortable throughout the treatment process.
• Medications should only be prescribed for specific diagnoses occurring co-morbidly (other mental illnesses) that someone with Avoidant Personality Disorder may have.
• Appropriate therapies: While CBT is often particularly helpful for people struggling with avoidant personality disorder, many are initially reluctant to participate in verbally-based therapies that require direct social interactions. As such, the availability of non-verbal therapies, such as holistic, creative, and experiential modalities, can help you feel more comfortable in exploring yourself. These therapies can help bolster your confidence and give voice to your struggles in a supportive and nonjudgmental environment, enhancing your ability to participate in verbal therapies as time goes on.
• Gradual independence: Healing from avoidant personality disorder doesn’t happen overnight and overcoming the functional limitations caused by the disorder can take time. Providing you with the support you need at each stage of healing will be crucial to ensuring that you are met where you are at and are not overwhelmed by responsibilities for which you are not ready. This includes support not only with emotional wellbeing, but with concrete skill-building to increase independence, resilience, and self-reliance. For people with avoidant personality disorder, breaking through isolation, building and maintaining social relationships, and fostering the ability to fulfill educational and professional goals will be of particular importance.
• Psychotherapy Psychotherapy, or talk therapy, is the primary avoidant personality disorder treatment and may include cognitive-behavioral therapy, which focuses on reducing negative thought patterns and building social skills. Sometimes group therapy is used to help people with similar challenges and create a safe space to build solid relationships. Family therapy can also prove useful so that family members understand the condition and can provide a supportive environment that promotes growth and healthy risk-taking.Therapy is generally short-term and oriented toward solution-based approaches looking for solutions to specific life problems. the primary purpose of both individual therapy and social skills.
• Therapy in a safe and encouraging environment can help you explore the intense anxiety you experience in social situations and your fear of rejection or criticism. Together, you and your therapist can practice challenging negative beliefs and explore the small but significant steps you can take to build solid friendships, be more engaged at work, and develop intimate relationships with others.
• Group Therapy Group therapy may be useful if the person with Avoidant Personality Disorder agrees to attend sessions, although group therapy is often a tool that is used later in treatment, once the person feels more comfortable in social situations. Group therapy is designed for people with avoidant personality disorder to start challenging their exaggerated negative beliefs about themselves.

With appropriate care delivered in an environment of love, you can come to uncover your own strengths and purpose and harness your inner resources for healing. The guidance of clinicians will be paramount to this process, but so too will the support of your peers, who can help you learn and practice new social skills and reframe your understanding of yourself as a competent social actor. Most importantly, you will be empowered to develop a strong sense of self-worth, helping you remove the current of self-devaluation that underlies avoidant personality disorder, releasing you from fear and opening up infinite possibilities for your future.

Without treatment, a person with this disorder can become isolated from society, causing long-term

For Loved Ones: Coping Strategies for Avoidant Personality Disorder:

What To Do For A Loved One:

First, in order to understand what our loved one is going through we must understand how their personality disorder functions. Education and understanding is key for a relationship with someone who has AvPD.

It doesn’t make you a bad person to feel annoyance or displeasure, you may feel frustrated at their irrational behavior. You may feel the pressure to choose between caring for the person who is behaving in an avoidant way and your desire for healthy social interaction. You may feel pressured to become a hermit with them, and begin to resent that pressure.

Detach yourself emotionally from any dysfunctional attitudes. You don’t have to agree with them and you don’t have to fight with them. You can agree to disagree.

Maintain healthy outside interests, recreational pursuits and supportive relationships.

Get support from people who understand personality disorders. Join a support group.

What Not To Do For A Loved One:

Don’t blame yourself for the avoidant behavior and attitudes of a loved one. This isn’t and never will be your fault.

Don’t give in to pressure to isolate yourself from healthy relationships. The pressure may be particularly strong to give in and begin to isolate yourself as much as your loved one. This is nor fair to you, your social life, and your way of life. Keep up with your relationship with others at all cost.

Don’t try to “thought police” the person with the personality disorder. Thought Policing is a term used to describe the assumption that they know exactly what another person is thinking. You’re not omniscient (probably) and sometimes, no matter how well you know the person, you will make an assumption that hurts your loved one.

Don’t try to control their behavior – focus on being healthy yourself. It’s not worth it to tangle yourself up trying to control the behavior of your loved one, you can’t do it, it won’t work, and you too need to be healthy.

Additional Resources for Avoidant Personality Disorder

Out of the Fog – information and support for those with a loved one suffering any type of personality disorder.

Avoidant Personality Disorder – Support group and website devoted to people with Avoidant Personality Disorder and those who love them.

Histrionic Personality Disorder

by Aunt Becky | May 7, 2019

What Is Personality?

Personality is a particular set of behaviors, traits, emotions, and patterns that make up a person, his character, and their individuality. Personality includes how we see the world, our thoughts, attitudes, and feelings. Personality is strongly influenced by our values, attitudes, perception of ourselves, and predicts our reactions to people, the world, stress, and problems.

While there are many different definitions of personality, most focus on the pattern of behaviors and characteristics that can help predict and explain a person’s behaviors.

What Is A Personality Disorder?

A person’s personality may be influenced by experiences, environment (surroundings, life situations) and inherited – genetic – characteristics. A person’s personality typically stays the same over time.

While personality disorders differ from mental disorders, like schizophrenia and bipolar disorder, they do, by definition, lead to significant impairment. Personality disorders are estimated to affect about 10 percent of people, although this figure ultimately depends on where clinicians draw the line between a “normal” personality and one that leads to significant impairment.

A personality disorder is a way of thinking, feeling, and behaving that is different from the expectations of the culture, causes distress, problems functioning, and lasts over time. Personality disorders are almost always associated with marked social and personal disruption and are both pervasive and inflexible. While these behaviors can produce poor coping skills, leading to personal issues including anger, anxiety, depression, and distress, they are considered appropriate by the person with the disorder.

There are 10 specific types of personality disorders. Personality disorders are long-term patterns of behavior and inner experiences that differs significantly from what is expected. The pattern of experience and behavior begins by late adolescence or early adulthood and causes distress or problems in functioning.

Without treatment, personality disorders can be long-lasting. Personality disorders must affect at least two of the following areas:

• Way of thinking about oneself and others
• Way of responding emotionally
• Way of relating to other people
• Way of controlling one’s behavior

What is Histrionic Personality Disorder?

Histrionic Personality Disorder (HPD) is a personality disorder characterized by a pattern of extreme, intense emotions as well as attention-seeking behavior. A person who has histrionic personality disorder needs to be the center of attention in a group – any group – and when they are not, they become upset and uncomfortable. Histrionic personality disorder (HPD) also majorly interferes with emotional stability, and are prone to emotional overreaction in a wide variety of situations, and from the viewpoint of others, they may seem constantly on edge. When they do react, it is usually from a self-centered perspective, and the needs of others are seldom their priority.

In addition to the extremes of their emotional sensitivity and reactivity, people with histrionic personality disorder have a strong need to be the center of attention and frequently exhibit a range of attention-seeking behavior. They also want instant satisfaction and are easily frustrated or overwhelmed by obstacles or criticism. People with HPD usually have good communication skills and are often quite charismatic, projecting a “life of the party” or “larger than life” image. But beyond good initial first impressions they have a difficult time establishing and maintaining close and satisfying relationships.

Despite their self-absorption, people with HPD are subsumed by insecurity, which usually leaves them frustrated and miserable and seeking answers for their feelings of inadequacy.

HPD is classified as a Cluster B personality disorder, along with borderline personality disorder, narcissistic personality disorder, and antisocial personality disorder. People with Cluster B conditions are known to be highly emotional, erratic in their feelings and behavior, and self-centered in their approach to socializing and building relationships.

Nearly 15 percent of the American population meet the diagnostic criteria for one or more of 10 recognized personality disorders. Histrionic personality disorder is one of the least common of these personality disorders, affecting about 1.8 percent of the population – which still represents about four million people. Histrionic personality disorder is diagnosed more frequently among women, who comprise about two-thirds of the known cases. This may not reflect the true incidence of the disorder, but could relate to the willingness of women (or unwillingness of men) to seek assistance for the symptom of HPD when they manifest.

The seeds of histrionic personality disorder are likely sown in childhood, but its symptoms don’t normally become apparent until late adolescence. The severity of the condition may then escalate during early adulthood and become a dominant factor from that point on.

Those with histrionic personality disorder need novelty and thrills, which may lead them to become bored with the usual routines. This may lead to frustration when gratification is delayed, as they want immediate satisfaction. Interest in jobs, friendships, and relationships may quickly dwindle in favor of the shiny newness of other relationships.

Someone with histrionic personality disorder often appears as effervescent, lively, and interesting (sometimes shallow), and cannot handle it when the attention is not focused entirely upon them. In order to direct attention back to themselves, they may begin sexually suggestive or seductive behavior. Despite being highly sexual, people with histrionic personality disorder often have problems with emotional intimacy in sexual or romantic relationships.

Whether or not they are aware, they often choose a role (victim, princess) within their relationships. People with histrionic personality disorder may try to control their partner through seductiveness or emotional manipulation while displaying a strong dependency on their partners on another level. Because people with histrionic personality disorder crave excitement and newness, longer-term relationships are difficult for them to maintain.

It’s hard for those with histrionic personality disorder to maintain same-sex friendships because their sexually-charged style may come across as a threat to their friends’ romantic relationships. In addition, people with histrionic personality disorder can alienate friends through their demands for constant attention, and their depression when that attention is not provided.

What Are The Core Features of Personality Disorders?

The general requirements for the diagnosis of a personality disorder are:

• a pervasive pattern of maladaptive traits and behavior
• beginning in early adult life
• it usually has its first manifestations in childhood and is clearly evident in adolescence
• it is not diagnosed before early adult life because these maladaptive traits are very common in childhood and adolescence, but most individuals age-out of these traits before early adulthood
• leading to substantial personal distress and/or social dysfunction, and disruption to others
• is of long duration, typically lasting at least several years
• Severity Rating Scale For Personality Disorders:

Severity rating scale for personality disorders in the International Classification of Diseases (ICD)-11:

Mild Personality Disorder: notable problems in many interpersonal relationships and the performance of expected work and social etiquette, but some relationships are maintained and/or some roles carried out. Mild personality disorder is typically not associated with substantial harm to self or others.

Moderate Personality Disorder: marked problems in most interpersonal relationships and in the performance of expected occupational and social roles across a wide range of situations that are sufficiently extensive that most are compromised to some degree. Moderate personality disorder often is associated with a past history and future expectation of harm to self or others, but not to a degree that causes long-term damage or has endangered life.

Severe Personality Disorder: There are severe problems in interpersonal functioning affecting all areas of life. The person’s general social dysfunction is profound and the ability and/or willingness to perform expected occupational and social roles is absent or severely compromised. Severe personality disorder usually is associated with a past history and future expectation of severe harm to self or others that has caused long-term damage or has endangered life.

HPD is a serious condition that isolates those who surround the people who have the disorder.

A mnemonic that has sometimes been used to describe the criteria for histrionic personality disorder is “PRAISE ME”:

 

 

 

 

 

 

 

 

P – provocative (or seductive) behavior
R – relationships, considered more intimate than they are
A – attention, must be at center of
I – influenced easily
S – speech (style) – wants to impress, lacks detail
E – emotional liability, shallowness

M – make-up – physical appearance used to draw attention to self
E – exaggerated emotions – theatrical

However, people who suffer from HPD are often just as interested in attracting negative attention, including shock, anger, outrage, shame, guilt and remorse.

What Causes Histrionic Personality Disorder?

What Are Symptoms of Histrionic Personality Disorder? 

While people with Histrionic Personality Disorder are able to function at a high-level and be socially successful, they often use these skills to manipulate others and become the center of attention.

Personality disorders generally are marked by an obsessive concern for the self, rigid and uncompromising attitudes, and an inability or unwillingness to adapt to the needs and desires of others. These disorders function as a cover for deep-seated self-esteem issues, representing a form of overcompensation for feelings of insecurity and inferiority.

An accurate histrionic definition focuses on the distinctive symptoms HPD produces, which include:

• Strong and volatile emotions, both negative and positive
• Rapid shifts in mood, often triggered by seemingly benign events
• Self-centeredness, in conversation and behavior
• Exaggerated gestures or words designed to draw attention
• Expressions of sentiments toward others that seem shallow or insincere, as if meant to manipulate or create a certain impression
• Grossly exaggerated emotional displays
• Believe that their relationships are fa more intimate than they are
• A lack of patience, often accompanied by childish reactions
• Tendency to become flustered or frustrated when things go wrong
• Extreme sensitivity to criticism or perceived rejection
• Constant approval-seeking behavior
• Constant reassurance-seeking behaviors
• Flirtatious or sexually suggestive behavior that may violate interpersonal boundaries
• Exhibition-type behaviors
• Unwillingness to change; suggestions of change are viewed as threats
• Obsessive concern with physical appearance
• A tendency to become bored or distracted, making it difficult to finish tasks or projects
• Lack of empathy, no capacity to read the emotions of others or correctly interpret their words and actions
• Inability to maintain satisfying relationships due to self-centered tendencies and emotional outbursts

Many of these symptoms are common to other personality disorders, which inevitably interfere with personal, social, and professional functioning.

What Are Some Of The Traits Of Those Who Have HPD?

The following list is a collection of some of the more commonly observed behaviors and traits of those who suffer from HPD. Note that these traits are given as a guideline only and are not intended for diagnosis. People who suffer from HPD are all unique and so each person will display a different subset of traits. Also, note that everyone displays “borderline” behaviors from time to time. Therefore, if a person exhibits one or some of these traits, that does not necessarily qualify them for a diagnosis of HPD. See the DSM Criteria on this page for diagnostic criteria.

Catastrophizing – The habit of automatically assuming a “worst case scenario” and inappropriately characterizing minor or moderate problems or issues as catastrophic events.

Chaos Manufacture – Unnecessarily creating or maintaining an environment of risk, destruction, confusion or mess.

Baiting – A provocative act used to solicit an angry, aggressive or emotional response from another individual.

Acting Out – Acting Out behavior refers to a subset of personality disorder traits that are more outwardly-destructive than self-destructive.

“Always” and “Never” Statements – “Always” and “Never” Statements are declarations containing the words “always” or “never.” They are commonly used by most people but arerarely true.

Anger – People who suffer from personality disorders often feel a sense of unresolved anger and a heightened or exaggerated perception that they have been wronged, invalidated, neglected or abused.

Belittling, Condescending, and Patronizing – This kind of speech is a passive-aggressive approach to giving someone a verbal put-down while maintaining a facade of reasonableness or friendliness.

Blaming – The practice of identifying a person or people responsible for creating a problem, rather than identifying ways of dealing with the problem.

Cheating – Sharing a romantic or intimate relationship with somebody when you are already committed to a monogamous relationship with someone else.

Circular Conversations – Arguments which go on almost endlessly, repeating the same patterns with no resolution.

Confirmation Bias – The tendency to pay more attention to things which reinforce your beliefs than to things which contradict them.

Denial – Believing or imagining that some painful or traumatic circumstance, event or memory does not exist or did not happen.

Dependency – An inappropriate and chronic reliance by an adult individual on another individual for their health, subsistence, decision making or personal and emotional well-being.

Depression – People who suffer from personality disorders are often also diagnosed with symptoms of depression.

Dissociation– A psychological term used to describe a mental departure from reality.

Emotional Abuse – Any pattern of behavior directed at one individual by another which promotes in them a destructive sense of Fear, Obligation or Guilt (FOG).

Emotional Blackmail – A system of threats and punishments used in an attempt to control someone’s behaviors.

Engulfment – An unhealthy and overwhelming level of attention and dependency on another person, which comes from imagining or believing one exists only within the context of that relationship.

Escape To Fantasy – Taking an imaginary excursion to a happier, more hopeful place.

False Accusations – Patterns of unwarranted or exaggerated criticism directed towards someone else.

Favoritism and Scapegoating – Systematically giving a dysfunctional amount of preferential positive or negative treatment to one individual among a family group of peers.

Fear of Abandonment – An irrational belief that one is imminent danger of being personally rejected, discarded or replaced.

Feelings of Emptiness – An acute, chronic sense that daily life has little worth or significance, leading to an impulsive appetite for strong physical sensations and dramatic relationship experiences.

Frivolous Litigation – The use of unmerited legal proceedings to hurt, harass or gain an economic advantage over an individual or organization.

Harassment – Any sustained or chronic pattern of unwelcome behavior by one individual towards another.

Holiday Triggers – Mood Swings in Personality-Disordered individuals are often triggered or amplified by emotional events such as family holidays, significant anniversaries and events which trigger emotional memories.

Hoovers & Hoovering – A Hoover is a metaphor taken from the popular brand of vacuum cleaners, to describe how an abuse victim trying to assert their own rights by leaving or limiting contact in a dysfunctional relationship, gets “sucked back in” when the perpetrator temporarily exhibits improved or desirable behavior.

Hysteria – An inappropriate over-reaction to bad news or disappointments, which diverts attention away from the real problem and towards the person who is having the reaction.

Identity Disturbance – A psychological term used to describe a distorted or inconsistent self-view

Impulsiveness – The tendency to act or speak based on current feelings rather than logical reasoning.

Invalidation – The creation or promotion of an environment which encourages an individual to believe that their thoughts, beliefs, values or physical presence are inferior, flawed, problematic or worthless.

Lack of Conscience – Individuals who suffer from Personality Disorders are often preoccupied with their own agendas, sometimes to the exclusion of the needs and concerns of others. This is sometimes interpreted by others as a lack of moral conscience.

Lack of Object Constancy – An inability to remember that people or objects are consistent, trustworthy and reliable, especially when they are out of your immediate field of vision.

Low Self-Esteem – A common name for a negatively-distorted self-view which is inconsistent with reality.

Manipulation – The practice of steering an individual into a desired behavior for the purpose of achieving a hidden personal goal.

Masking – Covering up one’s own natural outward appearance, mannerisms and speech in dramatic and inconsistent ways depending on the situation.

Mood Swings – Unpredictable, rapid, dramatic emotional cycles which cannot be readily explained by changes in external circumstances.

“Not My Fault” Syndrome – The practice of avoiding personal responsibility for one’s own words and actions.

No-Win Scenarios – When you are manipulated into choosing between two bad options

Panic Attacks – Short intense episodes of fear or anxiety, often accompanied by physical symptoms, such as hyperventilating, shaking, sweating and chills.

Push-Pull – A chronic pattern of sabotaging and re-establishing closeness in a relationship without appropriate cause or reason.

Raging, Violence and Impulsive Aggression – Explosive verbal, physical or emotional elevations of a dispute. Rages threaten the security or safety of another individual and violate their personal boundaries.

Relationship Hyper Vigilance – Maintaining an unhealthy level of interest in the behaviors, comments, thoughts and interests of others.

Riding the Emotional Elevator – Taking a fast track to different levels of emotional maturity.

Sabotage – The spontaneous disruption of calm or status quo in order to serve a personal interest, provoke a conflict or draw attention.

Selective Memory and Selective Amnesia – The use of memory, or a lack of memory, which is selective to the point of reinforcing a bias, belief or desired outcome.

Selective Competence – Demonstrating different levels of intelligence, memory, resourcefulness, strength or competence depending on the situation or environment.

Self-Aggrandizement – A pattern of pompous behavior, boasting, narcissism or competitiveness designed to create an appearance of superiority.

Self-Harm – Any form of deliberate, premeditated injury, such as cutting, poisoning or overdosing, inflicted on oneself.

Self-Loathing – An extreme hatred of one’s own self, actions or one’s ethnic or demographic background.

Self-Victimization – Casting oneself in the role of a victim.

Sense of Entitlement – An unrealistic, unmerited or inappropriate expectation of favorable living conditions and favorable treatment at the hands of others.

Silent Treatment – A passive-aggressive form of emotional abuse in which displeasure, disapproval and contempt is exhibited through nonverbal gestures while maintaining verbal silence.

Situational Ethics – A philosophy which promotes the idea that, when dealing with a crisis, the end justifies the means and that a rigid interpretation of rules and laws can be set aside if a greater good or lesser evil is served by doing so.

Splitting – The practice of regarding people and situations as either completely “good” or completely “bad.”

Stunted Emotional Growth – A difficulty, reluctance or inability to learn from mistakes, work on self-improvement or develop more effective coping strategies.

Testing – Repeatedly forcing another individual to demonstrate or prove their love or commitment to a relationship.

Thought Policing – Any process of trying to question, control, or unduly influence another person’s thoughts or feelings.

Threats – Inappropriate, intentional warnings of destructive actions or consequences.

Triggering -Small, insignificant or minor actions, statements or events that produce a dramatic or inappropriate response.

Tunnel Vision – The habit or tendency to only see or focus on a single priority while neglecting or ignoring other important priorities.

What Other Mental Health Disorders Occur In People Who Have HPD?

It is possible for a person to have the symptoms of more than one personality disorder as these disorders often blend into one another.

Among people diagnosed with HPD, borderline personality disorder, dependent personality disorder, and narcissistic personality disorder are also frequently diagnosed. Borderline personality disorder is the most commonly detected of these conditions, and some mental health professionals actually classify HPD as a borderline personality disorder subtype.

Some of the other mental and behavioral health disorders routinely diagnosed in people with histrionic personality disorder include:

• Depression. HPD creates strong emotional responses, and when rejection or disappointment is experienced people with histrionic personalities can easily slip into clinical depression.
• Anxiety disorders, including panic disorder. In one study, between 35 and 52 percent of those with various anxiety disorders also met the diagnostic criteria for a personality disorder, usually of a type that affects emotion and stress responses (such as HPD)
• Somatoform Disorders
• Attachment Disorders, such as reactive attachment disorder
• Eating disorders. About one-third of eating disorder sufferers also have one or more co-occurring personality disorders, often including HPD.
• Substance use disorders. While different studies have produced varying results, most research has shown as least some relationship between histrionic personality disorder and addiction. However, the association is not as strong as with several other types of personality disorder.

When an additional mental or behavioral health condition is diagnosed in people with HPD, treatment plans must be developed that focus equally on each disorder.

How is Histrionic Personality Disorder Diagnosed?

HPD is not a devastating psychological disorder, which means that people with this disorder rarely seek treatment as most people with HPD function successfully in society and at work. In fact, people with HPD usually have great people skills. unfortunately, however, they often use these skills to manipulate others.

According to the Diagnostic and Statistical Manual of Mental Disorders (5^th edition), people with histrionic personality disorder must have at least five (or more) of the following symptoms:

• Is uncomfortable in situations in which they are not the center of attention
• Has interactions with others characterized by inappropriate sexually seductive or provocative behavior
• Displays rapidly shifting and shallow expression of emotions
• Consistently uses their physical attention to draw attention to self
• Has a style of speech that is excessively impressionistic and lacking in detail
• Shows self-dramatization, theatricality, and exaggerated expression of emotion
• Is suggestible (that is, they are easily influenced by others or circumstances)
• Considers relationships to be more intimate than they actually are

If you have HPD, you might also be easily frustrated or bored with routines, make rash decisions before thinking, or threaten to commit suicide in order to get attention.

The World Health Organization’s ICD-10 lists histrionic personality disorder as:

A personality disorder characterized by:

• shallow and labile affectivity,
• self-dramatization,
• theatricality,
• exaggerated expression of emotions,
• suggestibility,
• egocentricity,
• self-indulgence,
• lack of consideration for others,
• easily hurt feelings, and
• continuous seeking for appreciation, excitement and attention.

It is a requirement of ICD-10 that a diagnosis of any specific personality disorder also satisfies a set of general personality disorder criteria.

A diagnosis of histrionic personality disorder occurs through a thorough examination by a psychiatrist or psychologist by reviewing symptoms and taking a detailed health history. If the symptoms meet the diagnostic criteria, a diagnosis of histrionic personality disorder is made.

What Are The Subtypes for Histrionic Personality Disorder?

Histrionic Personality Disorder Subtypes (As Suggested by Million)

Subtypes of HPD	Description	Personality Qualities
Infantile HPD	includes borderline PD symptoms	Labile, high-strung, volatile emotions; childlike hysteria and nascent pouting; demanding, overwrought; fastens and clutches to another; is excessively attached, hangs on, stays fused to and clinging.
Vivacious Histrionic	The seductiveness of the histrionic mixed with the energy typical of hypomania. Some narcissistic features may also be present	Vigorous, charming, bubbly, brisk, spirited, flippant, impulsive; seeks momentary cheerfulness and playful adventures; animated, energetic, ebullient.
Tempestuous histrionic	Includes passive aggressive PD	Impulsive, out of control; moody complaints, sulking; precipitous emotion, stormy, impassioned, easily wrought-up, periodically inflamed, turbulent.
Appeasing histrionic	Includes compulsive and depended PD	Seeks to placate, mend, patch up, smooth over troubles; knack for settling differences, moderating tempers by yielding, compromising, conceding; sacrifices self for commendation; fruitlessly placates the unplacatable.
Disingenuous histrionic	HPD and antisocial PD	Underhanded, double-dealing, scheming, contriving, plotting, crafty, false-hearted; egocentric, insincere, deceitful, calculating, guileful.
Theatrical histrionic	Variant of “pure” pattern	Affected, mannered, put-on; postures are striking, eyecatching, graphic; markets self-appearance; is synthesized, stagy; simulates desirable/dramatic poses.

How Is Histrionic Personality Disorder Treated?

Those who suffer Histrionic Personality Disorder are generally hard to treat for many reasons. People with HPD often only seek treatment when their symptoms have become too much for them to handle. Once in treatment, however, these people often exaggerate their symptoms and lack of ability to function. They also have a hard time, as they are emotionally needy, terminating therapy may become a problem.

If people who have HPD are truly determined to change their emotional and psychological reactions, HPD can be amenable to treatment.

Inpatient or intensive outpatient treatment programs in mental health treatment facilities are ideal for people diagnosed with HPD, who require peace, quiet, and ample social and psychological support in the early stages of recovery.

Psychotherapy is the preferred method of intervention for histrionic personality disorder. Some of the therapies that have proven effective for this condition include:

• Cognitive behavioral therapy (CBT). Through CBT people with histrionic personalities can begin to think and act more calmly and with more deliberation and contemplation. CBT is also effective against depression and anxiety disorders, which can co-occur with HPD.
• Interviews and self-report methods generally, in clinical practice with assessment of personality disorders, one form of interview is the most popular; an unstructured interview. The actual preferred method is a semi-structured interview. The reason that a semi-structured interview is preferred over an unstructured one is that semi-structured interviews tend to be more objective, systematic, replicable, and comprehensive. Unstructured interviews, despite popularity, tend to have problems with unreliability and are susceptible to errors leading to false assumptions of the client. One of the single most successful methods for assessing personality disorders by researchers of normal personality functioning is the self-report inventory following up with a semi-structured interview. There are some disadvantages with the self-report inventory method that with histrionic personality disorder there is a distortion in character, self-presentation, and self-image. This cannot be assessed simply by asking most clients if they have the criteria for the disorder.
• Psychodynamic therapy. The goal in psychodynamic therapy is to decrease emotional reactivity by identifying and demystifying the underlying reasons for the development of HPD.
• Family and couples therapy. Family therapy should be explored only after the person with HPD has done some hard work on him or herself; otherwise, the person with HPD is apt to dominate all conversations
• Holistic mind-body practices. Mindfulness techniques acquired through meditation, yoga, Tai Chi, biofeedback, and other holistic therapies have much to offer people with HPD, who need to reprogram their minds to more effectively control their hair-trigger emotional reflexes.
• Medications are not indicated for treatment of histrionic personality disorder, though they may be used to treat some of the symptoms and/or other, co-morbid, disorders.
• Self-help groups and/or group therapy is not effective for those who have HPD as they are prone to hysterics and outbursts

With careful and compassionate intervention that extends from initial treatment through aftercare, people with histrionic personality disorder can learn to minimize the condition’s influence on their lives. HPD cannot be cured, but over time its capacity to control emotional reactions can be reduced to a manageable level.

Coping With Histrionic Personality Disorder:

Lots of people with HPD lead normal lives and are able to work and be a part of society. In fact, many people with HPD do very well in casual settings. Many of them only encounter problems in more intimate relationships. Depending on your case, your HPD may affect your ability to hold a job, maintain a relationship, or stay focused on life goals. It may also cause you to constantly seek adventure, putting you into risky situations.

You are also at a higher risk for depression if you have HPD. The disorder can affect how you handle failure and loss. It can also leave you feeling more frustrated when you don’t get what you want. You should talk to your primary care provider if you have symptoms of HPD, especially if they are interfering with your everyday life and work or your ability to lead a happy, fulfilling life.

Loving Someone With Histrionic Personality Disorder:

It is exhausting to deal with a person who has this personality disorder as they are particularly demanding – which is part of the disorder. Sometimes, it may be possible to stop being around such a person and extricate oneself from the situation, in other cases, especially where family members are concerned, that is never a choice. Then what is one to do and how is one to keep the relation going?

Sometimes, people with HPD may be abusive. You are not obligated to spend time with an abusive person, and you have the right to distance yourself or cut contact altogether. Do what’s right for you.

Here are some ideas for dealing with a person who has histrionic personality disorder:

Establish And Maintain Boundaries:

Create realistic goals. Histrionic personality disorder is a complicated disorder, and there may be limited things that you can do to help your loved one. Therefore, realistic goals are incredibly important when you decide to help them.You must understand that you may never be able to help them with their condition.  Create some safe space between you for your own self care. You must take care of your self.

• Help your loved one set their own goals. For example, you may want to help them set goals related to the way they dress, the types of sexual relationships they have, or the amount of times they act out in a dramatic or theatrical way.

Set limits and stick to them. When your loved one has Histrionic Personality Disorder, you need to establish strict boundaries for your relationship. Your loved one may engage in attention-seeking, manipulative, or embarrassing behavior at any time, which does directly affect you. Try to have an open, honest discussion with them about your personal limits.

• For example, tell your loved one, “If you start manipulating me, I will leave” or “If you start acting out or embarrassing yourself to get attention, I will leave” and stick with this plan.

Make sure they know that you still love them. A relationship with a loved one with HPD can be complicated and tense as this personality disorder can cause major problems that cause hurt feelings and complicated, strained relationships. You should try to your loved one know that you still love them, even though you have limits and may sometimes leave, you still love and care for them.

• You can tell them, “I love you and want you in my life. However, there are times I cannot be around you because of your behavior.”

Know how and when to distance yourself. You may find yourself in a situation where your loved one is being manipulative, cruel, hurtful, embarrassing, or harmful which can be overwhelming to you. People with HPD often do anything to be the center of attention; including manipulation, acting dramatically, and love to play the victim. They may act in an overly provocative way, or act out in a hateful or angry way to gain attention. As you know, all of this can negatively affect you. Be aware that you may have to distance yourself from your loved one to protect yourself and your own well-being.

• Some people just aren’t equipped to help a person with HPD. Be aware that as a last resort, you may have to completely remove yourself from the situation and sever all ties.

Taking Care of Yourself:

Consider seeing a therapist. Talking with a therapist about your challenges and feelings regarding your loved one’s histrionic personality disorder is a good way to care for yourself. A therapist can help you to develop healthy coping mechanisms, learn how to communicate with your loved one more effectively, and work through your emotions. Consider talking to a therapist as part of your self-care strategy.

Seek help from your friends and family. Dealing with a loved one with HPD can be an emotionally exhausting rollercoaster and you may feel helpless, trapped, and/or confused. Find support from your loved ones when you need it, and ensure that you make time to be away from your loved one, and instead, visit and interact with others. This can help you feel supported.

• Talk to your friends and family about your difficulties. You can even ask them for advice if things get too much to bear.

Don’t let your loved one to dictate your other relationships. Because people with HPD often feel inadequate or inferior, they may throw fits or act in an over-dramatic way when you form relationships and spend time with other people. You cannot let the person with HPD dictate your other relationships.

• Your loved one may see another friend, partner, or even child as a threat. Discourage this behavior. Don’t give into any behavior in which your loved one tries to discourage the relationship.
• For instance, you can say, “I have friends and invite them over once in a while. This does not affect my love for you.”
• Your loved one may get jealous or threatened by you participating in activities that don’t include them. Refrain from giving up activities because of your loved one’s HPD.

Come to terms with the idea that your loved one may never understand your needs. People with HPD appear to be self-centered, which means that they may not understand or respect your needs, even if you have clearly outlined them. People who hav do not realize their actions are wrong, or how their actions affect other people.

• You may need to accept that your loved one will never treat you how you deserve to be treated. This is why setting boundaries and limits in the relationship is so important.

How To Cope With HPD:

Don’t make excuses. If your loved one has HPD, you may find yourself wanting to make excuses for their behavior, cover up their behavior, or clean up any messes they have made. This is not your job, and can take a toll on you. Try not to make excuses or mediate any messes your loved one has made. This may just enable your loved one’s behavior.

• Your loved one’s behavior may be humiliating for you. However, learning to walk away or detach yourself may be the best way to take care of yourself.

Avoid trying to teach your loved one a lesson. Sometimes, loved ones of those with HPD abandon the person to teach them some sort of lesson. This can arise when the person with HPD manipulates you too much or you feel nothing that you do is working. This kind of punitive behavior does not work with people with HPD, so you should avoid the temptation.

• • If you do this, your loved one may feel abandoned and throw a dramatic fit since you abandoned them.
  • You may end up feeling helpless and manipulated if you try to use this kind of manipulation on your loved one. Avoid using games with your loved one. Stay direct and open with them instead.

Don’t reward attention-seeking behavior. Your loved one may engage in dramatic, attention-seeking behavior regularly, and one of the best ways to deal with this is to ignore it. Don’t engage with them when they are acting like this, it will further reinforce the negative behavior with attention.

• Your loved one likely has a chemical imbalance, which means they may not be able to help their behavior. Instead of getting into an argument or encouraging behavior, just ignore it and let it pass.

Remain calm. One of the best things you can do to help your loved one is to stay calm. A person with Histrionic Personality Disorder thrives on chaos and drama, if/when they get dramatic or have a fit, reacting to them in a negative way will play into what they want and encourage the behavior. Instead, remain calm during these fits.

• You may need to engage in deep breathing exercises or step away from your loved one for a few moments to collect yourself.

Put physical distance between you and your loved one. People with HPD form intimate attachments very easily, which means they may cross physical boundaries. They may not be able to understand or respect the boundaries you have set for yourself. You may find your loved one hugs you, touches you, or invades your space more than you wish. Your loved one may interpret your actions as threatening or inappropriate. To help with this, keep physical distance between you and them.

• For example, you may want to sit in a chair if your loved one is on the couch, or sit on the other end of the couch. When standing, keep a few feet between you and your loved ones.
• Be mindful not to do anything that might be suggestive or interpreted as inappropriate. You don’t want your loved one to misinterpret what you are doing. Always be mindful of your boundaries.

Encourage your loved one to evaluate and think about what other people say. Some people who have HPD are highly suggestible and will go along with what other people say without enforcing their own boundaries and desires. If you notice that your loved one is blindly agreeing with people or doing what other people tell them to do, try to encourage your loved one to think for him or herself.

• If you notice that your loved one is agreeing with someone without evaluating the statement, you could try asking some questions to help you loved one evaluate what the person said.
  • For example, your loved one might repeat a political opinion as a fact because they heard someone else say it. You could then ask your loved one questions like, what is the evidence for that? How did they come to that conclusion? Why do you agree with them?
• If your loved one is doing something because someone has suggested it, then you can also use questioning to help.
  • For example, your loved one might start dressing differently because someone suggested it. You might ask your loved one questions like, do you really want to do that? Would you be doing that if he or she had not suggested it? What might you be doing if he or she had not suggested that?

Suggest different clothing for your loved one. One of the main symptoms of HPD is wearing provocative clothing to garner attention. This type of attire is not suitable for all situations, such as work. You can help your loved one by suggesting they dress differently for certain situations.

• Make sure to start any suggestion with a compliment. Those with HPD respond extremely negatively to any criticism. By complimenting them, you can help yourself get a positive response.
• For example, you may say, “I really love that outfit. You should wear that tomorrow night when you go out with your friends! Why don’t you wear this to work instead today? It looks great on you, and everyone will think you look classy.”

Ask for support when your loved one states their opinion. Often, people with HPD will just talk or argue because they like the attention and drama. They may offer strong opinions while offering no support. When this happens, ask your loved one to back up their opinion.

• For example, you may say, “What are you basing that opinion on?” or “Do you have any examples to support your opinion?” You may also say, “That doesn’t sound like a correct statement. Can you give me some evidence to support your position?”
• If your loved one cannot support their opinion, explain that they need to only provide opinions based on facts or details. Encourage research issues so they can make informed opinion

Help your loved one come up with solutions. Often, people with HPD ignore solutions in favor of focusing on the drama of the problem. One way you can try to help your loved one is by encouraging them to come up with solutions and focus on problem-solving techniques instead of the problem.

• For example, when your loved one gets dramatic about a problem, listen to what they say about the problem. Then say, “I understand you have a problem, but dwelling on it will not help you or anyone else. Let’s work together to find a solution.”

Explore other things. To help keep your loved one’s attention-seeking or manipulative behavior to a minimum, you should talk about or do other things with them. Don’t let your loved one dwell on problems or dominate the spotlight. Talk about yourself or suggest that the two of you do an activity together.

• • For example, you may want to say, “We have been talking about you for a long time now. I would like to share with you things about my life.”
  • You can try to distract your loved one if they are in a middle of an attention-seeking or manipulative episode. You can change the subject, start watching television, or suggest that you go for a walk or to a movie.

Communication With Your Loved One:

Try empathizing with them, then set a limit. People with HPD may feel sensitive to rejection, because they’re deeply insecure. Helping them label their feelings allows them to better understand how they’re feeling, and know that you aren’t rejecting them (just asking them to stop doing something).

• • • “I get that you’re feeling lonely. But faking an injury isn’t a healthy way to get attention. If you want, we could do something simple together, like taking a walk or playing a board game.”
    • “I know you’re excited to be with friends. Please remember to let Jamal talk, too.”
    • “I can tell that you’re upset. I’m exhausted, though, and I don’t have the energy to talk about it. Could you call your sister, or talk to me in the morning?”

Try labeling their behaviors. People with HPD report being somewhat oblivious to their destructive habits, meaning that they may not realize when they are out of line. Make an observation or question about what they’re doing. This encourages them to step back and re-evaluate what they’re doing.

• • • “You’re spiraling.”
    • “Are you trying to manipulate me?”
    • “It looks like you’re starting something self destructive.”
    • “Honey, you’re making it about you again.”

Remind them of the consequences of what they’re doing. People with HPD may not think things through, or realize that their actions could have destructive consequences. Calmly remind them of what could happen if they act, or keep acting, a certain way.

• • • “You’re making me uncomfortable. If you keep doing this, I will leave.”
    • “This is John’s special day. If you do that at his party, he’ll feel really hurt and upset.”
    • “You could get seriously hurt if you do that.”
    • “When you do this, it makes me not want to spend time with you.”

Express feelings and boundaries clearly and calmly. People with HPD can benefit from explicit boundaries and reminders. Try using “I” language to explain how their behavior makes you feel. This can serve as a warning so that they can slow down and think.

• • • “When you ______, I feel ______. Because of this, _________.”
    • “Please, stop interrupting me. I’m getting frustrated.”
    • “That really hurt my feelings.”
    • “You’re embarrassing me. It makes me want to leave.”

Follow through with consequences if your loved one doesn’t heed your warning. They need to know that when you set boundaries, you mean what you say.

• • • For example, if you say that you’re going to leave if they keep doing something, and they keep doing it, then leave.

Talk about inappropriate behavior, without criticizing them personally. People with HPD act out because they feel insecure, and you don’t want to be cruel or make things even worse. Talk about their behavior, and the consequences of their behavior, without labeling them as selfish or bad. This helps them re-examine their actions and learn from them.

• • • Unhelpful: “You’re such a drama queen! I can’t deal with you anymore! I’m never taking you anywhere again.”
    • Helpful: “I’m disappointed and embarrassed that you flirted with my boss, even after I asked you to stop. It makes me not want to take you to work parties anymore, because I don’t know how to deal with this.”
    • Unhelpful: “You’re so embarrassing! If you don’t stop being like this, you’ll end up sad and alone.”
    • Helpful: “You really embarrassed me in the grocery store today. Now I feel bad, and I don’t know what I’ll do next time I see Mrs. Martinez in public.”

Helping Your Loved One Get Treatment for HPD:

Encourage treatment. The best way a person with HPD can get better is through treatment. However, most people with HPD either don’t seek treatment or they only stay in treatment for a short period of time. You should encourage your loved one to get treatment. If they are already seeking treatment, help encourage them to continue treatment, even when they get bored or want to quit.

• • • “I love you, and your behavior is hurting yourself and me. Would you be willing to get treatment?”
    • “I know you feel that treatment is no longer exciting or that you are better, but this is a major condition that cannot be fixed quickly. Will you please reconsider going back to treatment?”

Help them get psychotherapy. Psychotherapy is the most effective treatment for HPD. This includes talking with a therapist who can use different therapeutic approaches to help your loved one, such as cognitive behavioral therapy. Most people with HPD don’t continue with their therapy after beginning because they lose interest, think they are better, or are too impulsive to follow through with their treatment.

• Cognitive behavioral therapy can address problematic behaviors, such as impulsive actions, manipulative behaviors, and theatrics.

Seek treatment for underlying conditions. Often, people with HPD also have other, co-occurring disorders, such as depression. Because of their feelings of insecurity, inadequacy, and abandonment, they may feel depressed and need to be treated for this.

• If this is the case, your loved one can take selective serotonin reuptake inhibitors (SSRIs) to treat the depression, which may help their overall mood. SSRIs are common in the treatment of depression, and include medications such as Zoloft, Celexa, and Prozac.

Keep watch for destructive behavior. Histrionic personality disorder may lead to self-destructive behavior. People with HPD often exhibit suicidal behavior or behavior leading to self-harm. The person may just be threatening these behaviors to gain attention, so you need to make a decision about the seriousness of the threat.

• Some people with HPD will harm themselves or try to commit suicide to gain attention. Try to notice when your loved one is getting to this destructive stage.
• People with HPD may also exhibit dangerous behavior towards others. Watch your loved one to see if they exhibit any tendencies to hurt those around them

Personality Disorder Resources

by Aunt Becky | May 6, 2019

What Is Personality?

Personality is a particular set of behaviors, traits, emotions, and patterns that make up a person, his character, and their individuality. Personality includes how we see the world, our thoughts, attitudes, and feelings. Personality is strongly influenced by our values, attitudes, perception of ourselves, and predicts our reactions to people, the world, stress, and problems.

While there are many different definitions of personality, most focus on the pattern of behaviors and characteristics that can help predict and explain a person’s behavior.

Explanations for personality can focus on a variety of influences, ranging from genetic explanations for personality traits to the role of the environment and experience in shaping an individual’s personality.

Environmental factors that can play a role in the development and expression of personality include such things as parenting and culture. How children are raised can depend on the individual personalities and parenting styles of caregivers as well as the norms and expectations of different cultures.

So what actually makes up a personality? Traits and patterns of thought and emotions play important roles, and some of the other fundamental characteristics of personality include:

• Consistency: There is generally a recognizable order and regularity to behaviors. Essentially, people act in the same ways or similar ways in a variety of situations.
• Psychological and physiological: Personality is a psychological construct, but research suggests that it is also influenced by biological processes and needs.
• It impacts behaviors and actions: Personality does not just influence how we move and respond in our environment; it also causes us to act in certain ways.
• Multiple expressions: Personality is displayed in more than just behavior. It can also be seen in our thoughts, feelings, close relationships, and other social interactions.

Personality is not just who we are, it is also how we are.

What Is A Personality Disorder?

A person’s personality may be influenced by experiences, environment (surroundings, life situations) and inherited – genetic – characteristics. A person’s personality typically stays the same over time.

While personality disorders differ from mental disorders, like schizophrenia and bipolar disorder, they do, by definition, lead to significant impairment. Personality disorders are estimated to affect about 10 percent of people, although this figure ultimately depends on where clinicians draw the line between a “normal” personality and one that leads to significant impairment.

A personality disorder is a way of thinking, feeling, and behaving that is different from the expectations of the culture, causes distress, problems functioning, and lasts over time. Personality disorders are almost always associated with marked social and personal disruption and are both pervasive and inflexible. While these behaviors can produce poor coping skills, leading to personal issues including anger, anxiety, depression, and distress, they are considered appropriate by the person with the disorder.

Some types of personality disorder were in previous versions of the diagnostic manuals but have been removed. Examples include sadistic personality disorder (pervasive pattern of cruel, demeaning, and aggressive behavior) and self-defeating personality disorder or masochistic personality disorder (characterized by behaviors consequently undermining the person’s pleasure and goals). They were listed in the DSM-III-R appendix as “Proposed diagnostic categories needing further study” without specific criteria. The psychologist Theodore Millon and others consider some relegated diagnoses to be equally valid disorders, and may also propose other personality disorders or subtypes, including mixtures of aspects of different categories of the officially accepted diagnoses.

Now, there are 10 specific types of personality disorders. Personality disorders are long-term patterns of behavior and inner experiences that differs significantly from what is expected. The pattern of experience and behavior begins by late adolescence or early adulthood and causes distress or problems in functioning.

Without treatment, personality disorders can be long-lasting. Personality disorders must affect at least two of the following areas:

• Way of thinking about oneself and others
• Way of responding emotionally
• Way of relating to other people
• Way of controlling one’s behavior

What Causes Personality Disorders?

The development of personality disorders in certain people – and not others from a similar background – remains the subject of much debate among researchers and scientists, however, research suggests that genetics, abuse, and other factors may contribute to the development personality disorders.

In the past, many people believed that people who have personality disorders were lazy, the devil, or evil. Thankfully, new research has begun to explore such potential causes as genetics, parenting, and peer influences in the development of personality disorders:

Genetic Factors: Researchers are beginning to identify some possible genetic factors behind personality disorders. New developments into the role of genetics in mental health and personality disorders occur every single day.

• (for example) One research team has identified a malfunctioning gene that may be a factor in obsessive-compulsive disorder.
• Other researchers are exploring genetic links to aggression, anxiety and fear — traits that may play a role in the lives of those who have personality disorders.

Childhood trauma. Findings from one of the largest studies of personality disorders, offer clues about the role of childhood experiences in the development of personality disorders.

• One study found a link between the number and type of childhood traumas and the development of personality disorders. People with borderline personality disorder, for example, had especially high rates of childhood sexual trauma.

Verbal abuse. Even verbal abuse can have an impact. In a study of 793 mothers and children, researchers asked mothers if they had screamed at their children, told them they didn’t love them or threatened to send them away.

• Children who had experienced such verbal abuse were three times as likely as other children to have borderline, narcissistic, obsessive-compulsive or paranoid personality disorders in adulthood.

High reactivity: Sensitivity to light, noise, texture and other stimuli may also play a role in developing personality disorders

• Overly sensitive children, who have what researchers call “high reactivity,” are more likely to develop shy, timid or anxious personalities.
• However, high reactivity’s role is still far from clear-cut. Twenty percent of infants are highly reactive, but less than 10 percent go on to develop social phobias.

Peers. Certain factors can help prevent children from developing personality disorders.

• Even a single strong relationship with a relative, teacher or friend can offset negative influences from peers, say psychologists.

As researchers continue to make new discoveries about the roles of genetic, environmental factors, and abuse in personality disorders, we will be able to understand, identify, and treat people who have personality disorders more effectively.

What Are TheTypes of Personality Disorders?

Before jumping into characterization of these 10 personality disorders, it should be emphasized that they are more the product of historical observation than of scientific study, so that they are rather vague and imprecise constructs. As a result, these personality disorders rarely present in their classic textbook form, but instead tend to blur into one another. Their division into three clusters in DSM-5 is intended to reflect this tendency – any given personality disorder most likely to blur with other personality disorders within its cluster.

The majority of people with a personality disorder never come into contact with mental health services, and those who do usually do so in the context of another mental disorder, or at a time of crisis; commonly after self-harming or breaking the law. Nevertheless, personality disorders are important to health professionals, because they predispose people to other mental health disorders and affect the presentation and management of existing mental disorders. Personality disorders also result in considerable distress and impairment, and so may need to be treated on their own.

These personality disorders have been divided into three clusters, Cluster A, Cluster B, and Cluster C. Each cluster has personality disorders (not all listed here) that fall within them.

Cluster A: Paranoid, Odd, or Eccentric Behavior

Cluster A is comprised of paranoid, schizoid, and schizotypal personality disorders.

Paranoid Personality Disorder:

Those who suffer with paranoid personality disorder interpret the actions of others as deliberately threatening or demeaning. People who have paranoid personality disorder are often unforgiving, distrusting, and prone to aggressive outbursts (without justification) as they see others as disloyal, condescending, unfaithful, or lying. People with paranoid personality disorder may be jealous, secretive, guarding, and scheming, and may seem emotionally cold or extremely serious.

Paranoid personality disorder is characterized by a pervasive distrust of others, including even friends, family, and partners. As a result, a person with paranoid personality disorder seems guarded, suspicious, and constantly on the lookout for clues or suggestions to validate their fears. They will also has a strong sense of personal rights: they are overly sensitive to setbacks and rebuffs, are easily shamed and humiliated, and persistently bears grudges. Unsurprisingly, they tends to withdraw from others and to struggle with building close relationships.

The principal ego defense in paranoid PD is projection, which involves attributing one’s unacceptable thoughts and feelings to other people. A large, long-term twin study found that paranoid PD is modestly heritable, and that it shares a portion of its genetic and environmental risk factors with schizoid PD and schizotypal PD.

Schizoid Personality Disorder:

People who suffer from Schizoid Personality Disorder are solitary introverts that seem cold, distant, and withdrawn. People who have schizoid personality disorder spend much time lost in their own thoughts and feelings and feel fearful of intimacy with others.

The term “schizoid” means that a person a natural tendency to direct attention toward one’s inner life and away from the external world. A person with schizoid PD acts detached and are aloof and prone to introspection and fantasy. They have no desire for social or sexual relationships, they are indifferent to others and to social norms and conventions, and lacks a visible emotional response.

A competing theory about people who have schizoid PD is that they are actually highly sensitive with a rich inner life: they experience a deep longing for intimacy, but find initiating and maintaining close relationships too difficult or distressing, and so they go back into their inner world. People with schizoid PD rarely present for medical treatment, because despite their reluctance to form close relationships, they are mostly well-functioning and untroubled by their apparent oddness.

Schizotypal Personality Disorder:

Those who suffer Schizotypal Personality Disorder exhibit a pattern of peculiarities, with odd mannerisms while speaking or dressing. Schizotypal PD is characterized by oddities of appearance, behavior, and speech, unusual perceptual experiences, and anomalies of thinking similar to those seen in schizophrenia People who have schizotypal personality disorder often have wildly paranoid beliefs and, as such, have difficulties with relationships and feel marked anxiety while in social situations. They may not react at all (or react inappropriately) during a conversation, or instead, they may talk to themselves. People with schizotypal personality disorder may also believe that they can see the future or read minds, have odd beliefs, magical thinking (for instance, thinking that speaking of the devil can make him appear), suspiciousness, and obsessive ruminations.

People with schizotypal PD often fear social interaction and think of others as harmful. This may lead them to develop so-called ideas of reference — that is, beliefs or intuitions that events and happenings are somehow related to them. So whereas people with schizotypal PD and people with schizoid PD both avoid social interaction, with the former it is because they fear others, whereas with the latter it is because they have no desire to interact with others or find interacting with others too difficult.

People with schizotypal PD have a higher than average probability of developing schizophrenia, and the condition used to be called “latent schizophrenia.”

Cluster B: Dramatic, Erratic, or Emotional Behavior

Borderline Personality Disorder:

In borderline PD (or emotionally unstable PD), the person essentially lacks a sense of self and, as a result, experiences feelings of emptiness and fears of abandonment. There is a pattern of intense but unstable relationships, moods, self-image, interpersonal behaviors,  emotional instability, outbursts of anger and violence (especially in response to criticism), and impulsive behavior. Suicidal threats and acts of self-harm are common, for which reason many people with borderline PD frequently come to medical attention. Borderline PD was named as people who suffered from it were believed to be walking the border between neurotic (anxiety) disorders and psychotic disorders, like schizophrenia and bipolar disorder. I

Research seems to show that people who have borderline personality disorder as a result of childhood sexual abuse, which makes it much more common in women, in part because women are more likely to suffer sexual abuse. However, feminists have argued that borderline PD is more common in women, because women presenting with angry and promiscuous behavior tend to be labeled with it, whereas men presenting with similar behavior tend instead to be labeled with antisocial PD.

Abrupt, extreme mood swings, an unstable, fluctuating self-image, and stormy relationships are common for a person with borderline personality disorder. People with borderline personality disorder often view the world in black and white – all good or all bad. Someone with borderline personality disorder may have an intense relationship, only to have it devolve over a simple perceived slight. Extreme fear of abandonment may lead to extreme dependency upon others and self-injurious behaviors may be used as manipulation or as a means to get attention.

Antisocial Personality Disorder:

Until Kurt Schneider broadened the concept of personality disorders to include those who “suffer from their abnormality,” being diagnosed with a “personality disorder” was more or less synonymous with antisocial personality disorder. Those with Antisocial Personality Disorder ignore social rules of behavior and act out their problems as they desire. People with Antisocial Personality Disorder are callous, irresponsible, and impulsive. Generally speaking, someone with antisocial personality disorder may have a history of legal problems, aggressive or violent relationships, and a belligerent attitude. Those with antisocial personality disorder often have no regard for others, no respect for others, and feel no remorse about their actions.

Antisocial PD is found to occur much more often in men than in women and is characterized by a callous unconcern for the feelings of others. The person disregards social rules and obligations, is irritable and aggressive, acts impulsively, lacks guilt, and fails to learn from experience. In many cases, they have had no difficulty finding relationships – and can even appear superficially charming (as a “charming psychopath”) – but these relationships are usually fiery, turbulent, and short-lived.

As antisocial PD is the mental disorder most closely correlated with crime, they are likely to have a criminal record or have a history of being in and out of prison.

Narcissistic Personality Disorder:

For people who have narcissistic PD, the affected individual has an overblown feeling of self-importance, a tremendous sense of entitlement, absorbed by fantasies of grandeur, and an excessive need to be admired, and seek constant attention. This person is jealous of others and expects them be jealous in return. This person also lacks empathy and readily lies and exploits others to achieve their aims. To others, they may seem self-absorbed, controlling, intolerant, selfish, or insensitive. If this person feels obstructed or ridiculed, they can fly into a fit of destructive anger and revenge. This is called “narcissistic rage” and can have disastrous consequences for all involved.

People with Narcissistic Personality Disorder are overly sensitive to failure and often complain of mild somatic (non-specific, medical-type) symptoms, such as headaches or stomach aches.

Histrionic Personality Disorder:

People with histrionic PD lack a sense of self-worth and depend on attracting the attention and approval of others for their well-being. They often seem to be overly-dramatizing or “playing a part” in a bid to be heard and seen. Indeed, “histrionic” derives from the Latin histrionicus, which means “about to the actor.” People with histrionic PD may take great care of their appearance and behave in a manner that is overly charming or inappropriately seductive. As they crave excitement and act on impulse or suggestion, they can place themselves at risk of accident or exploitation. Their dealings with others often seem insincere or superficial, which in the longer term can adversely impact their social and romantic relationships.

This is especially distressing, as they are sensitive to criticism and rejection and react badly to loss or failure. A vicious circle may take hold in which the more rejected they feel, the more histrionic they become — and the more histrionic they become, the more rejected they feel. These people want to be the center of attention in any group, and become very angry if they are not. People with histrionic PD have shallow relationships and may use their social skills to manipulate others around them.

It can be argued that a vicious circle of some kind is at the heart of every personality disorder and, indeed, every mental disorder.

Cluster C: Anxious or Fearful Disorders

Obsessive-Compulsive (Anankastic) Personality Disorder:

First and foremost, obsessive-compulsive personality disorder is not the same thing as obsessive-compulsive disorder.

Anankastic  PD is characterized by an excessive preoccupation with details, rules, lists, order, organization, or schedules; perfectionism so extreme that it prevents a task from being completed. Their unending and devotion to work and productivity costs many their interpersonal relationships. A person with anankastic PD is typically doubting and cautious, rigid and controlling, humorless, and miserly. Their underlying anxiety arises from a perceived lack of control over a world that they don’t understand, and the more they try to exert control, the more out of control they feels. As a consequence, they have little tolerance for complexity or nuance, and tends to simplify the world by seeing things as either all good or all bad (often referred to as black and white thinking).

Their relationships with colleagues, friends, and family are often strained by the unreasonable and inflexible demands that they makes upon loved ones.

Dependent Personality Disorder:

Dependent PD is characterized by a major lack of self-confidence, often show patterns of dependent and submissive behavior, and have an excessive need to be cared for by another person or persons. People with dependent personality disorder need a lot of help to make everyday decisions and often surrenders important life decisions to others. They greatly fear abandonment and may go through considerable lengths to secure and maintain relationships. A person with dependent PD sees themselves as inadequate and helpless, and gives up any personal responsibility and submits themselves to one or more protective others. They imagine that they are at one with these protective other(s), whom they idealize as competent and powerful, and towards whom they behave in a manner that is ingratiating and self-effacing. Those who have Dependent Personality Disorder will rarely initiate projects or work independently.

People with dependent PD often end up with people with a cluster B personality disorder, who feed on the unconditional high regard in which they are held. Overall, people with dependent PD maintain a naïve and child-like perspective and have limited insight into themselves and others. This entrenches their dependency, leaving them vulnerable to abuse and exploitation. These people require extreme advice and reassurance and are easily hurt by disapproval or criticism. People with Dependent Personality Disorder feel helpless when alone and may be devastated when a relationship ends, due in part to their strong fear of rejection.

Avoidant Personality Disorder:

People with avoidant PD believe that they are socially inept, unappealing, or inferior, and fear being embarrassed, criticized, or rejected. People with Avoidant Personality Disorder often avoid any activities that involve interpersonal contact as they’re afraid of saying something wrong, they worry they’ll cry in front of others, and are very hurt when they are disapproved of by others. These people are sensitive to rejection and avoid meeting others and engaging in activities unless they are certain that they’ll be liked or good enough; they’re restrained even in their intimate relationships. Avoidant PD is strongly associated with anxiety disorders, and may also be associated with actual – or imagined – rejection by parents or peers during their childhood.

Research is showing that people who have avoidant PD excessively monitor internal reactions – of their own and those of others – which prevents them from engaging naturally or fluently in social situations. A vicious circle takes hold in which the more they monitor their internal reactions, the more inept they feel; and the more inept they feel, the more they monitor their internal reactions.

They feel extremely uncomfortable in social situations, are timid, and are afraid of being criticized.

These people may have no close relationships beyond their family (although they’d like to) because they’re too afraid of their inability to relate well to others.

Other Ways Of Classifying Personality Disorders:

In addition to classifying by category and cluster, it is possible to classify personality disorders using additional factors such as attribution, its impact on social functioning, and severity of the disorder.

Impact on Social Functioning: Social function is affected by many other aspects of mental functioning than just that of personality. But, whenever there is persistently impaired social functioning in conditions in which it wouldn’t be expected, evidence suggests that this may be more likely to be created by personality abnormality than by other clinical variables.

Attribution: Many people who have a personality disorder don’t see any abnormality in their functioning and will continue to believe that there is no abnormality with how the person functions. This group of people have been called the “Type R,” or “treatment-resisting personality disorders,” as opposed to the Type S or treatment-seeking ones, who are very interested on altering their personality disorders and often clamor for treatment  The classification of 68 personality disordered patients on the caseload of an assertive community team using a simple scale showed a 3 to 1 ratio between Type R and Type S personality disorders with Cluster C personality disorders being significantly more likely to be Type S, and paranoid and schizoid (Cluster A) personality disorders significantly more likely to be Type R than others.

Severity of the Personality Disorder: The extent to which the dysfunctions in the below areas are associated with distress or impairment in personal, family, social, educational, occupational or other important areas of functioning.

Aspects of personality functioning that contribute to severity determination in Personality Disorder (Adapted from the ICD-11 Clinical Descriptions and Diagnostic Guidelines for Personality Disorder) include the following:

Degree and pervasiveness of disturbances in functioning of aspects of the self:

• Stability and coherence of one’s sense of identity (such as: the extent that the sense of self is always changing and inconsistent or overly rigid and fixed).
• Ability to maintain an overall positive and stable sense of self-worth.
• Accuracy of one’s view of one’s characteristics, strengths, and limitations.
• Capacity for self-direction, ability to plan, choose, and implement appropriate goals.
• Degree and pervasiveness of interpersonal dysfunction across various types of relationships such as, romantic relationships, school/work, parent-child, family, friendships, peer contexts
• Interest in engaging in relationships with others.
• Ability to understand and appreciate others’ perspectives.
• Ability to develop and maintain close and mutually satisfying relationships.
• Ability to manage conflict in relationships.
• Pervasiveness, severity, and chronicity of emotional, cognitive, and behavioral manifestations of the personality dysfunction

Emotional manifestations:

• Range and appropriateness of emotional experience and expression.
• Tendency to be emotionally over- or under-reactive to stimuli
• Ability to recognize and acknowledge unwanted emotions (such as anger, sadness).

Cognitive manifestations

• Accuracy of situational and interpersonal appraisals, especially under stress.
• Ability to make appropriate decisions in situations of uncertainty.
• Appropriate stability and flexibility of belief systems.

Behavioral manifestations

• Flexibility in controlling impulses and modulating behavior based on the situation and consideration of the consequences.
• Appropriateness of behavioral responses to intense emotions and stressful circumstances (such as a propensity to self-harm and/or violence).

Common Traits of A Person Who Has A Personality Disorder (per Out Of The Fog):

The list below contains descriptions of some of the more common traits of people who suffer from personality disorders, as observed by family members and partners. Examples are given of each trait, with descriptions of what it feels like to be caught in the crossfire.

Of note: these descriptions are not intended for diagnosis. Refer to the DSM-V or ICD-11 Criteria for Personality Disorders for clinical diagnostic criteria. No one person exhibits all of the traits and the presence of one or more of these traits is not evidence of a personality disorder.

One common criticism is that this list of traits seems so “normal” – more like traits of an unpleasant person than traits of a mentally ill person. This is no accident. Personality disordered people are normal people. Approximately 1 in 11 people meet the diagnostic criteria for having a personality disorder. Personality-disordered people don’t fit the stereotypical models for people with mental illnesses but their behaviors can be just as destructive. These descriptions are offered in the hope that non-personality-disordered family members, caregivers and loved-ones might recognize some similarities to their own situation and discover that they are not alone. Many thanks to Out of the Fog for their amazing list of personality traits. These traits may include:

How Are Personality Disorders Diagnosed?

Every person has a characteristic manner of thinking, feeling, and way relating to others. Some of these personality traits can be so dysfunctional as to warrant a diagnosis of personality disorder. The World Health Organization’s International Classification of Diseases (ICD- 10) includes ten personality disorder diagnoses. Three issues of particular importance for the diagnosis of personality disorders are their differentiation from other mental disorders, from general personality functioning, and from each other. Each of these issues is discussed in turn, and it is suggested that personality disorders are more accurately and effectively diagnosed as maladaptive variants of common personality traits.

Researchers have been unable to identify a qualitative distinction between normal personality functioning and personality disorder. DSM-IV and ICD-10 provide specific and explicit rules for distinguishing the presence versus absence of each of the personality disorders, but the basis for these thresholds are largely unexplained and are weakly justified. The DSM-III schizotypal and borderline personality disorders are the only two for which a published rationale has ever been provided.

Characterizing the 10 personality disorders is difficult, but diagnosing them reliably is even more so. For example, how far from the norm must personality traits deviate before they can be counted as disordered? How significant is “significant impairment”? And how is “impairment” to be defined?

Whatever the answers to these questions, they are bound to include a large part of subjectivity. Personal dislike, prejudice, or a clash of values can all play a part in arriving at a diagnosis of personality disorder, and it has been argued that the diagnosis amounts to little more than a convenient label for undesirables and social deviants.

It is important to understand the difference between personality styles and personality disorders. A person who is shy or likes to spend time alone does not necessarily have an avoidant or schizoid personality disorder. The difference between personality style and a personality disorder often can be determined by assessing the person’s personality function in certain areas, including

• Work
• Relationships
• Feelings/emotions
• Self-identity
• Awareness of reality
• Behavior and impulse control

If symptoms are present, the doctor will begin an evaluation by performing a complete medical history and physical examination. Although there are no laboratory tests to specifically diagnose personality disorders, the doctor might use various diagnostic tests- such as X-rays and blood tests- to rule out physical illness as the cause of the symptoms.

If the doctor finds no physical reason for the symptoms, he or she might refer the person to a psychiatrist or psychologist, health care professionals who are specially trained to diagnose and treat mental illnesses. Psychiatrists and psychologists use specially designed interview and assessment tools to evaluate a person for a personality disorder. The doctor or therapist bases his or her diagnosis on the person’s description of the symptoms and on his or her observation of the person’s attitude and behavior. The therapist then determines if the person’s symptoms point to a personality disorder as outlined in the DSM-5.

According to DSM-5, a personality disorder can be diagnosed if there are significant impairments in self and interpersonal functioning together with one or more pathological personality traits. In addition, these features must be (1) relatively stable across time and consistent across situations, (2) not better understood as normative for the individual’s developmental stage or socio-cultural environment, and (3) not solely due to the direct effects of a substance or general medical condition.

Treatment of Personality Disorders:

People with personality disorders might not seek treatment on their own; and as a result, many go untreated. One reason for the failure to seek treatment might be that many people with personality disorders can function normally in society, outside of the limitations of their disorder.

Most personality disorders are constant, unrelenting, and very hard to cure. However, treatment can help relieve some of the more disturbing symptoms of many types of personality disorders.

Treatment varies depending on the type of disorder, but psychotherapy (a type of counseling) is the main form of treatment. In some cases, medication might be used to treat extreme or disabling symptoms that might occur. Medications that might be used include antidepressants, anti-psychotics, anti-anxiety drugs, and impulse-stabilizing medications.

Psychotherapy focuses on evaluating faulty thinking patterns, and teaching new thinking and behavior patterns. Therapy also aims to improve coping and interpersonal skills.

There are many options for treatment for those who have a personality disorder. These treatments may include therapies (individual, group, or family), which focus upon helping to see how their thought processes may lead to or cause their symptoms. Therapies may also help people with personality disorders learn to become more flexible in their thoughts and behaviors.

Certain types of psychotherapy are effective for treating personality disorders. During psychotherapy, an individual can gain insight and knowledge about the disorder and what is contributing to symptoms, and can talk about thoughts, feelings and behaviors. Psychotherapy can help a person understand the effects of their behavior on others and learn to manage or cope with symptoms and to reduce behaviors causing problems with functioning and relationships. The type of treatment will depend on the specific personality disorder, how severe it is, and the individual’s circumstances.

Commonly used types of psychotherapy include:

• Psychoanalytic/psychodynamic therapy
• Dialectical behavior therapy
• Cognitive behavioral therapy
• Group therapy
• Psychoeducation (teaching the individual and family members about the illness, treatment and ways of coping)

There are no medications specifically to treat personality disorders. However, medication, such as antidepressants, anti-anxiety medication or mood stabilizing medication, may be helpful in treating some symptoms. More severe or long lasting symptoms may require a team approach involving a primary care doctor, a psychiatrist, a psychologist, social worker and family members.

Outlook for Those With Personality Disorders: 

It is generally assumed that all personality disorders are linked to impaired functioning and a reduced quality of life (QoL) because that is a basic diagnostic requirement. But research shows that this may be true only for some types of personality disorder.

In several studies, higher disability and lower QoL were predicted by avoidant, dependent, schizoid, paranoid, schizotypal and antisocial personality disorder. This link is particularly strong for avoidant, schizotypal and borderline PD. However, obsessive-compulsive PD was not related to a compromised QoL or dysfunction. A prospective study reported that all PD were associated with significant impairment 15 years later, except for obsessive compulsive and narcissistic personality disorder.

One study investigated some aspects of “life success” (status, wealth and successful intimate relationships) and showed somewhat poor functioning for schizotypal, antisocial, borderline and dependent PD, schizoid PD had the lowest scores regarding these variables. Paranoid, histrionic and avoidant PD were average. Narcissistic and obsessive-compulsive PD, however, had high functioning and appeared to contribute rather positively to these aspects of life success.

There is also a direct relationship between the number of diagnostic criteria and quality of life. For each additional personality disorder criterion that a person meets there is an even reduction in quality of life.

Issues For People Who Have Personality Disorders:

In Children:

Early stages and preliminary forms of personality disorders also require a multi-dimensional and early treatment approach if this disorder is to be successfully managed. Personality development disorder is considered to be a childhood risk factor or early stage of a later personality disorder in adulthood.

Research indicates that some children and adolescents do suffer from clinically significant syndromes that resemble adult personality disorders, and that these syndromes have meaningful correlates and are consequential. Much of this research has been framed by the adult personality disorder constructs from Axis II of the Diagnostic and Statistical Manual. Children today are less likely to encounter clinicians and researchers who are simply avoiding use of the PD construct in youth. However, these children and families may encounter under-appreciation of the developmental context in which these syndromes occur.

That is, although PD constructs show continuity over time, they are probabilistic predictors; not all youths who exhibit PD symptomatology become adult PD cases.

At Work:

Depending on the diagnosis, severity and individual, and the job itself, personality disorders can be associated with difficulty coping with work or the workplace—potentially leading to problems with others by interfering with interpersonal relationships. Indirect effects also play a role; for example, impaired educational progress or complications outside of work, such as substance abuse and co-morbid mental disorders, can plague sufferers.

However, personality disorders can also bring about above-average work abilities by increasing competitive drive or causing the sufferer to exploit his or her co-workers.

In 2005 and again in 2009, psychologists Belinda Board and Katarina Fritzon at the University of Surrey, UK, interviewed and gave personality tests to high-level British executives and compared their profiles with those of criminal psychiatric patients at Broadmoor Hospital in the UK. They found that three out of eleven personality disorders were actually more common in executives than in the disturbed criminals:

• Histrionic personality disorder: including superficial charm, insincerity, egocentricity and manipulation
• Narcissistic personality disorder: including grandiosity, self-focused lack of empathy for others, exploitativeness and independence.
• Obsessive-compulsive personality disorder: including perfectionism, excessive devotion to work, rigidity, stubbornness and dictatorial tendencies.

According to leadership academic Manfred F.R. Kets de Vries, it seems almost inevitable that some personality disorders will be present in a senior management team.

Versus Mental Disorders:

The disorders in each of the three clusters may share with each other underlying common vulnerability factors involving cognition, affect and impulse control, and behavioral maintenance or inhibition, respectively. But they may also occur on a spectrum of other mental illnesses.

• Paranoid, schizoid or schizotypal personality disorders have be observed to be premorbid antecedents of delusional disorders or schizophrenia.
• Borderline personality disorder is seen in association with mood and anxiety disorders, with impulse control disorders, eating disorders, ADHD, or a substance use disorder.
• Avoidant personality disorder is seen with social anxiety disorder.

Coping With Personality Disorders:

In addition to actively participating in a treatment plan, some self-care and coping strategies can be helpful for people with personality disorders.

• Learn about the condition. Knowledge and understanding can help empower and motivate.
• Get active. Physical activity and exercise can help manage many symptoms, such as depression, stress and anxiety.
• Avoid drugs and alcohol. Alcohol and illegal drugs can worsen symptoms or interact with medications.
• Get routine medical care. Don’t neglect checkups or regular care from your family doctor.
• Join a support group of others with personality disorders.
• Write in a journal to express your emotions.
• Try relaxation and stress management techniques such as yoga and meditation.
• Stay connected with family and friends; avoid becoming isolated.

Challenges For People Who Have Personality Disorders (Including Loved Ones And Therapists):

The management and treatment of personality disorders can be a challenging and controversial area, as the difficulties are enduring and affect multiple areas of functioning. Challenges often involve interpersonal issues, and there can be difficulties looking for and finding help from area organizations, especially when trying to engage in a therapeutic relationships with a treatment team. Alternately, a person may not consider that they have a mental health problem. On the other hand, community mental health services may view people who have personality disorders as too complex or difficult, and may directly or indirectly exclude people with such diagnoses or associated behaviors.

The disruptiveness that people with personality disorders can create in an organization makes these, arguably, the most challenging conditions to manage.

Many people who have personality disorders don’t believe that they have them. This perspective can be caused by the person’s ability to see him or herself clearly, and unfortunately, there is major social stigma and discrimination related to the diagnosis of a personality disorder.

The term “personality disorder” involves a wide range of issues, each with a different level of severity or disability; thus, personality disorders require fundamentally different approaches and understandings.

Consider that while some disorders or people are characterized by continual social withdrawal and the shunning of relationships, others may cause fluctuations in forwardness. The extremes are worse still: at one extreme lies self-harm and self-neglect, while at the other people with PDs may commit violence and crime. There can be other factors such as problematic substance use, dependency, or behavioral addictions. A person may meet the criteria for multiple personality disorder diagnoses and/or other mental disorders, either at certain times or continually, making coordinated input from multiple services a requirement.

Therapists in this area can become disheartened by lack of initial progress, or by apparent progress that then leads to setbacks. People may be perceived as negative, rejecting, demanding, aggressive or manipulative.

Social skills, coping efforts, defense mechanisms, or deliberate strategies; of moral judgments, or the consideration for motivations for specific behaviors or conflicts can be incredibly challenging in people who have personality disorders and those who treat them. The vulnerabilities of a client (and therapist) may get lost in actual or apparent strength and resilience.

There is always a need to maintain appropriate professional personal boundaries, while allowing for emotional expression, and therapeutic relationships. However, there may be difficulty acknowledging the different worlds and views that both the client and therapist may believe in. A therapist may assume that the kinds of relationships and ways of interacting that make them feel safe and comfortable have the same effect on clients. An example of one extreme is this: people who may have been exposed to hostility, deceptiveness, rejection, aggression, or abuse in their lives, may be made confused, intimidated, or suspicious by presentations of warmth, intimacy, or positivity. On the other hand, reassurance, openness, and clear communication are usually helpful and needed.

It can take several months of sessions, and perhaps several stops and starts, to begin to develop a trusting relationship that can meaningfully address a client’s issues.

Coping With A Loved Ones Personality Disorder:

Family members can be important in an individual’s recovery and can work with the individual’s health care provider on the most effective ways to help and support. But having a family member with a personality disorder can also be distressing and stressful. Family members may benefit from talking with a mental health provider who can provide help coping with difficulties.

It may help to tailor how you approach someone based on the stage of acceptance they appear to be in.

Unawareness: Most people living with a personality disorder don’t realize they have one, even if they realize they aren’t easy to live with. It’s best to share your concern by giving someone specific examples of problem behaviors and follow up by offering the resources needed to find a doctor, or make or attend an appointment.

Denial. Most people who are told they have a personality disorder don’t believe it. It isn’t uncommon for them to get angry or defensive. Keep trying to share your concerns if someone is refusing help.

Resistance. When people first begin to accept there’s a problem, they fight the belief that it’s a serious problem. People with personality disorders often resist getting medical treatment as they believe they can change their behaviors on their own. At this stage, encourage a family member or friend to make medical help a part of their personal treatment plan.

Flakiness. Once they start therapy or medication, people with personality disorders often skip or stop treatment without warning. Be there to remind them that no one is perfect, no one is always at the top of their game, and that tomorrow offers new chances to make healthier choices.

Acceptance. After receiving the support needed to overcome denial, resistance and struggles with staying in treatment, patients with these disorders may come to a place of acceptance. In these situations, treatments are seen as a top priority and appreciated as tools for healthy living.

Coping With A Teen Who Has A Personality Disorder:

It’s sometimes difficult to tell the difference between childhood behaviors, teen angst and true personality disorders. When in doubt, it’s best to get a professional opinion. Talking to a child or teen before or after that stage can be daunting. It’s recommended that loved ones are:

• Be mindful of labels. No one wants to be defined by an illness.
• Learn as much as you can so you can pass on information instead of assumptions.
• Focus on feelings and behaviors.
• Emphasize they have a treatable medical condition.
• Stay positive by choosing words like “challenges” instead of “problems.
• If your child is on medication, talk with them about side effects they might be having.
• Invite your child to talk to you whenever questions arise. The worst-case scenario is having to say, “I’m not sure, but we can find out the answer.

Postpartum Psychosis (PP) Resources

by Aunt Becky | Apr 30, 2019

What Is Postpartum Psychosis (PP)?

Postpartum Psychosis (PP) is a severe, yet treatable, form of postpartum mental illness that occurs to some women after they’ve had a baby. It can happen to women without previous experience of mental illness, and usually begins in the first few days to weeks after childbirth. About half of women who experience it have no risk factors; but women with a prior history of mental illness, like bipolar disorder, a history of prior episodes of postpartum psychosis, or a family history are at a higher risk. Postpartum psychosis is different from postpartum depression and the Baby Blues Baby blues is common 2-3 days after childbirth but should pass. In some cases, the depressed mood lingers for more than 2 weeks and months after the labor, when some women receive a diagnosis of postpartum depression.

Postpartum Psychosis is a rare mental illness, compared to the rates of postpartum depression or postpartum anxiety. It occurs in approximately 1 to 2 out of every 1,000 deliveries, or approximately .1 -.2% of births. The onset is usually sudden, most often within the first two weeks postpartum, Unlike the Baby Blues symptoms, postpartum psychosis is treated as a medical emergency and requires urgent treatment. Most women get committed to a mental hospital, residing either in Mother and Baby units, at the general psychiatric ward, or in postpartum depression treatment centers.

Postpartum psychosis can worsen extremely quickly and should always be treated as a medical emergency. Most women need to be treated with medication and admitted to hospital for emergent care to treat the woman for the symptoms of this frightening mental illness.

Of the women who develop a postpartum psychosis, research has suggested that there is approximately a 5% suicide rate and a 4% infanticide rate associated with the illness. This is because the woman experiencing psychosis is experiencing a break from reality. In her psychotic state, the delusions and beliefs make sense to her; they feel very real to her and are often religious. Immediate treatment for a woman going through psychosis is imperative.

It is also important to remember that many survivors of postpartum psychosis never experience delusions that give violent commands. Delusions can take many forms, and not all of them are destructive. Most women who experience postpartum psychosis do not harm themselves or anyone else. However, there is always the risk of danger because psychosis includes delusional thinking and irrational judgment, and this is  illness must be quickly assessed, treated, and carefully monitored by a trained mental healthcare team.

Postpartum psychosis is temporary and treatable with professional help, but it is an emergency and it is essential that you receive immediate help. If you feel you or someone you know may be suffering from this illness, know that it is not your fault and you are not to blame. Call your doctor or an emergency crisis hotline right away so that you can get the help you need.

Fortunately, with  the right treatment, women with PP can and do make a full recovery. Recovery takes time and the journey may be tough. The illness can be frightening and shocking for both the woman experiencing it and her partner.  Women do return to their normal selves, and are able to regain the mothering role they expected. There is no evidence that the baby’s long term development is affected by Postpartum Psychosis.

What Are Postpartum Mood Disorders?

Postpartum mood disorders can include severe depression (sometimes mixed with anxiety), as well as other seriously disabling problems labeled with terms such as anxiety/ \panic disorder, obsessive-compulsive disorder, post-traumatic stress disorder, and, very rarely, psychosis. Postpartum depression is by far the most common of postpartum mood disorders, affecting about one in seven new mothers. It can start anytime in the first year after giving birth. Symptoms of postpartum depression can include hopelessness, suicidal thoughts, sleep and eating problems, inability to feel good or be comforted, and withdrawing into oneself. A woman experiencing postpartum depression may have a hard time caring for her baby or meeting the other demands of daily life.

Besides postpartum depression, women sometimes experience other postpartum mood disorders. Feelings of intense anxiety, fear, or panic, along with rapid breathing, an accelerated heart rate, hot or cold flashes, chest pain, and shaking or dizziness are symptoms of an anxiety/panic disorder. Recurrent frightening thoughts, including obsessing over the baby’s health or acting out repetitive behaviors such as compulsive hand washing, are symptoms of an obsessive-compulsive disorder. A combination of depression with anxiety/panic disorder or obsessive-compulsive disorder is also possible.

Postpartum Psychosis is the label used by most professionals for an episode of mania or psychosis that occurs soon after childbirth. However, other names can be used, including: Puerperal Psychosis; Postnatal Psychosis; Mania or Bipolar Disorder triggered by childbirth (this doesn’t necessarily mean that your partner will develop ongoing Bipolar Disorder); Schizoaffective Disorder with onset following childbirth (this doesn’t necessarily mean that you will develop ongoing Schizoaffective Disorder); Postnatal Depression with psychotic features.

While there appears to be a strong link between postpartum psychosis and bipolar disorder, it’s estimated that about half of women who present with postpartum psychosis have no psychiatric history prior to delivery, making it difficult to identify women who are at greatest risk for this illnessThere are many other mental health conditions that occur following childbirth, including Postpartum Depression, Postpartum Anxiety, and Postpartum Obsessive Compulsive Disorder (P-OCD). It is important that these conditions are not grouped under the term Postpartum Depression. PPD is much more common than PP, but tends to require different treatments and has different causes and outcomes.

Help is available

You’re not alone. 

What Are The Causes Risk Factors For Postpartum Psychosis?

If you’re at high risk of developing postpartum psychosis, you should have specialist care during pregnancy, though about half of women who experience postpartum psychosis have no risk factors. While research into Postpartum Psychosis is ongoing, we still have much to learn about this serious mental illness. What is currently known about Postpartum Psychosis is this:

• Lower birth weight increases the risk of postpartum psychosis, whereas gestational diabetes and birth weight were associated with a reduced risk of first-onset psychoses during the postpartum period.
• Older mothers (over 35 years) are about 2.4 times as likely to experience postpartum psychosis than younger mothers (under 19 years).
• PP is not your fault. It is not caused by anything you or your partner have thought or done.
• Relationship problems, family, money troubles, or an unwanted baby do not cause PP.
• The dramatic changes in hormone levels following birth are thought to trigger PP, but studies have not yet identified how these factors are involved.
• For a woman with no history of mental illness who has a close relative (a mother or sister) who had postpartum psychosis, the risk is about 3%
• The first month after delivery is the time of greatest risk for psychotic illness.
• Genetic factors are thought to play a role. Women are more likely to have PP if a close relative has had PP. There may be a genetic component; while mutations in chromosome 16 and in specific genes involved in serotoninergic, hormonal, and inflammatory pathways have been identified, none had been confirmed as of 2019
• Women with a history of Bipolar Disorder or schizophrenia are at very high risk of PP.
• Disrupted sleep patterns may cause PP for some
• Women who already have a diagnosis of bipolar disorder, schizoaffective disorder, schizophrenia, or another psychotic illness are considered to be at a higher risk for developing postpartum psychosis.
• Women with a history of bipolar disorder, schizophrenia, prior episode of postpartum psychosis, or a family history of postpartum psychosis are at high risk; about 25-50% of women in this group will have postpartum psychosis.
• After one episode of postpartum psychosis, the risk for additional episodes of postpartum psychosis increases to 30-50%.
• There is mixed evidence about whether the type of delivery or a traumatic delivery plays a role. It is possible that there are overlaps with physical illnesses that occur during childbirth, such as pre-eclampsia and infection..

What Are The Symptoms of Postpartum Psychosis?

Symptoms of postpartum psychosis usually start suddenly within the first two weeks after giving birth. Rarely, they can develop several weeks after the baby is born. For some women, Postpartum Psychosis may develop very quickly and become obvious that something is wrong. For other people, symptoms may emerge more gradually. This can be difficult to determine if the symptoms are part of the natural childbirth process, or if it’s an actual emergency. When in doubt, call for help.

The symptoms vary and can change quickly. The most severe symptoms last from 2 to 12 weeks, and recovery usually takes 6 months to a year.

Postpartum Psychosis is a medical emergency and must be treated immediately.

Women with Postpartum Psychosis experience some or all of the following symptoms:

• Excited, elated, or feeling “high”
• Depressed, anxious, or confused.
• Excessively irritable or changeable in mood (also called mood lability)

Postpartum Psychosis must also include one or more of the following:

• Strange beliefs that could not be true (delusions).
• Hearing, seeing, feeling or smelling things that are not there (hallucinations).
• High mood with loss of touch with reality(mania).
• Severe confusion.

These are also common symptoms:

• Being more talkative, sociable, on the phone an excessive amount.
• Having a very busy mind or racing thoughts.
• Feeling very energetic and like Super Mom
• Agitated and restless.
• Having trouble sleeping, or not feeling the need to sleep.
• Behaving in a way that is out of character or out of control.
• Feeling paranoid or suspicious of people’s motives.
• Feeling that things are connected in special ways or that stories on the TV or radio have special personal meaning.
• Feeling that the baby is connected to God or the Devil in some way.

The majority of postpartum survivors rarely or never experience violent tendencies and delusions. The vast majority of women who survive postpartum psychosis won’t harm themselves or the baby. However, staying quiet about the debilitating condition, the loneliness deprives both mother and child of bonding and forming the strong connection that would otherwise occur.

Suicide and infanticide, the most devastating outcomes of severe postpartum psychosis, occur in between 4 and 5% of women afflicted with the illness. Tragic outcomes happen when the symptoms in a mother worsen to the point of detaching from reality. Mothers become deeply affected by irrational, paranoid ideas that make sense to them.

Most often, infanticide takes place when the mother believes that the child is in danger, often from supernatural forces, so ending the baby’s life looks like the only remaining option. Tragic outcomes can only be avoided through urgent medical treatment.

How is Postpartum Psychosis Diagnosed?

Diagnosis of postpartum psychosis always requires hospitalization, where treatment is antipsychotic medication, mood stabilizers, and, in cases of strong risk for suicide, electroconvulsive therapy. Women who have been hospitalized for a psychiatric condition immediately after delivery are at a much higher risk of suicide during the first year after delivery.

The rapid and accurate diagnosis of postpartum psychosis is essential to expedite appropriate treatment and to allow for quick, full recovery, prevention of future episodes, and reduction of risk to the mother and her children and family.

How Is Postpartum Psychosis Treated?

Postpartum Psychosis is a psychiatric EMERGENCY and must be treated immediately.

Call 911 or your doctor.

Treatment of Postpartum Psychosis has no official guidelines. Once tests are administered and all the proper medical causes have been excluded from the diagnosis then the proper treatment is given based on the symptoms. Before the mother is released from the hospital, the team that administered treatment will work with the mother and her family to create a discharge plan that will strengthen her support, along with close follow-up, and prevent stressors that will risk the mother relapsing. Also, for future pregnancies, the mother’s primary care provider is advised to work jointly with other specialists on her care team giving her care in thought of anti-manic prophylaxis during pregnancy or after childbirth.

The mother may not recognize that she has anything wrong with her, so it may be up to the family to insist upon proper psychiatric care. At no time should the mother be left alone with the child until it is determined that the mother is being properly treated and the mother and child are both safe. It is vital that there be a supportive network of family and friends to care for both the mother and the baby.

The mother should be thoroughly evaluated by a doctor both during the episode and for some time afterwards. Symptoms may reappear within a year or two postpartum. Hospitalization is required in order for the mother’s treatment, particularly any medication regimens, to be properly administered and monitored. Women do return to their normal selves, and are able to regain the mothering role they expected. There is no evidence that the baby’s long term development is affected by Postpartum Psychosis.

Note: It is not uncommon for people to think the term postpartum schizophrenia is interchangeable with the diagnosis of postpartum psychosis. Postpartum schizophrenia is not a real diagnosis. Schizophrenia itself is a different diagnosis than psychosis. The disease of schizophrenia is treatable, but not curable. Postpartum psychosis, on the other hand, is both treatable and curable.

Admission To The Hospital:

As Postpartum Psychosis is an actual emergency, the very best and safest place for someone who has PP is in the hospital, which can cause major feelings within the family. Often, people don’t want to go or stay in the hospital for treatment, but as PP can lead to murder, suicide, and infanticide, ensuring your safety is the most important goal. In the hospital, you will be treated using a variety of different medications, other therapies, and therapy.

If you’re the partner of someone who has postpartum psychosis, it’s very likely that you may have to involuntarily to commit your loved one – for the safety of all involved. The length of time for hospital admission is highly individual. An average stay for PP is around 8 –12 weeks, but some women are admitted for only 2 weeks and some for much longer

Partners say that seeking treatment can bring about a vast array of difficult emotions – feelings of disloyalty, guilt, relief, helplessness, stress and frustration. The health system can be hard to navigate, and a great deal of tenacity is sometimes needed.

Before you is discharged from the hospital, you and your partner should ask for help in making a plan of action with your treatment team in case she gets ill again. The plan should include:

• Triggers that may make you more vulnerable to high or low moods, such as stress.
• Early warning signs to look out for, such as sleeplessness.
• Which treatments or medications, and what doses, have worked well in the past.
• Any medications you’d like to avoid.
• Where you would like to be treated if you were to go back into a hospital.
• The phone numbers of any health professionals and services you’ll need.
• Activities you find helpful to your recovery.

Medication For Postpartum Psychosis:

You may only be in hospital for a short time, but it’s likely that you’ll probably need to take medication for a longer period after being discharged from hospital.

Different medications and dosages work for different people and it’s hard to find the right balance of psychiatric medications, so you may have to change medications and treatment at any time. Many medications used to treat Postpartum Psychosis have some side effects, so be sure to continue to chat with your treatment team about your treatment, including any side effects you are experiencing. Dosage can be changed or taken at different times of the day depending upon the side effects.

Many medications for postpartum psychosis can take 3 – 4 weeks to have an effect, which can cause major anger and frustration for all involved. Your doctors will be keeping an eye on how you and may change medication as needed. Be sure to ask the doctors and nurses any questions you have about your medications.

It’s very likely that your treatment team will use some of the medications listed below. It’s important to note that some of the medications for PP may have some unpleasant side effects for some, people, particularly when just starting to take them. Make certain to report any and all side effects to your treatment plan.

• Antidepressants are used to help improve low mood and are often used alongside a mood stabilizer.
• Antipsychotics are used to help treat psychotic symptoms such as unusual beliefs (delusions) and seeing or hearing things that are not there (hallucinations). They can also help to reduce anxiety and high mood (mania). At higher doses, many antipsychotics can cause you to feel sleepy and unmotivated, but remember that you may need these higher doses to fully recover.
• Benzodiazepines may be used to help to reduce agitation and anxiety.
• Mood stabilizers may be used to treat high mood (mania), low mood (depression) and dramatic changes in mood.
• Sleeping medications can be used in the short term to help regain normal sleeping patterns.
• ECT (Electroconvulsive therapy) In some cases, severe symptoms of Postpartum Psychosis persist even when you’ve been taking medication for quite awhile.If this is the case, or if the illness is particularly severe, the psychiatrist treating your partner may recommend that you consider ECT. ECT can be an effective treatment for PP.
• Other types of therapies may also be used to help you, including psychological therapy. As you move forward with your recovery, you will receive a referral to a therapist for therapy.

Most women who have recovered say that taking medication was vital to their recovery as medications help bring the symptoms of psychosis under control and to stabilize your mood.You may feel, however, that medication only helps with half the problem – symptoms but not self confidence. It is important to use more active recovery methods alongside medication to help with self confidence and the social side of recovery.

The great majority of women with postpartum psychosis make a full recovery as long as they receive the right treatment.

The Aftermath of Postpartum Psychosis:

You and your family should have emergency contact numbers for local crisis services, if you, your partner, or family think you are becoming unwell. If you think you are becoming unwell again, don’t wait to seek help.

Postpartum psychosis can go undetected and pass spontaneously in many women. Considering the risks, the best way to help yourself is to surround yourself with support. Being open and honest about your feelings, thoughts and fears will help your family and friends understand your condition better.

In the early days after being diagnosed and/or receiving treatment in hospital you may feel a sense of confusion about the events of your baby’s birth and your illness. Many women find it hard to remember the exact sequence of events. Some of the following ideas may help you to piece together what happened:

• Ask your treatment for a summary of events and your treatment.
• Talk to your partner or family about what happened – but some people find this very hard and need time to recover first.
• Write your story as you can remember it.
• Use photos or memories to put together a timeline of events. This can help you look back on your baby’s first days even though they weren’t how you expected them to be.
• Read other women’s stories Many women behave in ways that are really out of character during an episode of Postpartum Psychosis. It may help just to know that these experiences are usual symptoms of the illness.

These ideas may help you learn to cope with what has happened:

• You may feel let down, angry, and/or unhappy about the way treatment was started, especially if you had to go to hospital under an involuntary admission.Remind yourself that these were symptoms of the illness and not a permanent change in you.
• It is very common during PP to become angry, excitable, use inappropriate language, be overfamiliar with strangers, or believe you have special insight or powers.
• Distressing thoughts about harming yourself or your baby are also common, though very upsetting. It is very normal to feel embarrassment or shock at the things you did when unwell.
• Talk through upsetting symptoms with your partner.
• Ask to speak to a health professional (such as a support worker, specialist midwife, community psychiatric nurse, or another member of the your treatment team) about how you feel about your symptoms.
• A psychologist or counsellor (particularly one with specialist knowledge of postnatal illness) may be able to help you talk through your experiences.

It’s normal to feel a whole range of emotions when you begin to recover from Postpartum Psychosis (PP). Below are some common emotions:

• Shock
• Embarrassment
• Why me?
• Anger
• Exhaustion
• Guilt
• Worries and anxiety about bonding with your baby, your relationships, and your future health.

People recover from distressing experiences in different ways. Some need to talk about it, others may find that they’d like to face recovery in a different way, and you may find that you and your partner are dealing with the impact of PP in the same way, or in very different manners. This is where you and your partner must work together, be patient with each other, provide support and love, and don’t hesitate to ask the treatment team if what you’re experiencing is normal.

Here are some of the things you can do to cope with postpartum psychosis:

• Be open about your thoughts, fears, and doubts. The postpartum period is always a rocky emotional and mental journey and a time of great mental adjustment.
• Beat fear and shame. Most women who experience aggressive or irrational thoughts about themselves and their babies feel ashamed of talking about it. Sharing your thoughts with close ones helps them help you. Once you’ve experienced and received support, you will feel more confident in your recovery and gradually regain faith in your own judgment.
• Be kind to yourself and understand that postpartum psychosis doesn’t define you. You’re no less of a mother because you have a mental illness. You didn’t choose to get sick, and you are equally valuable to your baby and your family regardless of your mental state.
• Follow your care plan. Stay devoted to taking medication as prescribed and keeping up with appointments. At times, you might too tired or drowsy to stay on schedule. Make sure to have a backup plan to meet all of your appointments, including someone to drive you and someone to stay with the baby.
• Focus on rest, recovery, and bonding with your child. Recovery from postpartum psychosis isn’t the time to worry about housework. Rely on friends and relatives to help as much as possible so that you can spend plenty of time resting and bonding with the baby.

Many women who have been through PP find that there are ups and downs in their mood over the first year of recovery, which can lead to feelings of a relapse or setback, if things have been otherwise going well. Having another bout of anxiety, depression, and other symptoms can make women feel as they’ll never recover. An episode of postpartum psychosis is sometimes followed by a period of depression, anxiety and low confidence.

It might take a while for you to come to terms with what happened. Some mothers have difficulty bonding with their baby after an episode of postpartum psychosis, or feel some sadness at missing out on time with their baby. With support from your partner, family, friends, and your mental health team, you can overcome these feelings.

Neither you or your partner can make this mental illness get better by toughing it out. It’s something that must be closely monitored and treated and watched and talked about. Try to have a discussion about PP at least every day.

Set small achievable goals. As you monitor your progress you’ll see that every setback doesn’t take you back to square one. It’s important for you to see how far you’ve come.

Keep a mood diary, which can help you track triggers for high and low moods. This is handy to bring to the treatment team, so they can best monitor and treat your mental illness Partners may want to keep a mood diary of their own. Getting to know yourself better allows you to notice any things you do which particularly affect the mood at home, for better or worse.

Make a a list of things that make you feel happy, and try them out when you’re feeling down and make a list of things that help you feel calmer and more relaxed, use them to try something from it if you’re feeling stressed or high.

What Are The Outcomes For Women Who Have Postpartum Psychosis?

The most severe symptoms of PP usually last from 2 to 12 weeks; it can take between six months and a year to recover – every woman is different in her recovery. Women often experience low self-esteem and difficulties as they recover, but most women fully recover. Many women who have PP  have a hard time bonding with their child as they recover, but end up with healthy relationships with their babies.

Postpartum psychosis can disappear gradually in the months after labor, but can also linger for years. Women who choose to speak openly about the illness and seek help often find that antepartum psychiatrists and medication have a beneficial long-term impact.

About half of women who experience postpartum psychosis have further experiences of mental illness unrelated to childbirth; further pregnancies do not change that risk. Women hospitalized for a psychiatric illness shortly after giving birth have a 70 times greater risk of suicide in the first 12 months following delivery.

Should I Have Another Baby?

Making the decision to have another baby isn’t straightforward. Thinking about it might bring a lot of worries – will you and your partner go through the same painful experiences all over again? The more you can both share about your
hopes and fears, the easier it will be to make an informed decision together.

Many women who have had Postpartum Psychosis go on to have more children, and about 50% do not experience PP again after the birth of another baby. With the right care, if your partner does have another episode, you should be able to spot the signs, get help before it becomes too severe, and recover more quickly the second time around.

You can plan as many children as you want, even with history of postpartum psychosis. However, you will have to set up a support system and be prepared for the illness right after childbirth. Those with high risk from postpartum psychosis should have a support team monitoring their state during the pregnancy and after childbirth. If you’re expecting to experience postpartum psychosis after childbirth, specialist care during the pregnancy, as well as consultations with a psychiatrist are a good way to support mental health.

At around 32 weeks of pregnancy, everyone involved with your care, including family and friends, midwife, GP, and obstetrician, should meet to exchange information and agree on the postpartum care plans. In some maternity units, you may see a psychiatrist or mental health nurse before you leave hospital, even if you are well. This is to check that you are well at the time you go home. They should also check the plan made at your pre-birth planning meeting. They can make sure you have any medication you need and set up any support services as possible.

You should get a copy of your written care plan. This should include early warning symptoms and a plan for your care. There should also be details of how you and your family can get help quickly if you do become unwell.

The best solution for your postpartum care is to define the treatment course after the delivery. Some women have symptoms so severe that they need to be admitted to the psychiatric ward right after the childbirth. Others rely on the help of friends and family with housework and the baby. In some cases, mothers are under constant supervision from family members and never left alone with the baby. Though it might seem unsettling to know you can’t be alone with your child, this is the only way to ensure the safety of both of you. When someone is always present to help out with the baby, you are left with more time to recover and bond with the child.

You should discuss:

• The risk of developing postpartum psychosis.
• Risks and benefits of medication in pregnancy and after birth. This should give you the information you need to make decisions about your treatment.
• The type of care you can expect in your local area from perinatal mental health and maternity services and how professionals work together with you and your family.
• If you are at high risk of postpartum psychosis, you should have specialist care in pregnancy, If you are already under the care another mental health service they can work together

Postpartum Mood Disorders

by Aunt Becky | Apr 28, 2019

What Are Postpartum Mood Disorders?

Pregnancy is a whirlwind of tons of emotions and sensations – our body is ever changing as well as our wishes, dreams, plans, hopes, and expectations that come at us both from every direction. It’s completely normal to feel overwhelmed by the idea of bringing a new life and person into the world, while strangers and loved ones alike bombard you with their experiences and ideas.

Most pregnant women feel their appetite increase, an eager anticipation of the new life to come, and sleep should be good (excepting getting comfortable, which is always a challenge during pregnancy). Normal worries and concerns will be sprinkled throughout the pregnancy experience, but they shouldn’t dominate our days or nights.

Ask yourself, “Do I emotionally feel like ‘me’ most of the day?” “Can I to sleep at night?” “Am I mostly excited about the baby coming?,” and “Am I eating enough?”

All of the above should be answered with a resounding “YES.”

If you’re not, it’s time to seek out a specialized health care practitioner who can help understand what’s happening with you

Depression and anxiety affect just as many pregnant women as new mothers, and can happen to the strongest, most intelligent, and loving moms. If you experience depression during your pregnancy, speak to your obstetrician – this is called antepartum depression, and it affects a great many men and women during pregnancy. There are a number of ways you can get help, and not all of them involve medications.

Every trimester you should either be given a formal screening or simply asked a few key questions to determine how you’re doing emotionally.  Receiving the right help during pregnancy will not only be best for you and your entire family, it will help you minimize the risk of postpartum depression.

Several days to weeks after giving birth, some mothers and fathers notice that they’re experiencing some strange symptoms, (most commonly) sadness, and/or anxiety after the birth of their child.

An estimated 1 out of every 6 women and 1 out of every 10 men experiences troubling depression or anxiety after the birth or adoption of a child, and in most people, these feelings are generally transient in nature. Given the tremendously stressful period of learning to live life with a newborn or new child is tremendously stressful to all involved, which is why we now recognize then men can also have postpartum mood disorders.

During the postpartum period, about 85% of women experience some type of mood disturbance. Generally, these symptoms are mild and short-lived; however, 10 to 15% of women and men go on to develop more significant symptoms of depression or anxiety. Postpartum psychiatric illnesses are typically divided into categories:

• Antenatal/Antepartum Depression
• Postpartum Baby Blues
• Postpartum Depression
• Postpartum Anxiety Disorders
• Postpartum OCD
• Postpartum Psychosis

It may be useful to conceptualize these disorders as existing along a continuum, where postpartum blues is the mildest and postpartum psychosis the most severe form of postpartum mood disorders.

Postpartum mood disorders are often characterized by despondency, emotional instability, anger, guilt, tearfulness, worrying, anxious thoughts or images, feelings of inadequacy and the inability to cope. It may occur shortly after the arrival of a new baby or many months later. For some, symptoms may begin in pregnancy; which is called or Antenatal Depression. The types of postpartum mood disorders generally lay on a spectrum.

Risk Factors for Developing Postpartum Mood Disorders:

Some things can make you more likely than others to develop postpartum mood disorders, including PPD. These are called risk factor. and having a risk factor or a few doesn’t mean for sure that you’ll have any problems with your mental health during or after pregnancy, but these risk factors, may increase your chances. Talk to your health care provider to see if you’re at risk for a postpartum mood disorder.

Your health care provider should assess you for PPD at your postpartum care checkups, including questions about your risks, feelings, stress level, as well as your moods.

Risk factors for postpartum mood disorders include:

• Depression during pregnancy (Antenatal depression) or you’ve had major depression or another mental illness before
• Family history of depression or mental health disorders.
• You’ve been physically or sexually abused in your life
• Problems with your partner, including domestic violence (also called intimate partner violence or IPV).
• Extra stress in your life, such being separated from your partner, the death of a loved one, or an illness that affects you or a loved one.
• Unemployed or have low income, little education, or little support from family or friends.
• Pregnancy is unplanned or unwanted, or you’re younger than 19.
• You have diabetes. Diabetes can be pre-existing diabetes (also called pre-gestational diabetes) or it can be gestational diabetes.
• Pregnancy complications such as premature birth, birth before 37 weeks of pregnant
• Multiples (twins, triplets) pregnancy
• Pregnant with a child who has been diagnosed birth defects
• Experiencing pregnancy loss.
• You have trouble breastfeeding or caring for your baby.
• Infant is sick or has ongoing health conditions.
• Negative thoughts about being a mom and/or having trouble adjusting to being a parent.

Negative thoughts and feelings about being a mom may include:

• Doubts that you can be a good mom
• Pressure to be a perfect mom
• Feeling that you’re no longer the person you were before you had your baby
• Feeling that you’re less attractive after having your baby
• Having no free time for yourself
• Feeling tired and moody because you aren’t sleeping well or getting enough sleep

What is Antenatal Depression?

Depression during pregnancy, or antepartum depression, is a mood disorder just like clinical depression as far as symptoms are concerned. Mood disorders are biological illnesses that involve changes in brain chemistry and men and women who suffer from major depression are at a higher risk for developing antenatal depression.

During pregnancy, as I’m sure you’re aware, hormone changes affects the chemicals in your brain, including those that tell you to eat, sleep, and rest. Some of the other hormone changes are directly related to Antenatal Depression and Antenatal Anxiety. Unfortunately, these hormones can be exacerbated by difficult life situations, stress, and other factors which can result in depression during pregnancy.

Women with Antepartum Depression tend experience some of the following symptoms for at least two weeks:

• Persistent sadness
• Problems concentrating
• Sleeping too little or too much
• Loss of interest in activities that you usually enjoy
• Recurring thoughts of death, suicide, or hopelessness
• Anxiety without a trigger
• Feelings of guilt or worthlessness
• Change in eating habits

What Are The Postpartum Baby Blues?

Specialists believe that approximately 50 to 85% of women and men experience postpartum blues during the first few weeks after delivery; part of it is related to wildly changing hormone levels, the stress of having a new person to care for, and not feeling as though they’ll be able to manage. As this type of mood disorder is common – even expected, it can be more accurate to consider The Baby Blues as a normal experience following childbirth rather than a psychiatric illness.

Rather than feelings of sadness, men and women with The Baby Blues more commonly report mood lability, tearfulness, anxiety, and/or irritability. These symptoms typically peak on the fourth or fifth day after delivery and may last for a few hours or a few days, remitting spontaneously within two weeks of delivery.

While these symptoms are unpredictable and often unsettling, they do not interfere with a woman’s ability to function. No specific treatment is required; however, it should be noted that sometimes The Baby Blues heralds the development of a more significant mood disorder, particularly in women who have a history of depression.

If symptoms of depression persist for longer than two weeks, you should be evaluated to rule out a more serious postpartum mood disorder.

What Is Postpartum Depression (PPD)?

PPD tends to emerge over the first two to three months postpartum but can occur at any point after delivery. Some men and women actually note the onset of milder depressive symptoms during pregnancy. Postpartum depression is clinically indistinguishable from depression occurring at other times during a woman’s life.

In women and men who have milder cases of PPD, it can be quite difficult to detect postpartum depression because many of the symptoms used to diagnose depression (such as sleep and appetite disturbance, fatigue) also occur in postpartum women in the absence of depression.

The Edinburgh Postnatal Depression Scale is a 10-item questionnaire that may be used to identify women who have PPD.

On this scale, a score of 12 or greater or an affirmative answer on question 10 (presence of suicidal thoughts) raise concern and indicate a need for more thorough evaluation.

Some of the symptoms of postpartum depression include:

• Depressed or sad mood
• Persistent sadness not otherwise explained
• Tearfulness
• Loss of interest in usual activities
• Feelings of guilt
• Feelings of worthlessness or incompetence
• Fatigue
• Sleep disturbance
• Change in appetite
• Poor concentration
• Suicidal thoughts

What Causes Postpartum Depression?

The postpartum period is characterized by a rapid shift in the hormonal environment. Within the first 48 hours after delivery, estrogen and progesterone concentrations fall dramatically. As these gonadal steroids modulate neurotransmitter systems involved in the regulation of mood, many investigators have proposed a role for these hormonal shirts in the emergence of postpartum affective illness.

While seems as if there is no consistent correlation between serum levels of estrogen, progesterone, cortisol, or thyroid hormones and the occurrence of postpartum mood disturbance, some investigators hypothesize that there is a subgroup of women who are particularly sensitive to the hormonal changes that take place after delivery. This population of women may be more vulnerable to PPD and to other hormonally driven mood disturbances, such as those occurring during the premenstrual phase of the menstrual cycle or during the perimenopause.

Other factors may play a role in the development of PPD. One of the most consistent findings is that among women and men who report marital dissatisfaction and/or inadequate social supports, postpartum depressive mental illnesses is more common. Several investigators have also demonstrated that stressful life events occurring either during pregnancy or near the time of delivery appear to increase the likelihood of postpartum depression.

While all of these factors may act together to cause PPD, the emergence of this disorder probably reflects an underlying vulnerability to affective illness. Women with histories of major depression or bipolar disorder are more vulnerable to PPD, and women who develop PPD will often go on to have recurrent episodes of depression unrelated to pregnancy or childbirth.

Who is at Risk for Postpartum Depression?

All women are vulnerable to postpartum depression, regardless of age, marital status, education level, or socioeconomic status. While it is impossible to predict who will develop PPD, certain risk factors for PPD have been identified, including:

• Previous episode of PPD
• Depression during pregnancy (antenatal depression)
• History of depression or bipolar disorder
• Recent stressful life events
• Inadequate social supports
• Marital or family issues

What Is Postpartum Anxiety?

Recent research suggests that 6% of pregnant women and 10% of postpartum women develop significant anxiety disorders. Sometimes these men and women experience anxiety alone, and sometimes they experience it in addition to postpartum depression. You do not have to be diagnosed with OCD to experience these common symptoms of perinatal anxiety

Generalized anxiety is common in both the general population and the postpartum period, however some women may also develop more challenging types of anxiety, such as panic disorder, and/or hypochondriasis in the postpartum period. Postpartum obsessive-compulsive disorder has also been reported, in which women report disturbing and intrusive thoughts of harming their infant.

• Constant worry
• Feeling that something bad is going to happen
• Racing thoughts
• Disturbances of sleep and appetite
• Inability to sit still
• Physical symptoms like dizziness, hot flashes, and nausea

Risk factors for perinatal anxiety and/or panic disorder may include a personal or family history of anxiety, previous perinatal depression or anxiety, or thyroid imbalance; however, many men and women develop Postpartum Anxiety without any risk factors.

Postpartum Panic Disorder is a form of anxiety with which the sufferer feels very nervous and has recurring panic attacks after the birth or adoption of a baby or child. During a panic attack, he or she may experience any or all of the following:

• Shortness of breath
• Feeling of someone sitting on his or her chest
• Chest pain
• Claustrophobia
• Dizziness
• Heart palpitations
• Numbness and tingling in the extremities.

Panic attacks seem to go in waves, but it is important to know that they will pass and will not hurt you.

What Is Postpartum Obsessive-Compulsive Disorder?

Postpartum Obsessive-Compulsive Disorder (OCD) is probably most misunderstood and misdiagnosed of the perinatal mood disorders. It is estimated that as many as 3-5% of new mothers and some new fathers will experience some of these symptoms. The repetitive, intrusive images and thoughts are very frightening and can feel like they come “out of the blue.” Fortunately, postpartum OCD is temporary and treatable with professional help. If you feel you may be suffering from one of this illness, know that it is not your fault and you are not to blame.

Research has shown that these images are anxious in nature, not delusional, and have very low risk of being acted upon. It is far more likely that the parent with this symptom takes steps to avoid triggers and avoid what they fear is potential  harm to the baby.

Some women and men do not have OCD but are bothered by obsessive-compulsive symptoms.

Symptoms of Postpartum Obsessive-Compulsive symptoms can include:

• Obsessions, also called intrusive thoughts, which are persistent, repetitive thoughts or mental images related to the baby. These thoughts are very upsetting and not something the woman has ever experienced before.
• Compulsions, where the mom may do certain things over and over again to reduce her fears and obsessions. This may include things like needing to clean constantly, check things many times, count or reorder things.
• A sense of horror about the obsessions
• Overly occupied with keeping your baby safe
• Compelled to do certain things over and over again to help relieve her anxiety and fears–This can include counting things, ordering things, listing things, checking and rechecking actions already performed, and cleaning repeatedly. This may manifest itself in cleaning, feeding, or taking care of the baby.
• May recognize these obsessions but feels horror and shame associated with them
• Obsessions or thoughts that are persistent, are repetitive and can include mental images of the baby that are disturbing
• Fear of being alone with the baby
• Women who suffer from PPOCD often know that these thoughts, actions, and feelings are not normal and do not act on them. But the obsession can get in the way of a mom taking care of her baby properly or being able to enjoy her baby. With the right treatment, women with PPOCD can experience freedom from being controlled by these obsessions and compulsions
• Fear of being left alone with the infant
• Hypervigilance in protecting the infant

Moms with postpartum OCD know that their thoughts are bizarre and are very unlikely to ever act on them.

Risk factors for postpartum OCD include a personal or family history of anxiety or OCD.

Given the potential adverse effects of untreated mood and anxiety symptoms in either the mother, father, careful screening and early recognition of anxiety symptoms during the postpartum period is recommended. Antepartum anxiety are temporary and treatable with professional help. If you feel you may be suffering from one of these illnesses, know that it is not your fault and you are not to blame.

What Is Postpartum Post-Traumatic Stress Disorder (PPTSD)?

Postpartum post-traumatic stress disorder (P-PTSD) often affects women who experienced a real or perceived trauma during childbirth or immediately after the baby was born.

P-PTSD is not a well-researched postpartum mood disorder, but for the estimated 3 to 16 percent of new moms and dads who suffer from it, this postpartum mood disorder is very real and incredibly frightening. P-PTSD can greatly impact the way they experience parenthood and care for their new baby.

For most women, the safe delivery of a healthy baby is moment remembered with great happiness. But not every new mom’s birth experience is a joyful one. In fact, more than a third of recently delivered moms describe their birth as traumatic, and the American College of Obstetricians and Gynecologists estimate that 3 to 16 percent display severe traumatic stress responses in the postpartum period. Like war veterans who suffer from PTSD – intrusive memories and flashbacks after suffering traumatic experiences on the battlefield – moms with P-PTSD look at their childbirth experience as a source of pain and anxiety and suffer from very similar post-traumatic symptoms.

P-PTSD is triggered by a traumatic event or events – real or perceived –– during pregnancy, labor, delivery, or during the postpartum period.

A mom-to-be may experience a traumatic event, such as severe morning sickness, fertility treatments, or serious pregnancy complications. Some women might experience trauma during childbirth if their labor was long and painful, if there was a cord prolapse, shoulder dystocia, a severe tear, previously undiscovered birth defects, hemorrhage, or an emergency C-section.

Trauma may result from a home birth that resulted in a transfer to a hospital due to complications; it could be from a planned hospital delivery that ended up unexpectedly at home. Trauma may develop if someone who’d wanted an intervention-free birth ends up requiring life-saving interventions.

Postpartum traumas may include having a premature baby, a baby who needs to be in the NICU, breastfeeding difficulties, or worse, a stillbirth or loss of a child early on.

Often the trauma is an emotional one: feelings of being powerless, of not being listened to, of not having adequate support during childbirth.

It’s important to remember that postpartum PTSD can develop after a real or perceived threat of death of the mother, father, or baby.

Traumas that may cause postpartum post-traumatic stress (P-PTSD) disorder include:

• Unplanned or emergency C-section
• Emergency complication such as prolapsed umbilical cord
• Birth that requires invasive interventions such as vacuum extractor or forceps
• Baby requiring a NICU stay
• Lack of support and assurance during the delivery
• Lack of communication from the birth and support team
• Feelings of powerlessness

Symptoms of P-PTSD may include:

• Nightmares and flashbacks to the birth or trauma
• Anxiety and panic attacks
• Feeling a detachment from reality and life
• Irritability, sleeplessness, hyper-vigilance, startles more easily
• Avoidance of anything that brings reminders of the event such as people, places, smells, noises, feelings
• May begin re-experiencing past traumatic events, including the event that triggered the disorder

Women who are experiencing PPTSD need to talk with a health care provider about what they are feeling. With the correct treatment, these symptoms will lessen and eventually go away.

What Is Postpartum Psychosis?

Postpartum Psychosis (PP) is a severe, but treatable, form of mental illness that occurs after having a baby. It can happen ‘out of the blue’ to women without previous experience of mental illness. There are some groups of women, women with a history of bipolar disorder for example, who are at much higher risk. PP normally begins in the first few days to weeks after childbirth. It can get worse very quickly and should always be treated as a medical emergency. Most women need to be treated with medication and admitted to hospital.

Postpartum psychosis is the most severe form of postpartum mood disorders and is extremely – extremely dangerous. Postpartum Psychosis is a medical emergency. If you believe a friend or loved one is suffering from Postpartum Psychosis, don’t wait: call 911. This is an emergency.

Fortunately, postpartum psychosis It is a rare postpartum mood disorder that occurs in approximately 1 to 2 per 1000 women after childbirth.

The presentation is often dramatic, with onset of symptoms as early as the first 48 to 72 hours after delivery. The majority of women with puerperal psychosis develop symptoms within the first two postpartum weeks.

With the right treatment, women with PP do make a full recovery. Recovery takes time and the journey may be tough. The illness can be frightening and shocking for both the woman experiencing it and her family. Women do return to their normal selves, and are able to regain the mothering role they expected. There is no evidence that the baby’s long term development is affected by Postpartum Psychosis.

There are a large variety of symptoms that women with PP can experience. Women may be:

• Excited, elated, or ‘high’.
• Depressed, anxious, or confused.
• Excessively irritable or changeable in mood.

Postpartum Psychosis includes one or more of the following:

• Strange beliefs that could not be true (delusions).
• Hearing, seeing, feeling or smelling things that are not there (hallucinations).
• High mood with loss of touch with reality (mania).
• Paranoia
• Attempts to harm the child or herself
• Severe confusion.

These are also common symptoms:

• Being more talkative, sociable, on the phone an excessive amount.
• Having a very busy mind or racing thoughts.
• Feeling very energetic and like ‘super-mum’ or agitated and restless.
• Having trouble sleeping, or not feeling the need to sleep.
• Behaving in a way that is out of character or out of control.
• Feeling paranoid or suspicious of people’s motives.
• Feeling that things are connected in special ways or that stories on the TV or radio have special personal meaning.
• Feeling that the baby is connected to God or the Devil in some way.

It appears that in most cases, postpartum psychosis represents an episode of bipolar illness; the symptoms of puerperal psychosis most closely resemble those of a rapidly evolving manic (or mixed) episode. The earliest signs are restlessness, irritability, and insomnia. Women with this disorder exhibit a rapidly shifting depressed or elated mood, disorientation or confusion, and erratic or disorganized behavior. Delusional beliefs are common and often center on the infant.

Auditory hallucinations that instruct the mother to harm herself or her infant may also occur.

Risk for infanticide, as well as suicide, is significant in this population.

How Are Postpartum Mood Disorders Treated?

Postpartum depression presents along a continuum, and the type of treatment selected is based on the severity and type of symptoms present. However, before initiating psychiatric treatment, any medical causes for mood disturbances (including thyroid dysfunction and/or anemia) must be excluded. Initial evaluation of a man or woman for postpartum mood disorders should always include a thorough and complete history, a physical examination, as well as routine laboratory tests.

Non-pharmacological therapies are often useful in the treatment of postpartum depression. It has been wildly demonstrated that short-term cognitive-behavioral therapy (CBT) was as effective as treatment with fluoxetine in women who have postpartum depression. Interpersonal therapy (IPT) has also been shown to be effective for the treatment of women with mild-to-moderate postpartum depression. Not only is IPT effective for treating the symptoms of depression, women who receive IPT may also benefit from significant improvements in the quality of their interpersonal relationships.

These non-pharmacological interventions may be particularly attractive to those patients who are reluctant to use psychotropic medications (such as women who are breastfeeding) or for women who have milder forms of depressive illness. Women with more severe postpartum depression may choose to receive pharmacological treatment, either in addition to or instead of these non-pharmacological therapies.

Only a few studies have systematically assessed the pharmacological treatment of postpartum depression.

Conventional antidepressant medications (fluoxetine, sertraline, fluvoxamine, and venlafaxine) have shown efficacy in the treatment of postpartum depression, standard antidepressant doses were both effective and well tolerated. The choice of an antidepressant should be guided by the woman’s prior response to antidepressant medication and side effect profile. Specific serotonin reuptake inhibitors (SSRIs) are ideal first-line agents, as they are anxiolytic, non-sedating, and well-tolerated.

For women who cannot tolerate SSRIs, bupropion (Wellbutrin) may be an alternative; although one pilot study suggests bupropion may not be as effective as SSRIs

Tricyclic antidepressants (TCAs) are frequently used and, because they tend to be more sedating, may be more appropriate for women who present with prominent sleep disturbance. Given the prevalence of anxiety symptoms, adjunctive use of a benzodiazepine (including clonazepam, lorazepam) may be very helpful to help ease anxiety and allow for relaxation.

While it’s difficult to reliably predict which women in the general population will experience postpartum mood disorders, it is possible to identify certain subgroups of women (such as men and women with a history of mood disorders) who are more vulnerable to postpartum affective illness.

Current research indicates that prophylactic interventions may be instituted near or at the time of delivery to decrease the risk of postpartum illness. Several studies demonstrate that women with histories of bipolar disorder or puerperal psychosis benefit from prophylactic treatment with lithium instituted either prior to delivery (at 36 weeks gestation) or no later than the first 48 hours postpartum.

Women and men with postpartum psychiatric illness are offered a variety of services by clinicians with particular expertise in these areas:

• Clinical evaluation for postpartum mood and anxiety disorders
• Medication management
• Consultation regarding breastfeeding and psychotropic medications
• Recommendations regarding non-pharmacological treatments
• Referral to support services within the community

Puerperal psychosis is considered a psychiatric emergency that typically requires inpatient treatment.

Acute treatment with either typical or atypical anti-psychotic medications is indicated. Given the well-established relationship between puerperal psychosis and bipolar disorder, postpartum psychosis should be treated as an affective psychosis and a mood stabilizer is indicated.

Electroconvulsive therapy (ECT) is well-tolerated and rapidly effective for severe postpartum depression and psychosis.

Can I Take Medications While Breastfeeding?

The nutritional, immunologic and psychological benefits of breastfeeding have been well-documented. Women who plan to breastfeed must be informed that all psychotropic medications, including antidepressants, are secreted into the breast milk, though concentrations in the breast milk appear to vary widely throughout the day The amount of medication to which an infant is exposed depends on several factors including, dosage of medication, rate of maternal drug metabolism, and frequency and timing of feedings.

Over the past five years, we’ve learned more regarding the use of various antidepressants during breastfeeding. Available data on the tricyclic antidepressants, fluoxetine, paroxetine, and sertraline during breastfeeding have been encouraging and suggest that significant complications related to an infant’s exposure to these medications in breast milk appear to be rare. While less information is available on other antidepressants, there have been no reports of serious adverse events related to infant exposure to these medications.

Women who have bipolar disorder may discover breastfeeding may be much more problematic. The first concern is that on-demand, around-the-clock breastfeeding may significantly disrupt the mother’s sleep, which can increase her vulnerability to a relapse of bipolar disorder during the postpartum period. Second, there have been reports of toxicity in nursing infants who have been exposed to various mood stabilizers in the breast milk, including lithium and carbamazepine. Lithium, a gold standard in management of bipolar disorder, is excreted at high levels in the mother’s milk, so infant serum levels of Lithium are relatively high, which brings an increased risk of neonatal toxicity. Exposure to carbamazepine and valproic acid in the breast milk has also been associated with hepatotoxicity (liver toxicity) in a nursing infant.

If you’ve been diagnosed and treated for bipolar disorder, the very best thing that you can do for yourself and your infant is to develop a postpartum plan with your psychiatrist and your OB, based on the symptoms you experienced before you were pregnant. In this plan, you can address your postpartum concerns and ways to manage these concerns.

Additional Things You Can Do To Help Postpartum Mood Disorders: