Personality Disorders

By | February 4, 2015

Description of Medical Condition

A group of conditions, with onset at or before adolescence, characterized by enduring patterns of maladaptive and dysfunctional behavior that deviate markedly from one’s culture and social environment leading to functional impairment and distress to the individual, coworkers and the family. These behaviors are perceived by the patient to be “normal” and “right” and they have little insight as to their responsibility for these behaviors. These conditions are classified based on the predominant symptoms and their severity.

System(s) affected: Nervous

Genetics: Major character traits inherited; others result from a combination of genetics and environment

Incidence/Prevalence in USA:

• Prevalence 12%

• In male prisoners the prevalence of antisocial personality disorder is about 60%

Predominant age: Starts in adolescence and early twenties and persists throughout one’s life

Predominant sex: No difference as a whole; some personality disorders are more common in females and others are more common in males

Medical Symptoms and Signs of Disease

• Criteria for a personality disorder include an enduring pattern of:

– Inner experience and behavior manifesting in two or more of the following areas: cognition, affectivity. interpersonal functioning, or impulse control

– Inflexibility and pervasiveness across a broad range of personal and social situations

– Significant distress or impairment in social, occupational, or other important areas of functioning

– Onset can be traced to adolescence or early adulthood

– Not better accounted for as a manifestation or consequence of another mental disorder

– Not due to the direct physiological effects of a substance, such as a drug of abuse, or a medication, or a general medical condition, such as a head trauma

• Personality disorders (PD) are classified into three major clusters

– Cluster A : eccentricism and oddness

– Paranoid PD: unwarranted suspiciousness and distrust of others, defensive, guarded, and overly sensitive

– Schizoid PD: emotional, cold, or detached, apathetic to criticism or praise, socially isolated

– Schizotypal PD: eccentric behavior, odd belief system, perceptions and speech, social isolation, and general suspiciousness

– Cluster B: dramatic, emotional, or erratic behavioral patterns

– Antisocial PD: aggressive, impulsive, irritable, irresponsible, dishonest, deceitful, and at times reckless disregard for safety of self or others

– Borderline PD: pervasive pattern of unstable interpersonal relationships, self image, with high impulsivity from early adulthood. Intense fear of abandonment, mood swings, poor self-esteem, chronic boredom, and feelings of inner emptiness.

– Histrionic PD: excessive emotionality and attention seeking in a variety of contexts. Needs to be the center of attention with self-dramatizing behaviors; suggestive with flowing and impressionistic speech.

– Narcissistic PD: grandiosity, a need for affirmation and for admiration from others. Lack of empathy for other people’s pain or discomfort. Grandiose sense of self-importance and preoccupation with fantasies of success, power, brilliance, beauty or ideal love. Belief that the individual is special, unique and deserves special treatment. At times they may show arrogance, haughty behaviors, or attitudes.

– Cluster C: anxiety, excessive worry, fear and different patterns to cope with these emotions

– Avoidant PD: social inhibition, feelings of inadequacy, and hyper-sensitivity to negative evaluation. Avoidance of occupational and interpersonal activities that involve the risk of criticism by others. They avoid taking chances and risks involving significant interpersonal contact, preoccupied with fears of being criticized and rejected, and view themselves as socially inept, and personally unappealing or inferior to others.

– Dependent PD: excessive need to be taken care of that leads to submissive, clinging behavior, and fears of separation. Needs constant and repeated reassurance and guidance by others. Difficulties making decisions with the activities of daily living. Avoids expressing disagreements with others due to fear of losing support and approval. Usually seeks out strong and confident people as friends or spouses and feels more secure in such relationships.

– Obsessive-Compulsive PD (OCPD): pre-occupation with cleanliness, orderliness, perfectionism, and control of events and people at the expense of flexibility, openness, and efficiency. Preoccupation with excessive details, rules, lists, order, organization, and schedules to the extent that the major point of the activity is lost. Exhibits perfectionism that interferes with task completion. Indecisive, over conscientious, scrupulous, and rigid about matters of morality, ethics, or values. Reluctant to delegate tasks at work or home and some are unable to discard worn out or worthless objects even if they have no sentimental value.

– PD, not otherwise specified: a mixture of characteristics from other PDs without a predominant pattern compatible with above categories. It can also be used for specific personality disorders not mentioned in the APA classification (DSM-IV-TR) such as depressive PD, masochistic PD, passive-aggressive PD and others.

What Causes Disease?

Environmental and genetic factors

Risk Factors

• Positive family history

• Pregnancy risk factors

– Nutritional deprivation

– Use of alcohol or drugs

– Viral and bacterial Infections

• Dysfunctional family with child abuse and neglect

Diagnosis of Disease

Differential Diagnosis

• Medical disorders (e.g., brain diseases) with behavioral changes

• Other psychiatric disorders, with similar symptoms, have a specific time of onset signifying a change from a previously different pattern of behavior or have a difference in self-perception

– In obsessive compulsive disorder (OCD), symptoms are ego-dystonic, i.e., are perceived as foreign and unwanted. In addition, OCD has a pattern of relapse and perhaps remission.

– In obsessive compulsive personality disorder (OCPD), symptoms are perceived as desirable behaviors (ego-syntonic) that the patient feels proud of and wants others to emulate. In addition, OCPD has a life-long pattern (i.e., without significant relapse or remission).

Laboratory

TSH, VDRL, CBC, CMP, HIV

Drugs that may alter lab results: N/A

Disorders that may alter lab results: N/A

Pathological Findings

N/A

Special Tests

Psychological testing, e.g.. MMPI-II

Imaging

CT scan, and MRI of the brain may be necessary in newly developed symptoms to rule out organic brain disease (e.g., frontal lobe tumor)

Diagnostic Procedures

• Comprehensive interview and mental status examination

• Interview of relatives and friends helpful in establishing the enduring pattern of behavior

Treatment (Medical Therapy)

Appropriate Health Care

Outpatient individual psychotherapy and group therapy

General Measures

• Long term psychotherapy and cognitive behavior therapy

• Group therapy is helpful in the utilization of therapeutic confrontation and increasing one’s awareness and insight regarding the damaging effects of dysfunctional behavior patterns

Activity

Regular physical exercise helps in coping with stress and the activities of daily living

Diet

Emphasize variety of healthy foods, avoid obesity

Patient Education

Bibliotherapy and writing therapy, specific assignments and watching certain movies to better understand the nature and origin of one’s specific condition are helpful

• The movie “As Good As It Gets” illustrates someone with obsessive compulsive behaviors and their impact on activities of daily living and relationships with family and friends

• The movie series “The Godfather” is an example of several characters with anti-social personality disorder and how this affects their interpersonal relationships and their own physical and mental health

Medications (Drugs, Medicines)

Drug(s) of Choice

• No specific drugs treat personality disorders, however, specific medications can reduce the intensity, frequency, and dysfunctionality of certain behaviors, thoughts, and feelings

• Symptom management:

– Mini-psychosis (associated with paranoid, schizoid, and schizotypal personality disorders). Atypical antipsychotics: clozapine (Clozaril), risperidone (Risperdal), quetiapine (Seroquel), olanzapine (Zyprexa), ziprasidone (Geodon), and aripiprazole (Abilify). Start with a low dose gradually adjusting to the patient’s needs.

– Anxiety. Anxiolytics: benzodiazepines, buspirone, and the SSRIs

– Depressed mood. Anti-depressants: SSRIs

– Many patients with borderline personality disorder respond well to small doses of atypical neuroleptics and mood stabilizers

Contraindications: Refer to manufacturer’s profile of each drug

Precautions:

• Risperidone and ziprasidone may be associated with hyperglycemia and ketoacidosis

Significant possible interactions: Refer to manufacturer’s profile of each drug

Alternative Drugs

Mood stabilizers (e.g., lithium carbonate, divalproex [Depakote] and anti-epileptic drugs may be helpful)

Patient Monitoring

• If substance abuse is suspected, check drug screens

• Infrequent sessions, with relative or friends, helpful in monitoring progress and behavior changes

Prevention / Avoidance

N/A

Possible Complications

• Disruptive family life with frequent divorces and separations, alcoholism, substance abuse and drug addiction

• Disruptive behaviors in the work place may cause absenteeism, loss of productivity, and loss of self support

• Violation of the law and disregard for the concerns and rights of others

Expected Course / Prognosis

Personality disorders are enduring patterns of behavior throughout one’s lifetime and are not easily responsive to treatment

Miscellaneous

Associated Conditions

Depression, other psychiatric disorders in patient and family members

Age-Related Factors

Pediatric: History of childhood neglect, abuse, and trauma are not uncommon

Geriatric: Coping with stresses of elderly life difficult

Pregnancy

Adds pressure in coping with the activities of daily living

Synonyms

• Character disorders

• Character pathology

International Classification of Diseases

301.9 Unspecified personality disorder

301.50 Histrionic personality disorder, unspecified

300.3 Obsessive-compulsive disorders

301.0 Paranoid personality disorder

301.20 Schizoid personality disorder, unspecified

301.22 Schizotypal personality

301.6 Dependent personality disorder

301.7 Antisocial personality disorder

301.81 Narcissistic personality

301.82 Avoidant personality

301.83 Borderline personality

See Also

– bsessive compulsive disorder

Abbreviations

– CPD = obsessive compulsive personality disorder OCD = obsessive compulsive disorder