• Clinical science

Personality disorders

Summary

Personality disorders are characterized by deeply rooted, egosyntonic behavioral traits that differ significantly from the expected and accepted norms of an individual's culture. Consequently, regional and cultural characteristics should always be considered before diagnosing a patient with a personality disorder. Personality disorders usually arise during adolescence and are difficult to treat. A key feature of personality disorders is that they must cause impairment in social and/or occupational functioning. Personality disorders are associated with a higher risk of developing other psychiatric disorders, especially in times of stress.

Overview

Definition

Pervasive, inflexible, and maladaptive personality patterns that lead to significant distress or functional impairment and are stable over time.

Etiology

Multifactorial: due to a combination of hereditary (e.g., personality disorders in parents) and psychosocial factors (e.g., child neglect, abuse)

Epidemiology

  • Age of onset: late childhood or adolescence
  • Antisocial and narcissistic personality disorders are more commonly diagnosed in males.
  • Histrionic and borderline personality disorders are more commonly diagnosed in females.

Classification

The DSM-5 divides personality disorders into three clusters based on similar characteristics.

Prevalence Characteristic behavior Personality disorders Family history association
Cluster A
  • ∼ 5%
  • Odd
  • Eccentric
  • Psychotic disorders
Cluster B
  • ∼ 2%
  • Dramatic
  • Emotional
  • Erratic
  • Mood disorders
Cluster C
  • ∼ 5%
  • Fearful
  • Avoidant
  • Anxious

Clinical features

  • Egosyntonic symptoms (individuals lack insight as to their symptoms, considering them to be normal and not a problem)
  • Thinking and behavior that significantly differ from cultural expectations
  • See the individual disorders below.

Diagnostic criteria

  • At least two or more of the following deviate significantly from cultural expectations:
    1. Cognition (e.g., perceives events, others, or self in an inappropriate way)
    2. Affectivity
    3. Interpersonal functioning
    4. Impulse control
  • Begins in early adulthood and is stable over time
  • Leads to significant distress and impaired functioning in important areas of life (e.g., social, occupational)
  • Is not caused by another mental disorder, substance abuse, or other medical condition
  • Can be diagnosed in individuals < 18 years of age if features have been present for ≥ 1 year (except antisocial personality disorder) [1] DSM V page 647

Treatment

Personality disorders are associated with an increased risk of developing other psychiatric disorders, especially during times of stress!

References:[1][2]

Cluster A

Paranoid personality disorder

  • Pervasive distrust of others
  • Preoccupation with the loyalty of friends and family
  • Strong reactions to perceived attacks
  • Holding grudges
  • Superficial relationships

Schizoid personality disorder

  • Voluntary detachment from social relationships (unlike avoidant personality disorder)
  • Restricted emotional expression
  • Anhedonia
  • Indifference to praise or criticism
  • No interest in sexual relationships

Schizotypal personality disorder

  • Odd and eccentric behavior
  • Magical thinking
  • Excessive social anxiety
  • Ideas of reference
  • Unusual perceptual experiences
  • Constricted affect
  • Preference for social isolation because of paranoia and suspicion of others

References:[3][1][2]

Cluster B

Antisocial personality disorder

  • More common in men
  • Must be preceded by a history of conduct disorder
  • Three or more of the following are present after the age of 15 years:
    • Deceitfulness
    • A history of repeated aggression
    • Repeatedly engaging in criminal activity
    • Impulsivity/failure to plan ahead
    • A reckless disregard for one's own safety and/or the safety of others
    • A failure to fulfill work-related or financial obligations
    • A lack of remorse and/or emotional indifference to the plight of others
  • Cannot be diagnosed before 18 years of age; if the patient is less than 18 years of age, the diagnosis is conduct disorder.
  • Extremely difficult to treat
    • Prevention of conduct disorder progression
    • Older patients are typically incarcerated

Borderline personality disorder

  • More common in women
  • Presents with:
    • Unstable personal relationships
    • Fear of abandonment
    • Lack of impulse control
    • Intense anger
    • Self-harm
    • Suicidal behavior
    • Feelings of emptiness
    • Splitting (psychiatry): defense mechanism in which relationships are categorically good or bad
  • Treatment: dialectical behavior therapy

Histrionic personality disorder

  • Attention-seeking, excessively emotional behavior
  • Exhibiting inappropriate, sexually provocative, and/or seductive behavior during interactions with others
  • Drawing attention to self by way of physical appearance
  • Overestimating the degree of intimacy in relationships
  • Uncomfortable when not the center of attention

Narcissistic personality disorder

  • Attention-seeking behavior, grandiosity, and a need for admiration
  • Difficulty dealing with criticism
  • Lack of empathy
  • Important to distinguish from manic or hypomanic episodes in bipolar disorder
  • Three subtypes
    • Grandiose, overt
    • High-functioning
    • Vulnerable/covert

References:[3][1][2]

Cluster C

Avoidant personality disorder

  • Fear of rejection and feelings of inadequacy resulting in involuntary social withdrawal
  • Strong desire for social relationships (unlike schizoid personalities), but limited by extreme shyness and social anxiety

Dependent personality disorder

  • Difficulty making everyday decisions; often requiring others to assume responsibility
  • Difficulty initiating projects (e.g., applying for jobs) because of a lack of self-confidence
  • Feelings of helplessness when alone; urgently seeking new relationships when one fails
  • Both afraid of being abandoned and afraid to abandon their partner
  • Often stuck in abusive relationships
  • Associated with an increased risk of suicide

Obsessive-compulsive personality disorder

  • Perfectionism and obsession with control that is often egosyntonic (in contrast to obsessive-compulsive disorder, which is typically egodystonic)
  • Rigid routines
  • Features often occur at the expense of occupational success (e.g., missing deadlines), social relationships (e.g., excluding social activities to complete tasks), and pleasurable activities (e.g., not taking vacation)
  • In contrast to OCD, intrusive thoughts and repetitive behaviors are not present.

References:[3][1][2]

Differential diagnoses

The differential diagnoses listed here are not exhaustive.

  • 1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (DSM–5). https://www.psychiatry.org/psychiatrists/practice/dsm. Accessed May 26, 2017.
  • 2. Skodol A. Overview of Personality Disorders. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/overview-of-personality-disorders. Last updated December 1, 2017. Accessed May 24, 2018.
  • 3. Ganti L, Kaufman MS, Blitzstein SM. First Aid for the Psychiatry Clerkship. McGraw Hill Professional; 2016.
  • Kaplan Medical. USMLE Step 2 CK Lecture Notes 2017: Psychiatry, Epidemiology, Ethics, Patient Safety. New York, NY: Simon and Schuster; 2016.
last updated 04/23/2019
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