Personality Disorders

Personality Disorders

• The person-centered approach distinguishes psychiatry from other medical fields by viewing individuals as self-aware beings, not "machine-like objects." Personality encompasses characteristics that differentiate a continually developing, self-organizing human being from a predictable machine.

• Personality refers to how someone uniquely shapes and adapts to their changing internal and external environment.

• Individuals with personality disorders are less likely to seek psychiatric help and often deny their problems, unlike those with anxiety, depression, or obsessive-compulsive disorder.

• Personality disorder symptoms are often ego-syntonic (acceptable to the ego) and alloplastic (attempting to change the external environment rather than oneself).

• Individuals with personality disorders often do not feel anxiety about their maladaptive behavior and may seem disinterested in treatment.

The Clinical Presentation

• Individuals with these disorders exhibit long-standing, maladaptive behavior traits that are pervasive across personal and social contexts.

• Paranoid Personality Disorder: Characterized by long-standing suspiciousness and mistrust of others, refusal to take responsibility for their own feelings, and assignment of responsibility to others. They are often hostile, irritable, and angry.

• Schizoid Personality Disorder: Characterized by a lifelong pattern of social withdrawal. Individuals are often seen as eccentric, isolated, or lonely. They exhibit discomfort with human interaction, introversion, and a bland, constricted affect.

• Schizotypal Personality Disorder: Individuals are strikingly odd or strange. Magical thinking, peculiar notions, ideas of reference, illusions, and derealization are commonplace.

• Antisocial Personality Disorder: Characterized by an inability to conform to social norms. Though often marked by antisocial or criminal acts, it is not synonymous with criminality.

• Borderline Personality Disorder: Patients exhibit extraordinarily unstable affect, mood, behavior, object relations, and self-image, existing on the border between neurosis and psychosis.

• Histrionic Personality Disorder: Characterized by being excitable and emotional, behaving in a colorful, dramatic, extroverted fashion. They often struggle with maintaining sincere, long-lasting attachments.

• Narcissistic Personality Disorder: Individuals have a heightened sense of self-importance, lack of empathy, and grandiose feelings of uniqueness, with fragile self-esteem vulnerable to criticism underneath.

• Avoidant Personality Disorder: Individuals show extreme sensitivity to rejection and may lead socially withdrawn lives, desiring companionship but needing strong guarantees of uncritical acceptance. Often described as having an inferiority complex.

• Dependent Personality Disorder: Patients subordinate their own needs to those of others, rely on others to assume responsibility for their lives, lack self-confidence, and experience discomfort when alone.

• Obsessive-Compulsive Personality Disorder: Individuals are typically emotionally constricted, orderly, perseverative, stubborn, and indecisive, with a pervasive pattern of perfectionism and inflexibility.

• Personality Change due to a General Medical Condition: Marked by a significant change in personality style and traits from their previous level of functioning, with evidence of a causative medical factor antedating the personality change.

Diagnosis

• DSM-5's categorical approach to personality disorders is considered problematic by some experts who argue for a more dimensional approach grounded in temperament and personality research.

• The DSM-5 Personality Disorders Workgroup proposed focusing on impairments in personality functioning using a widely accepted model of personality, but this change was deemed too radical and included in a later section as "Emerging Measures and Models."

• The categorical approach remains controversial, with many questioning its validity. ICD-10 offers a more descriptive approach but is similar to DSM-5, listing more disorders.

• DSM-5 divides personality disorders into three clusters:

  • Cluster A: Odd, aloof features (paranoid, schizoid, schizotypal).

  • Cluster B: Dramatic, impulsive, exploitative, erratic features (borderline, antisocial, narcissistic, histrionic).

  • Cluster C: Anxious, fearful features (avoidant, dependent, obsessive-compulsive).

• Individuals may exhibit traits from multiple personality disorders; clinicians should diagnose each if criteria are met.

• A personality disorder diagnosis should only be used when features are typical of long-term functioning and not limited to a discrete episode of another mental disorder.

• Maladaptive behavior due to the direct psychological effects of another mental disorder or substance use does not warrant a personality disorder diagnosis.

• Personality change due to a medical condition, such as temporal lobe epilepsy, can be diagnosed, specifying the medical condition.

Table 19-1: Personality Disorders

• Compares general approaches to diagnosing personality disorders in DSM-5 and ICD-10, focusing on duration, symptoms, and exclusions.

• DSM-5: General Personality Disorder.

  • Duration: Persistent, long duration (since teens or early adulthood).

  • Symptoms: Fixed pattern of behavior in cognitive, mood, interpersonal, and behavioral domains.

  • Symptoms Needed: 2/4 domains.

  • Exclusions: Not due to another mental disorder, substance use, or medical illness.

  • Psychosocial Impact: Distress, functional impairment.

  • Specific Disorders: Cluster A (paranoid, schizoid, schizotypal), Cluster B (antisocial, borderline, histrionic, narcissistic), Cluster C (avoidant, dependent, obsessive-compulsive).

• ICD-10: Disorders of Adult Personality and Behavior.

  • Duration: Persistent.

  • Symptoms: Consistent, fixed, inflexible pattern of behaviors, involving dysfunctional relationships and distorted self-view.

  • Psychosocial Impact: Usually causes distress, difficulties with social performance.

  • Specific Disorders: Paranoid, schizoid, dissocial, emotionally unstable, histrionic, anankastic, anxious [avoidant], dependent, other specific (eccentric, haltlose, immature, narcissistic, passive- aggressive, psychoneurotic), personality disorder unspecified, mixed and other, enduring changes due to brain damage/disease/experience/illness/chronic pain.

Table 19-2: Paranoid Personality Disorder: Specific Symptoms

• DSM-5: Paranoid Personality Disorder.

  • Symptoms: Suspiciousness, evident from ≥4 of the following;

    • Suspicion/persecutory thoughts

    • Doubting others’ loyalty

    • Distrust, inability to confide in others

    • Interpreting experiences as threatening or hostile

    • Holds grudges

    • Feeling attacked by others

    • Distrusting partner’s faithfulness

  • Exclusions: Not a result of schizophrenia, depression with psychotic features, other psychoses, substance use, or a medical condition

• ICD-10: Paranoid Personality Disorder

  • Symptoms: Excessive sensitivity to setbacks or insults, suspiciousness, interpreting experiences as threatening or hostile, distrusting partner’s faithfulness

  • May also be self-important or self-referential

  • Exclusions: Not a result of psychosis, schizophrenia, or paranoid state (Cluster A: Odd and Eccentric)

Detailed Look at Cluster A Disorders

• Excessive suspiciousness and distrust of others, interpreting actions as deliberately demeaning, malevolent, threatening, exploiting, or deceiving.

• Expectation of exploitation or harm, disputing loyalty or trustworthiness, and pathological jealousy.

• Externalization of emotions and use of projection; attribution of unacceptable impulses and thoughts to others.

• Ideas of reference and logically defended illusions are common.

• Patients may seem formal and baffled; muscular tension, scanning the environment may be evident; manner is severe and humorless.

• Speech is goal-directed and logical, but thought content demonstrates projection, prejudice, and occasional ideas of reference.

Schizoid Personality Disorder in Depth

• Cold and aloof demeanor, remote reserve, and no involvement with everyday events or others' concerns.

• Quiet, distant, seclusive, and unsociable appearance; little need for emotional ties, unaware of social trends.

• Life histories reflect solitary interests and success in lonely jobs. Sexual lives may exist in fantasy only.

• Lifelong inability to express anger directly; lack of close friends and indifference to praise and criticism.

• Appears self-absorbed and lost in daydreams; average capacity to recognize reality.

• Appears ill at ease during psychiatric examination, avoids eye contact, affect may be constricted, speech is goal-directed but short, may use odd metaphors.

Table 19-3: Schizoid Personality Disorder: Specific Symptoms

• DSM-5: Schizoid Personality Disorder

  • Symptoms: Detachment from interpersonal relationships (≥4)

    • Doesn’t enjoy relationships

    • Prefers doing things alone

    • Not interested in sexual relations

    • Doesn’t enjoy activities

    • Few if any friends or acquaintances

    • Doesn’t care what others think of them

    • Emotionally constricted

  • Exclusions: Not a result of schizophrenia, depression with psychotic features, bipolar disorder with psychotic features, autism spectrum disorder, or another psychotic disorder or medical condition

• ICD-10: Schizoid Personality Disorder

  • Symptoms: Retreats from close contact or emotional encounters, prefers fantasy, isolation, and introspection, difficulty expressing emotions, difficulty experiencing pleasure

  • Exclusions: Not a result of Asperger syndrome, delusional disorder, schizophrenia, or schizotypal disorder

Table 19-4: Schizotypal Personality Disorder: Specific Symptoms

• DSM-5: Schizotypal Personality Disorder

  • Symptoms: Social difficulties and perceptual disturbances (≥5)

    • Ideas of reference

    • Magical/strange thinking

    • Odd perceptions

    • Odd speech/thoughts

    • Odd affect

    • Odd behavior

    • Suspicious or persecutory thoughts

    • Few if any friends or acquaintances

    • Socially anxious (because of thoughts)

  • Exclusions: Not a result of schizophrenia, depression with psychotic features, bipolar disorder with psychotic features, autism spectrum disorder, or another psychotic disorder

• ICD-10: Schizotypal Disorder (classified under the psychotic disorders in ICD-10, not personality disorders)

  • Symptoms: Eccentric behavior, abnormal thinking, cold affect, odd behavior, social isolation, perceptual disturbances (quasi-psychotic episodes, illusions, delusional-like ideas, hallucinations)

  • Starts suddenly, course is more like that for personality disorders

  • Exclusions: Not a result of schizophrenia or other psychiatric disorders, Asperger syndrome, or schizoid personality disorder

Schizotypal Personality Disorder in Depth

• Pervasive discomfort with and inability to maintain close relationships; eccentric behavior.

• Peculiarities of thinking, behavior, and appearance.

• History-taking may be difficult due to unusual communication.

• Speech may be peculiar, with meaning only to them, needing interpretation.

• May be superstitious, claim clairvoyance, or believe in special powers.

• Inner world may contain vivid imaginary relationships, child-like fears, fantasies, and perceptual illusions.

• Poor interpersonal relationships lead to isolation; may decompensate under stress with brief psychotic symptoms.

• Severe cases may exhibit anhedonia and severe depression.

Antisocial Personality Disorder: Cluster B

• Hallmarks are pervasive disrespect for and infringement on the rights of others.

• Must be 18 years of age or older, pattern of behavior since age 15, and evidence of conduct disorder before age 15 (violating rights of others or social rules).

Table 19-5: Antisocial Personality Disorder: Specific Symptoms

• DSM-5: Antisocial Personality Disorder

  • ≥age 18

  • Began by age 15, Conduct disorder before age 15 (diagnosed or evidence for) (≥3)

    • Disregards legal and social rules/norms

    • Lies

    • Impulsive

    • Irritable or aggressive

    • Neglects safety (self/others)

    • Irresponsible

    • No remorse

  • Exclusions: Not a result of schizophrenia or bipolar disorder

• ICD-10: Dissocial Personality Disorder

  • Disregards social norms, unconcerned by others’ feelings, easily frustrated/distressed, easily becomes aggressive, blames others

  • Exclusions: Not a result of conduct disorders or emotionally unstable personality disorder

Antisocial Personality Disorder in Depth

• Patients can seem normal, charming, and ingratiating, but histories reveal disordered life functioning.

• Lying, truancy, running away, thefts, fights, substance abuse, and illegal activities begin in childhood.

• Often impressive due to colorful, seductive personalities, but manipulative and demanding.

• Heightened sense of reality testing and excellent verbal intelligence.

• Representative of "con men," manipulative, and can talk others into schemes.

• Schemes may lead to financial ruin or social embarrassment.

• Do not tell the truth, cannot be trusted, and lack a conscience; no remorse for actions.

• Can fool even experienced clinicians, but stress interviews may reveal pathology.

• Diagnostic workup should include a thorough neurologic examination.

• Abnormal EEG results and soft neurologic signs may support the clinical impression.

Borderline Personality Disorder

• Patients almost always appear to be in a state of crisis.

• Frequent mood swings; argumentative, depressed, or feelingless.

• Short-lived psychotic episodes rather than full-blown breaks.

• Highly unpredictable behavior with achievements below abilities.

• Repetitive self-destructive acts such as wrist slashing to elicit help, express anger, or numb affect.

Table 19-6: Borderline Personality Disorder: Specific Symptoms

• DSM-5: Borderline Personality Disorder

  • Symptoms: Conflict/impulsivity (≥5)

    • Avoids abandonment

    • Intense, unstable relations marked by splitting

    • Unstable self-image

    • Self-harm, other impulsive behaviors

    • Suicidal ideation or behavior

    • Labile affect

    • Feeling empty inside

    • Poor anger management

    • Paranoia/dissociation, usually due to stress

• ICD-10: Emotionally Unstable Personality Disorder

  • Impulsiveness, labile mood, outbursts, interpersonal conflict. Two subtypes: (1) Impulsive type (emotional lability and lack of impulse control) (2) Borderline type (poor self-image, self-worth, relationships, with associated self-harm)

  • Exclusions: Not a result of dissocial personality disorder

Borderline Personality Disorder in Depth. Continued

• Feel both dependent and hostile, leading to tumultuous relationships.

• Cannot tolerate being alone, frantic search for companionship, promiscuity.

• Complain about chronic emptiness, boredom, and lack of identity (identity diffusion).

• Distort relationships by considering each person all good or all bad (splitting).

• Idealize the good person and devalue the bad person, with frequent shifts of allegiance.

• Concepts of panphobia, pananxiety, panambivalence, and chaotic sexuality are used to delineate these patients’ characteristics.

• Projective identification is a defense mechanism where the patient projects intolerable aspects onto another person, causing them to play the projected role.

Histrionic Personality Disorder

• High degree of attention-seeking behavior

• Tendency to exaggerate thoughts and feelings

• Display temper tantrums, tears, and accusations when not the center of attention

Table 19-7: Histrionic Personality Disorder: Specific Symptoms

• DSM-5: Histrionic Personality Disorder

  • Symptoms: Needing attention, very emotional (≥5)

    • Uncomfortable when not the center of attention

    • Flirtatious, provocatively sexual

    • Emotionally labile

    • Physically provocative or flamboyant

    • Speech is vague

    • Speech is exaggerated/dramatic

    • Suggestible

    • Overestimates the intimacy of relationships

• ICD-10: Histrionic Personality Disorder

  • Affect is shallow/labile, self-dramatization, speech and emotions are exaggerated, suggestible, egocentric, not concerned with others, attention-seeking, easily offended or hurt

Histrionic Personality Disorder in Depth. Continued

• Seductive behavior is typical in both sexes.

• Sexual fantasies are common, but patients may be coy or flirtatious rather than sexually aggressive.

• May have psychosexual dysfunction, such as anorgasmia.

• Relationships tend to be superficial; can be vain, self-absorbed, and fickle.

• Deep dependence needs make them overly trusting and gullible.

• Repression and dissociation are major defenses.

• Unaware of true feelings and cannot explain their motivations.

• Reality testing quickly becomes impaired under stress.

• Generally cooperative in interviews, eager to give a detailed history with dramatic punctuation; frequent slips of the tongue.

• Normal cognitive examination results, but may show a lack of perseverance.

Narcissistic Personality Disorder

• Grandiose sense of self-importance; considers themselves special and expects special treatment.

• Sense of entitlement is striking.

• Handles criticism poorly; may become enraged or utterly indifferent.

• Frequently ambitious to achieve fame and fortune.

• Relationships are tenuous; refusal to obey conventional rules of behavior.

• Interpersonal exploitativeness is commonplace.

• Cannot show empathy; feign sympathy for selfish ends.

• Susceptible to depression due to fragile self-esteem.

Table 19-8: Narcissistic Personality Disorder: Specific Symptoms

• DSM-5: Narcissistic Personality Disorder

  • Symptoms: Self-important, lacking empathy for others (≥5):

    • Grandiose

    • Preoccupied with fantasies about success

    • Feeling special/unique

    • Needing others to admire them for validation

    • Expecting special treatment

    • Exploiting others

    • Lacking empathy

    • Jealous of others’ success, assuming others are jealous of them

    • Arrogance

• ICD-10: No description; listed as an “other specific personality disorder.”

Avoidant Personality Disorder: Cluster C

• Hypersensitivity to rejection by others is the central feature.

• Timidity is the primary personality trait displayed.

• Desire warmth and security, but justify avoidance by fear of rejection.

• Express uncertainty, lack self-confidence, and speak self-effacingly.

• Hypervigilant about rejection; afraid to speak up or make requests.

• Misinterpret others’ comments as derogatory or ridiculing.

• Withdraw from others and feel hurt by refusal of requests.

Table 19-9: Avoidant Personality Disorder: Specific Symptoms

• DSM-5: Avoidant Personality Disorder

  • Symptoms: Hypersensitive, lacking confidence (

    • ≥4)

    • Avoids others

    • Fears being disliked

    • Avoids relationships for fear of shame

    • Fears rejection/criticism

    • Inhibited in relationships

    • Avoids novelty for fear of embarrassment

• ICD-10: Anxious [Avoidant] Personality Disorder

  • Fearful, insecure, feels inferior to others, craves acceptance, fears or is sensitive to rejection, relationships are superficial, avoids activities/situations perceived as risky

Avoidant Personality Disorder in Depth. Continued

• Take jobs on the sidelines, rarely attain advancement or authority, seem shy and eager to please.

• Unwilling to enter relationships unless with strong guarantee of acceptance.

• Often have no close friends or confidants.

• Anxious about talking with an interviewer; nervous and tense manner depends on interviewer's liking of them.

• Vulnerable to interviewer's comments and suggestions; may see clarification as criticism.

Dependent Personality Disorder

• Pervasive pattern of dependent and submissive behavior.

• Cannot make decisions without advice and encouragement.

• Avoid positions of responsibility and become anxious if asked to lead.

• Prefer to be submissive.

• Difficult to persevere at tasks alone, but easier when performing for someone else.

Table 19-10: Dependent Personality Disorder: Specific Symptoms

• DSM-5: Dependent Personality Disorder

  • Symptoms: Fears separation, needs others to care for them (≥5)

    • Cannot make decisions alone

    • Avoids taking on responsibility for important things

    • Relies on others and needs them for validation

    • Cannot make decisions without another’s approval

    • Fears abandonment

    • Cannot disagree with others for fear they will disapprove of them

    • Lacks confidence, cannot initiate new things

    • Seeks acceptance of others

    • Fears being alone/independence

    • When relationship ends, quickly seeks new one

• ICD-10: Dependent Personality Disorder

  • Fears having to take care of self, fears helplessness/incompetence, passive, lets another make decisions, avoids responsibility

Dependent Personality Disorder in Depth. Continued

• Seek out others on whom they can depend, and relationships are distorted.

• In a shared psychotic disorder (folie à deux), the submissive partner takes on the delusional system of the more aggressive partner.

• Pessimism, self-doubt, passivity, and fears of expressing sexual and aggressive feelings typify behavior.

• Abusive spouses may be tolerated to avoid disturbing attachment.

• Appear compliant and cooperative in interviews; seek guidance.

Obsessive-Compulsive Personality Disorder

• Preoccupied with rules, regulations, orderliness, neatness, details, and perfection.

• Constriction of the entire personality.

• Insist rules be followed rigidly; cannot tolerate infractions.

• Lack flexibility and are intolerant.

• Capable of prolonged work if routinized and does not require unadaptable changes.

Table 19-11: Obsessive-Compulsive Personality Disorder: Specific Symptoms

• DSM-5: Obsessive-Compulsive Personality Disorder

  • Symptoms: Orderliness, perfectionism, self-control (≥4)

    • Attention to rules/details/order

    • Cannot complete things because of needing it to be perfect

    • Relationships neglected because of devotion to work

    • Inflexible thinking

    • Cannot part with things

    • Cannot delegate

    • Stingy

    • Stubborn/rigid

• ICD-10: Anankastic Personality Disorder

  • Plagued by doubt, perfectionism, checking, attention to detail, stubborn/rigid, overly cautious, unwanted thoughts or impulses (but not to the point of obsessions or compulsions)

  • Exclusions (not result of Obsessive- compulsive disorder)

Obsessive-Compulsive Personality Disorder in Depth. Continued

• Limited interpersonal skills; formal, severe, and often lack a sense of humor.

• Alienate others, unable to compromise, and insist others submit.

• Eager to please those they see as powerful and carry out their wishes in an authoritarian manner.

• Indecisive and ruminate about decisions due to fear of mistakes.

• Stable marriage and occupational adequacy are common, but have few friends.

• Anxiety is bound up in rituals they impose on their lives and others'.

• May have a stiff, formal, and rigid demeanor.

• Affect is constricted, lacking spontaneity, and mood is serious.

• Anxious about not being in control.

• Give unusually detailed answers.

• Use defense mechanisms: rationalization, isolation, intellectualization, reaction formation, and undoing.

Personality Change due to Another Medical Condition

• Change in personality from previous patterns or exacerbation of previous characteristics.

• Impaired control of emotions and impulses is a cardinal feature.

• Emotions are labile and shallow, although euphoria or apathy may be prominent.

• Euphoria may mimic hypomania, but genuine elation is absent.

• Frontal lobe syndrome consists of indifference and apathy.

• Temper outbursts, especially after alcohol, can result in violent behavior.

• Diminished foresight; cannot anticipate consequences of actions.

• Temporal lobe epilepsy shows humorlessness, hypergraphia, hyperreligiosity, and aggressiveness during seizures.

Personality Change due to Another Medical Condition. Continued

• Clear sensorium; mild disorders of cognitive function may coexist.

• May be inattentive, accounting for recent memory disorders, but likely to recall information with prodding.

• Suspect in patients with marked changes in behavior or personality involving emotional lability and impaired impulse control, no history of mental disorder, and abrupt personality changes.

Other Specified and Unspecified Personality Disorders

• Other Specified Personality Disorder: Meets general criteria but doesn't fit any specific category. Examples: passive-aggressive or depressive personality.

• Unspecified Personality Disorder: Used when we choose not to indicate why the patient doesn't meet specific criteria or lack sufficient information for a diagnosis.

Differential Diagnosis

• Features of various personality disorders may occur during episodes of another mental disorder.

• Some personality disorders within a cluster may share common features.

• Paranoid Personality Disorder: Differentiated from delusional disorder by the absence of fixed delusions and from schizophrenia by the lack of hallucinations or formal thought disorder. Distinguished from borderline PD by rarely capable of overly involved, tumultuous relationships with others. Patients with paranoia lack the long history of antisocial behavior of persons with antisocial character. Persons with schizoid personality disorder are withdrawn and aloof and do not have paranoid ideation.

• Schizoid Personality Disorder: Differentiated from schizophrenia, delusional disorder, and affective disorder with psychotic features based on periods with positive psychotic symptoms. The former exhibits more social engagement, history of aggressive verbal behavior. Patients with obsessive-compulsive and avoidant personality disorders experience loneliness as dysphoric, possess a more abundant history of past object relations, and do not engage as much in autistic reverie. The chief distinction between a patient with schizotypal personality disorder is that the patient who is schizotypal is more similar to a patient with schizophrenia in oddities of perception, thought, behavior, and communication. Patients with avoidant personality disorder are isolated but do wish to participate in activities, a characteristic absent in those with schizoid personality disorder. Schizoid personality disorder is distinguished from autism spectrum disorder by more severely impaired social interactions and stereotypical behaviors and interests with autism.

• Schizotypal Personality Disorder: Distinguished from schizoid and avoidant by oddities in behavior, thinking, perception, and communication. If psychotic symptoms do appear, they are brief and fragmentary. Patients with paranoid personality disorder are suspicious but lack the odd behavior of patients with schizotypal personality disorder.

• Antisocial Personality Disorder: Differentiated from mere illegal behavior by involving many areas of a person's life. The diagnosis of antisocial personality disorder is not warranted when intellectual disability, schizophrenia, or mania can explain the symptoms. Those with borderline personality who commit crimes tend to display high novelty seeking and high harm avoidance behaviors, whereas those with antisocial personality tend to display high novelty seeking and low harm avoidance behaviors.

• Borderline Personality Disorder: Differentiated from major depressive disorder, bipolar disorder based on symptoms not typically present in mood disorders. It differs from identity problems, which are typically limited to a developmental stage.

• Histrionic Personality Disorder: Distinguished from borderline personality disorder in that suicide attempts, identity diffusion, and brief psychotic episodes are more likely. Somatic symptom disorder may occur in conjunction with histrionic personality disorder.

• Narcissistic Personality Disorder: Differentiated from borderline personality disorder by the level of anxiety. Patients with antisocial personality disorder have a history of impulsive behavior and patients with histrionic personality disorder show exhibitionism.

• Avoidant Personality Disorder: They may co-occur; however, in social anxiety disorder, specific situations, rather than interpersonal contact in general, are avoided. Patients with schizoid and schizotypal personality disorders may be indistinguishable from those with avoidant personality disorder. Those with dependent personality disorder are presumed to have a greater fear of being abandoned or unloved than those with avoidant personality disorder, but the clinical picture may be indistinguishable.

• Dependent Personality Disorder: Those with histrionic and borderline personality disorders, patients tend to have a high level of overt anxiety, panic, or depression, respectively.

• Obsessive-Compulsive Personality Disorder: Distinguishing involves whether traits are persistent and ego-syntonic.

Personality Change Resulting from a Separate Medical Condition

• The most critical factor is the origin of the changes and the relationship to the causative factor and resulting outcome. We must consider that dementia involves global deterioration.

Comorbidity

• Personality disorders are frequently comorbid with other clinical syndromes and are predisposing factors for other psychiatric disorders and symptoms.

• Paranoid Personality Disorder: Increased risk for depression, OCD, agoraphobia, and substance use disorders. Commonly co-occurs with schizotypal, schizoid, narcissistic, avoidant, and borderline.

• Schizoid Personality Disorder: Sometimes appears as a premorbid antecedent of delusional disorder, schizophrenia, or major depression.

• Schizotypal Personality Disorder: Commonly co-occurs with schizoid, paranoid, avoidant, and borderline.

• Antisocial Personality Disorder: Increased risk for impulse control disorders, major depression, substance use disorders, pathologic gambling, anxiety disorders, and somatic symptom disorder. Narcissistic, borderline, and histrionic are the most common co-occurring personality disorders.

• Borderline Personality Disorder: Increased risk for major depression, substance use disorders, eating disorders, PTSD, ADHD, and somatic symptom disorder. Most other personality disorders can co-occur with borderline.

• Histrionic Personality Disorder: Increased risk for major depression, somatic symptom disorder, and conversion disorder. Narcissistic, borderline, antisocial, and dependent are the most common co-occurring personality disorders.

• Narcissistic Personality Disorder: Increased risk for major depression and substance use disorders. Borderline, antisocial, histrionic, and paranoid are the most common co-occurring personality disorders.

• Avoidant Personality Disorder: The most common co-occurring personality disorders are schizotypal, schizoid, paranoid, dependent, and borderline. Somatic symptom disorder may be comorbid. The most common co-occurring personality disorders are schizotypal, schizoid, paranoid, dependent, and borderline.

• Dependent Personality Disorder: Somatic symptom disorder may be comorbid. The personality disorders that co-occur most commonly are histrionic, avoidant, and borderline.

• Obsessive-Compulsive Personality Disorder: Increased risk for major depression and anxiety disorder.

Course and Prognosis

• Personality disorders are chronic, interfering with treatment outcomes.

• Chronic impairments in work and relationships; often less educated, drug-dependent, single, unemployed, and have marital difficulties.

• Consume a large portion of community services.

Paranoid Personality Disorder

• No adequate, systematic long-term studies.

• May be lifelong or a harbinger of schizophrenia.

• Traits may give way to reaction formation, appropriate concern with morality, and altruistic concerns as they mature or as stress diminishes.

• Lifelong problems working and living with others are common.

• Occupational and marital problems are common.

• Complications may include brief reactive psychosis, particularly in response to stress.

• Treatment of choice is psychotherapy; therapists should be straightforward, honest, and avoid overzealous interpretation.

• Individual psychotherapy requires a professional and not overly warm style.

• Patients generally do not do well in group psychotherapy, although it can be useful for improving social skills.

• Behavior therapy can be difficult for patients to tolerate due to intrusiveness.

• Therapists should realistically handle delusional accusations gently without humiliating patients.

• Pharmacotherapy should be tailored to the individual patient and guided by target symptoms (e.g., low-dose novel antipsychotics for psychotic symptoms or anticonvulsants for irritability).

Schizoid Personality Disorder

• Onset usually occurs in early childhood or adolescence.

• Long-lasting but not necessarily lifelong.

• Proportion of patients who incur schizophrenia is unknown.

• Frequently have severe problems in social relations.

• Occupational problems develop when interpersonal involvement is required; solitary work may favorably affect overall performance.

• Complications may include very brief reactive psychosis, particularly in response to stress.

• Treatment is similar to that of paranoid personality disorder.

• Patients may become devoted if distant patients as trust develops.

• In group therapy settings, patients may be silent for long periods but do become involved; protect against aggressive attack by group members.

• Pharmacotherapy: Limited evidence exists; psychotropics may be used to target specific symptoms, such as social and emotional detachment.

Schizotypal Personality Disorder

• Can be the premorbid personality of the patient with schizophrenia.

• Some maintain a stable schizotypal personality throughout their lives and marry and work, despite their oddities.

• Complications may include transient psychotic episodes, particularly in response to stress.

• Symptoms sometimes become so significant that individuals meet the criteria for schizophreniform disorder, delusional disorder, and brief psychotic disorder.

• One long-term study reported that 10 percent of those with schizotypal personality disorder eventually committed suicide.

• Treatment principles do not differ from those of schizoid personality disorder, but clinicians must deal sensitively with patients’ odd beliefs.

• Pharmacotherapy: Antipsychotic medication may be useful for dealing with ideas of reference, illusions, and other symptoms; antidepressants are useful when a depressive component is present.

Antisocial Personality Disorder

• When it develops, it runs an unremitting course, with the height of antisocial behavior usually occurring in late adolescence.

• The prognosis varies; some reports indicate that symptoms decrease as a person ages.

• Even after the severe antisocial behavior “burns out,” people diagnosed with antisocial personality disorder usually continue to be irritable, impulsive, and detached.

• Complications may include dysphoria, tension, low tolerance for boredom, depressed mood, and premature, violent death.

• Limited evidence to guide the use of psychotherapeutic approaches.

• Individuals seem to respond better to contingency management and other reward-based interventions than they do to cognitive behavioral therapy.

• Pharmacotherapy can deal with incapacitating symptoms such as anxiety, rage, and depression, but medications should be used judiciously because patients often misuse substances.

• Anticonvulsants may be used to treat aggressive behaviors, especially if there are abnormal waveforms on an EEG; β-adrenergic receptor antagonists, lithium, and antipsychotics may also reduce aggression.

Borderline Personality Disorder

• Variable course, most commonly follows a pattern of chronic instability in early adulthood, with episodes of severe affective and impulsive dyscontrol.

• Impairment and the risk of suicide are highest in the young adult years and gradually wane with advancing age.

• In the fourth and fifth decades, these individuals tend to attain greater stability in their relationships and functioning.

• Impairment typically involves frequent job losses, interrupted education, and broken marriages.

• Complications may include psychotic-like symptoms (hallucinations, body image distortions, hypnagogic phenomena, ideas of reference) in response to stress, as well as premature death or physical handicaps from suicide and suicidal gestures, failed suicide, and self-injurious behavior.

• Psychotherapy is an area of intensive investigation and has been the treatment of choice, most successful in combination with pharmacotherapy.

• Patients regress quickly, act out their impulses, and show labile or fixed negative or positive transferences, which are difficult to analyze.

• Projective identification may also cause countertransference problems.

• The splitting defense mechanism causes patients to love and hate therapists and others in the environment alternately.

• A reality-oriented approach is more effective than in-depth interpretations of the unconscious.

• Behavior therapy helps patients manage their impulses and angry outbursts and to reduce their sensitivity to criticism and rejection.

• Social skills training, especially with videotape playback, helps patients to see how their actions affect others and thereby improve their interpersonal behavior.

• Patients often do well in a hospital setting in which they receive intensive psychotherapy on both an individual and a group basis.

• Dialectical behavior therapy (DBT) has received the most empirical support.

• Mentalization-based therapy (MBT) helps patients build relationship skills as they learn to regulate their thoughts and feelings better.

• Transference-focused psychotherapy (TFP) is a modified form of psychodynamic psychotherapy.

• Pharmacotherapy is useful to deal with specific personality features that interfere with patients’ overall functioning; antipsychotics may help control anger, hostility, and brief psychotic episodes; antidepressants improve depressed mood; benzodiazepines should be avoided due to the risk of abuse; anticonvulsants may improve functioning; serotonergic agents have been helpful in some cases.

Histrionic Personality Disorder

• With age, persons show fewer symptoms, but because they lack the energy of earlier years, the difference in the number of symptoms may be more apparent than real.

• Persons are sensation seekers and may get into trouble with the law, abuse substances, and act promiscuously.

• Complications may include frequent suicidal gestures and threats to coerce better caregiving; interpersonal relations that are unstable, shallow, and generally ungratifying; and frequent marital problems secondary to the tendency to neglect long-term relationships for the excitement of new relationships.

• Patients are often unaware of their real feelings; clarification of their inner feelings is a necessary therapeutic process.

• Psychoanalytically oriented psychotherapy is probably the treatment of choice.

• Pharmacotherapy can be adjunctive to target symptoms (e.g., antidepressants for depression and somatic complaints, antianxiety agents for anxiety, and antipsychotics for derealization and illusions).

Narcissistic Personality Disorder

• Chronic and difficult to treat.

• Patients must continuously deal with blows to their narcissism resulting from their behavior or life experience.

• Patients handle aging poorly; they value beauty, strength, and youthful attributes, to which they cling inappropriately.

• They may be more vulnerable to midlife crises than are other groups.

• Symptoms tend to diminish after the age of 40 years, when pessimism usually develops.

• Impairment is frequently severe and includes marital problems and interpersonal relationships in general.

• Complications may include social withdrawal, depressed mood, and dysthymic or major depressive disorder in reaction to criticism or failure.

• Treatment is challenging because patients must renounce their narcissism to make progress.

• Some experts have advocated using psychoanalytic approaches to effect change, but much research is required to validate the diagnosis and to determine the best treatment.

• Some clinicians advocate group therapy so patients can learn how to share with others and develop an empathic response to others.

• Lithium can help patients whose clinical picture includes mood swings.

• Antidepressants, especially serotonergic drugs, may also be of use because patients tolerate rejection poorly and are susceptible to depression.

Personality Change Due to Another Medical Condition

• Course and prognosis depend on its cause.

• If resulting from structural damage to the brain, the disorder tends to persist.

• In cases of head trauma or vascular accident, the disorder may follow a period of coma and delirium, and it may be permanent.

• The personality change can evolve into dementia in cases of brain tumors, multiple sclerosis, and Huntington disease.

• Personality changes produced by chronic intoxication, medical illness, or drug therapy may reverse with appropriate treatment of the cause.

• Some patients require custodial care or at least close supervision to meet their basic needs, avoid repeated conflicts with the law, and protect themselves and their families from the hostility of others and destitution resulting from impulsive and ill-considered actions.

• Management involves treatment of the underlying medical condition when possible.

• Psychopharmacological treatment of specific symptoms may help in some cases, such as antidepressants for depression or anticonvulsants for irritability, aggression, or impulsivity.

• Patients with severe cognitive impairment or weakened behavioral controls may need counseling to help avoid difficulties at work or to prevent social embarrassment.

• Patients’ families need emotional support and concrete advice on how to help minimize patients’ undesirable conduct.

• Patients should avoid alcohol, and social engagements should be curtailed when patients tend to act in a grossly offensive manner.

Treatment Approach for Personality Disorders

• Individuals often do not recognize they are ill and seldom seek help unless others are insistent.

• Maladaptive behaviors create marital, family, and career problems, or when other disorders (e.g., anxiety, depression, substance use) or somatic symptoms complicate their clinical picture.

• Patients generally require a multifaceted treatment plan that often combines psychotherapy and pharmacotherapy.

• Psychotherapy is the primary treatment, promoting character maturation and better adaptive solutions.

• Pharmacotherapy achieves a relatively prompt control of affect and behavior in the early stages of treatment, setting a more suitable platform for psychotherapy.

• Medications can target specific symptoms of their disorders to relieve subjective distress, risky or self-destructive behaviors, or conflict with others, thereby preparing them for or allowing them to participate in psychotherapeutic approaches.

• Target symptoms should be identified to choose appropriate agents.

Epidemiology of Personality Disorders

• Common, occurring in 10 to 20 percent of the general population and approximately 50 percent of all psychiatric patients.

• Paranoid Personality Disorder: 0.5 to 4.4 percent of the general population; more common in men; higher incidence among relatives of patients with schizophrenia or delusional disorder, persecutory type.

• Schizoid Personality Disorder: 3.1 to 4.9 percent of the general population; more common in men; increased prevalence among relatives of individuals with schizophrenia or schizotypal personality disorder.

• Schizotypal Personality Disorder: 3.9 to 4.6 percent of the population; sex ratio is unknown, higher association of cases exists among the biologic relatives of patients with schizophrenia.

• Antisocial Personality Disorder: 3 percent for males and 1 percent for females in the general population; frequent among the first-degree biologic relatives of individuals with this disorder; adoption studies have shown that both genetic and environmental factors contribute to the risk of this disorder.

• Borderline Personality Disorder: About 2 percent of the general population, more common in women than in men, five times more common among relatives of individuals with the same disorder, increased prevalence of mood disorders, antisocial personality disorder, and substance use disorder is common in first-degree relatives.

• Histrionic Personality Disorder: About 2 percent of the general population; some evidence to suggest that this disorder might be equally frequent among men and women; tends to run in families.

• Narcissistic Personality Disorder: Ranges from less than 1 percent in the general population to 2 to 16 percent in the clinical population; more common in men.

• Avoidant Personality Disorder: About 0.5 to 2 percent of the general population; occurs in men and women equally.

• Dependent Personality Disorder: Equally common in women and men; estimated prevalence of 0.5 to 0.6 percent.

• Obsessive-Compulsive Personality Disorder: Estimated prevalence ranging from 2 to 8 percent of the general population; more common in men than in women; some studies have demonstrated a familial aggregation of this disorder.

Etiology of Personality Disorders

• Genetic Factors: Concordance for personality disorders among monozygotic twins was several times that among dizygotic twins; monozygotic twins reared apart are about as similar as monozygotic twins reared together; Cluster A personality disorders are more common in the biologic relatives of patients with schizophrenia; antisocial personality disorder is associated with alcohol use disorders; depression is common in the family backgrounds of patients with borderline personality disorder; there is a strong association between histrionic personality disorder and somatic symptom disorder; Cluster C personality disorders may also have a genetic base; patients with avoidant personality disorder often have high anxiety levels; obsessive- compulsive traits are more common in monozygotic twins than in dizygotic twins.
  Hormones: Persons who exhibit impulsive traits also often show high levels of testosterone, 17-estradiol, and estrone; DST results are abnormal in some patients with borderline personality disorder who also have depressive symptoms.

• Low platelet monoamine oxidase (MAO) levels are associated with activity and sociability and occur in some patients with schizotypal disorders.

• Smooth pursuit eye movements are saccadic in persons who are introverted, who have low self- esteem and tend to withdraw, and who have schizotypal personality disorder.

• Studies of personality traits and the dopaminergic and serotonergic systems indicate an arousal-activating function for these neurotransmitters; levels of 5-hydroxyindoleacetic acid (5-HIAA), a metabolite of serotonin, are low in persons who attempt suicide and in patients who are impulsive and aggressive; serotonin reduces depression, impulsiveness, and rumination and can produce a sense of general well- being; increased dopamine concentrations in the central nervous system can induce euphoria.

Medical Conditions Associated with Personality Change

• Head trauma

• Cerebrovascular diseases

• Cerebral tumors

• Epilepsy

• Huntington disease

• Multiple sclerosis

• Endocrine disorders

• Heavy metal poisoning

• Neurosyphilis

• Acquired immune deficiency syndrome (AIDS)

• Changes in electrical conductance on the electroencephalogram (EEG) occur in some patients with personality disorders, most commonly antisocial and borderline types; these changes appear as slow-wave activity on EEGs.

• Structural damage to the brain is usually the cause of personality change due to another medical condition.

Psychoanalytic Factors

• Sigmund Freud suggested that personality traits are related to a fixation at one psychosexual stage of development.

• Wilhelm Reich coined the term character armor to describe individuals’ characteristic defensive styles for protecting themselves from internal impulses and interpersonal anxiety in significant relationships.

• Internal object relations: During development, a person develops particular patterns of the self in relation to others through introjection and identification.

Defense Mechanisms

• Psychiatrists must appreciate patients’ underlying defenses, the unconscious mental processes that the ego uses to resolve conflicts among the four lodestars of the inner life: instinct, reality, important persons, and conscience.

• Abandoning a defense increases conscious awareness of anxiety and depression.

• Each patient uses several defenses.

• Fantasy: Creating imaginary lives, especially imaginary friends; therapists should maintain a quiet, reassuring, and considerate interest.

• Dissociation: Separating a mental or behavioral process from the rest of the person’s psychic activity; patients with borderline personality disorder may demonstrate dissociation during times of increased stress.

• Isolation: Separating an idea or memory from its attached emotion; characteristic of obsessive-compulsive personalities; patients may show intensified self-restraint, overly formal social behavior, and obstinacy.

• Projection: Attributing unacknowledged feelings to others; clinicians should frankly acknowledge even minor mistakes and should discuss the possibility of future difficulties; counterprojection is especially helpful.

• Splitting: Dividing persons toward whom they are, or have been, ambivalent into good and bad; staff members should anticipate the process, discuss it at staff meetings, and gently confront the patient with the fact that no one is all good or all bad.

• Acting out: Directly expressing unconscious wishes or conflicts through action; clinicians faced with acting out must recognize that the patient has lost control.

• Projective identification: Involves three steps: the patient projects an aspect of the self onto someone else, the projector then tries to coerce the other person into identifying what they projected, and finally, the recipient of the projection and the projector feel a sense of oneness or union.

Temperament

• Temperament traits of harm avoidance, novelty seeking, reward dependence, and persistence are heritable differences underlying one’s automatic response to danger, novelty, social approval, and intermittent reward, respectively.

• Each of the four major dimensions is a normally distributed quantitative trait, moderately heritable, observable early in childhood, relatively stable in time, and moderately predictive of adolescent and adult behavior.

• The four dimensions are genetically homogeneous and independently inherited from one another.

• Temperament traits are similar to crystallized intelligence.

• Harm Avoidance: Involves a heritable bias in the inhibition of behavior in response to signals of punishment and frustrative non-reward; high harm avoidance is a fear of uncertainty, social inhibition, shyness, passive avoidance of problems/danger, rapid fatigability, and pessimistic worry; persons given serotonin drugs show decreased harm avoidance behavior.

• Novelty Seeking: Reflects a heritable bias in the initiation or activation of appetitive approach in response to novelty, increased reuptake of dopamine at presynaptic terminals.

• Reward Dependence: Reflects the maintenance of behavior in response to cues of social reward; the “love hormone” oxytocin’s plasma level is positively correlated (r = 0.5) with individual differences in reward dependence.

• Persistence: Reflects the maintenance of behavior despite frustration, fatigue, and intermittent reinforcement; individual differences in persistence have been strongly correlated (r = 0.8) with responses measured by fMRI in a circuit involving the ventral striatum, orbitofrontal cortex/rostral insula, and dorsal anterior cingulate cortex.