Personality Disorders

General Overview of Personality Disorders

• Definition: A manifestation of extreme personality traits that are inflexible and maladaptive, causing either distress or impaired functioning.

• Interpersonal Impact: Individuals struggle significantly with interpersonal relationships and dealing with others.

• Perspective: They typically possess a narrow view of the world and find participation in social activities difficult.

DSM-5 Diagnostic Criteria for Personality Disorders

To diagnose a personality disorder, the following essential features and criteria must be present:

• Essential Features:

  • A: Impairments in functioning.

  • B: The presence of pathological personality traits.

• Criterion 1: Functional Impairments:

  • Significant impairments in Self (Identity or self-direction) and Interpersonal (Empathy or intimacy) functioning.

  • Clinical Question: "Is this person struggling with who they are and how they relate to others?"

• Criterion 2: Pathological Domains: Presence of one or more pathological personality trait domains.

• Criterion 3: Stability: The impairments are stable across time (early adulthood onset) and consistent across various situations.

• Criterion 4: Exclusion: The impairments are not solely attributable to a substance or a general medical condition.

Pathological Personality Trait Domains

Pathological traits manifest across one or more of these five specific domains:

• Negative Affectivity: Characterized by emotional instability and anxiety.

• Detachment: Characterized by withdrawal and the avoidance of relationships.

• Antagonism: Characterized by manipulation, grandiosity, and callousness.

• Disinhibition: Characterized by impulsivity and irresponsibility.

• Psychoticism: Characterized by unusual perceptions and eccentric behavior.

Epidemiology

• General Prevalence: Up to $10\%$ of adults in the United States.

• Age Requirements: Diagnosis is not made until the patient is at least $18\,y/o$.

• Sex Ratios by Cluster:

  • Cluster A: Schizoid is more common in Males than Females ($M > F$).

  • Cluster B: Antisocial and Narcissistic are more common in Males than Females ($M > F$). Borderline PD affects women $3 \times$ more frequently than men.

  • Cluster C: Obsessive-Compulsive PD is more common in Males than Females ($M > F$).

Clinical Workup and Treatment Modalities

• Laboratory Evaluation:

  • Toxicology Screen: Used to rule out other causes for behavior.

  • HIV Screen and STI Panel: Indicated due to poor impulse control often associated with certain personality disorders.

• Screening Tools: The Minnesota Multiphasic Personality Inventory (MMPI).

• Treatment Options:

  • Therapies: Cognitive Behavioral Therapy (CBT), Dialectical Behavior Therapy (DBT), and Group Therapy.

  • Medication: Not curative. Most useful for Borderline PD. Notably, SSRIs are not as effective here as they are in Major Depressive Disorder (MDD).

Disposition and Prognosis

• Hospitalization: Necessary for those at risk of self-harm.

• Related Conditions and Risks: Suicide, substance abuse, accidents, depression, and homicide (specifically associated with Paranoid and Antisocial PD).

• Prognosis: Generally a lifelong condition.

  • Cluster A and B: Intensity of symptoms tends to decrease in middle age.

  • Cluster B specific: High risk for substance use, impulse control issues, and suicidal threats.

  • Cluster C: Symptoms tend to exaggerate in later life.

Cluster A: The "Weird" Personalities (Odd and Eccentric)

Paranoid Personality Disorder

• Core Characteristic: A pervasive distrust and suspicion of others, interpreting motives as malevolent.

• DSM-5 Criteria (Needs 4 or more):

  1. Suspects without sufficient basis that others are exploiting or deceiving them.

  2. Preoccupied with unjustified doubts regarding the loyalty or trustworthiness of friends.

  3. Reluctant to confide in others due to fear of malicious use of information.

  4. Reads hidden threatening meanings into benign remarks.

  5. Persistently bears grudges.

  6. Perceives attacks on character not apparent to others; quick to react angrily.

  7. Recurrent, unjustified suspicions regarding the fidelity of a spouse or partner.

• Exclusion: Must not occur exclusively during Schizophrenia, Bipolar, or Depressive episodes with psychotic features.

• Epidemiology: $0.5-2.5\%$ of the general population; $10-30\%$ of psychiatric inpatients; $23\%$ of prison inmates.

• Clinical Features: Genetic link to Schizophrenia. Unlike Schizophrenia, speech is goal-directed and logical; there are no hallucinations or true delusions (only persecutory ideation).

• Treatment: Psychotherapy. Anxiolytics may be used for agitation.

Schizoid Personality Disorder

• Core Characteristic: Voluntary social withdrawal.

• Epidemiology: $0.5-7\%$ of population; as high as $14\%$ in the unhoused population.

• Clinical History: Appears uneasy, demonstrates little eye contact, and seems aloof. Shows a preference for a solitary life and is socially detached.

• Mental Status Exam: Flat and unresponsive personality, but orientation and reality testing remain intact. Speech is goal-directed.

• Prognosis: Onset in early childhood. Long-lasting but not always lifelong. This group experiences less anxiety/depression than other PDs due to lack of interest in socializing.

• Treatment: Psychotherapy.

Schizotypal Personality Disorder

• Core Characteristic: "Schizoid + magical thinking." Social deficits marked by acute discomfort with close relationships and cognitive/perceptual distortions.

• DSM-5 Criteria:

  1. Ideas of Reference: Belief that public messages (TV, radio) are directed personally to them.

  2. Odd Beliefs/Magical Thinking: Influences behavior (e.g., belief in telepathy, clairvoyance).

• Clinical Presentation: Eccentricities in thinking, speech, and appearance. Socially isolated. Thought content is unusual but does not reach the level of full psychosis.

• Prognosis: $10\%$ commit suicide. Highly associated with the development of Schizophrenia.

• Schizotypal vs. Schizophrenia:

  1. No delusions, hallucinations, or gross disorganization.

  2. Presentation is stable and not episodic.

  3. Schizotypal is "the way they have always been," whereas Schizophrenia typically develops in the $20s-30s$.

• Treatment: Psychotherapy. Caution advised as patients are often involved in cults or the occult.

Cluster B: The "Wild" Personalities (Dramatic, Emotional, or Erratic)

Antisocial Personality Disorder

• Core Characteristic: Disregard for and violation of the rights of others since age $15$.

• DSM-5 Criteria:

  1. Failure to conform to social norms regarding lawful behaviors (repeated arrests).

  2. Deceitfulness (lying, aliases, conning for profit/pleasure).

  3. Impulsivity and failure to plan ahead.

  4. Irritability and aggressiveness (physical fights).

  5. Reckless disregard for safety of self or others.

  6. Consistent irresponsibility (employment or financial).

  7. Lack of remorse.

• Requirements: Individual must be at least $18\,y/o$ with evidence of Conduct Disorder onset before age $15$.

• Epidemiology: $3\%$ of men, $1\%$ of women. $75\%$ of the prison population.

• Etiology: Increased risk if father is antisocial or alcoholic.

• Treatment: CBT. Mood stabilizers or atypical antipsychotics may help with aggression.

Borderline Personality Disorder (BPD)

• Core Characteristic: Instability in interpersonal relationships, self-image, and affects; marked impulsivity and fear of abandonment.

• DSM-5 Criteria:

  1. Frantic efforts to avoid abandonment.

  2. Pattern of unstable/intense relationships (alternating between idealization and devaluation, known as "splitting").

• Assessment Model:

  1. Impaired Relatedness: Identity disturbance and chronic emptiness.

  2. Affective Dysregulation: Excessive anger and mood lability.

  3. Behavioral Dysregulation: Suicidality and self-injurious behavior.

• Treatment: Psychotherapy is first-line, specifically Dialectical Behavior Therapy (DBT). Lithium and Clozapine can reduce suicidal ideation.

Histrionic Personality Disorder

• Core Characteristic: Excessive emotionality and attention-seeking.

• DSM-5 Criteria:

  1. Discomfort when not the center of attention.

  2. Inappropriately seductive or provocative behavior.

  3. Uses physical appearance to draw attention.

  4. Impressionistic Speech: Vague, lacking detail, focused on emotions rather than facts.

  5. Theatrical expression of emotions.

  6. Highly suggestible.

  7. Views relationships as more intimate than they are.

• Epidemiology: $2-3\%$ of the population. More often diagnosed in women.

• Prognosis: Relatively good; patients tend to improve with age.

Narcissistic Personality Disorder (NPD)

• Core Characteristic: Grandiosity, need for admiration, and lack of empathy.

• DSM-5 Criteria:

  1. Grandiose sense of self-importance.

  2. Preoccupation with fantasies of success/power.

  3. Belief in being "special" or unique.

  4. Requirement for excessive admiration.

  5. Sense of entitlement.

  6. Interpersonally exploitative.

  7. Envious of others or believes others are envious of them.

  8. Arrogant attitudes.

Cluster C: The "Worried" Personalities (Anxious or Fearful)

Avoidant Personality Disorder

• Core Characteristic: Social inhibition and hypersensitivity to rejection. Unlike Schizoid, they seek relationships but fear them.

• DSM-5 Criteria:

  1. Avoids occupational activities involving contact due to fear of criticism.

  2. Unwilling to get involved unless certain of being liked.

  3. Restraint in intimate relationships due to fear of being shamed.

  4. Preoccupied with being rejected in social settings.

  5. Views self as socially inept or inferior.

• Differential Diagnosis: Social phobia (which is usually specific to certain settings).

Dependent Personality Disorder

• Core Characteristic: Pervasive need to be taken care of; submissive and clinging.

• DSM-5 Criteria:

  1. Difficulty making decisions without excessive advice.

  2. Needs others to assume responsibility for major life areas.

  3. Difficulty expressing disagreement (fear of loss of support).

  4. Feels helpless when alone.

  5. Urgently seeks new relationships when one ends.

• Epidemiology: $2-3\%$ of population; commonly seen in victims of spousal abuse.

Obsessive-Compulsive Personality Disorder (OCPD)

• Core Characteristic: Preoccupation with orderliness, perfectionism, and control at the expense of flexibility and efficiency.

• DSM-5 Criteria:

  1. Preoccupied with details/rules to the point that the major point of activity is lost.

  2. Perfectionism interferes with task completion.

  3. Excessive devotion to work/productivity.

  4. Overconscientious and inflexible about morality/ethics.

  5. Miserly spending style (money hoarded for catastrophes).

  6. Rigidity and stubbornness.

• Clinical Presentation: Patient appears stiff and formal; crucially, they do not see that they have a problem (egosyntonic), unlike OCD which is egodystonic.

Cluster A: The "Weird" Personalities (Odd and Eccentric)

Cluster B: The "Wild" Personalities (Dramatic, Emotional, or Erratic)

Cluster C: The "Worried" Personalities (Anxious or Fearful)