Personality disorders

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. In acute care settings, individuals with personality disorders may present with somatic or psychiatric (e.g., self-harm or suicidal ideation) symptoms. Physician-patient encounters may be challenging, and steps should be taken to establish a productive therapeutic relationship.

Personality

• Personality trait: a stable, repetitive pattern of thoughts, feelings, and behaviors characteristics of a particular individual as expressed in a wide range of social and personal contexts
• The Big Five dimensions of personality ^[1]
  • The most widely recognized personality model that maps personality according to five distinct dimensions, namely the degree of conscientiousness, agreeableness, neuroticism, openness to experience, and extraversion expressed by an individual.
  • The dimensions are equally determined by genetic and environmental factors and remain stable throughout adulthood.
  • Each dimension is the sum of several factors or characteristics and should not be assessed in binary categories of presence and absence but rather as traits on a spectrum.

Think OCEAN to remember the Big Five personality traits: Openness to experience, Conscientiousness, Extraversion, Agreeableness, and Neuroticism.

Personality disorders

• Definition: pervasive, inflexible, and maladaptive personality patterns that lead to significant distress and/or functional impairment
• Epidemiology
  • Age of onset: late childhood or adolescence
  • Antisocial and narcissistic personality disorders are more commonly diagnosed in male individuals.
  • Histrionic and borderline personality disorders are more commonly diagnosed in female individuals.
• Etiology
  • Multifactorial
  • Caused by a combination of hereditary (e.g., personality disorders in parents) and psychosocial factors (e.g., child neglect, abuse)
• Classification: : The DSM-5 divides personality disorders into three clusters (A, B, and C).

• Clinical features common to all personality disorders
  • Affected individuals consider their symptoms normal and nonproblematic.
  • Thinking and behavior that significantly differ from cultural expectations
• Diagnostic criteria
  • At least two or more of the following deviate significantly from cultural expectations:
    • Cognition (e.g., perceives events, others, or self in an inappropriate way)
    • Affectivity
    • Interpersonal functioning
    • Impulse control
  • Begins in early adulthood and remains 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) ^[3]
• Treatment
  • Psychotherapy, dialectical behavior therapy, group therapy, and/or cognitive therapy
  • Symptomatic medical therapy
    • Mood stabilizers: valproate, topiramate, and lamotrigine have been shown to decrease symptoms such as affective dysregulation, impulsivity, and aggression.
    • Antipsychotics: especially for symptoms of delusion
    • Antidepressants: selective serotonin reuptake inhibitors (SSRIs) are the drug of choice, especially in depressive episodes, anxiety disorders, and obsessive-compulsive disorders.
  • See “Acute medical care of patients with personality disorders” for special management considerations in acute settings.

Personality disorders are associated with a high risk of psychiatric comorbidities, especially during times of stress.

For the general character of each cluster, remember WWW: Weird (A), Wild (B), Worried (C)

References:^[3]

Overview

Cluster A: paranoid people are Accusatory, schizoid people are Aloof, and schizotypal people are Awkward.

Cluster A personalities

Paranoid personality disorder ^[2]

• Diagnostics: according to the DSM-5
  • At least 4 of the following criteria have to be met:
    • Pervasive distrust of others
    • Unjustified fear that others will use information against them
    • Unjustified suspicion about the loyalty of friends and family
    • Unjustified suspicion that others are deceiving or harming them
    • Suspicions of infidelity in sexual partners/spouse
    • Disproportionate reactions to perceived attacks
    • Perceives benign remarks as hidden humiliations
    • Holding grudges
• Differential diagnoses
  • Schizophrenia
  • Delusional disorder
  • Major depressive disorder with psychotic features
  • Schizophreniform disorder
  • Brief psychotic disorder
  • See “Differential diagnoses” in “Schizophrenia.”
  • Side effects of medication
  • Substance abuse
  • Alcohol withdrawal

Schizoid personality disorder ^[2]

• Diagnostics: according to the DSM-5
  • At least 4 of the following criteria have to be met:
    • Voluntary detachment from social relationships (e.g., family)
    • Enjoys few activities
    • Prefers solitary activities
    • No or little interest in sexual relationships
    • Lacks people to trust or close friends
    • Indifferent to praise or criticism
    • Restricted emotional expression, flattened affect
• Other features: comfortable with social isolation (unlike in avoidant personality disorder)
• Differential diagnoses
  • Major depressive disorder
  • Dementia
  • Side effects of medication
  • Substance abuse
  • Alcohol withdrawal
  • Hypothyroidism

Schizotypal personality disorder (a schizophrenia spectrum disorder) ^[2]

• Diagnostics: according to the DSM-5
  • At least 5 of the following criteria have to be met:
    • Odd and eccentric behavior or physical appearance
    • Magical thinking
    • Social awkwardness
    • Excessive social anxiety
    • Ideas of reference
    • Unusual perceptual experiences (e.g., body illusions)
    • Bizarre thinking/speech (e.g., metaphorical, overelaborate)
    • Paranoia and suspicion of others
    • Constricted affect
    • Few or no close friends
    • Social anxiety and preference for social isolation because of paranoia
• Differential diagnoses
  • Schizophrenia
  • Schizophreniform disorder
  • Brief psychotic disorder
  • Schizoaffective disorder
  • Side effects of medication
  • Substance abuse
  • Alcohol withdrawal
  • Thyroid disorders

People with schizO-TYPE-al personality disorder are Odd TYPEs.

References:^[3]

Overview

Cluster B: antisocial people are Bad, some people are Borderline, histrionic people are flamBoyant, and narcissistic people must be the Best.

Antisocial personality disorder ^[2]

• Epidemiology: : more common in men
• Diagnostics: according to the DSM-5
  • The patient is at least 18 years of age.
  • Three or more of the following symptoms of conduct disorder are present from at least 15 years of age.
    • Deceitfulness, manipulation
    • A history of hostility and 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
  • Antisocial behavior that is not only due to manifestations of bipolar disorder or schizophrenia
• Differential diagnoses
  • Intermittent explosive disorder
  • Conduct disorder (if < 18 years of age)
  • Substance abuse
  • Alcohol withdrawal
• Treatment: : extremely difficult to treat
  • The aim of treatment is usually to prevent existing symptoms from progressing.
  • Older individuals with antisocial personality disorder are typically incarcerated.

People with antiSOCIal personality disorders are SOCIopaths.

“Travel to CONey (CONduct disorder) island before age 15 and you will be sent to ANTarctica (ANTisocial personality disorder) after age 18”

Borderline personality disorder ^[2]

• Epidemiology: : more common in women
• Diagnostics: according to the DSM-5
  • At least 5 of the following criteria have to be met:
    • Unstable mood (e.g., irritability, anxiety)
    • Intense anger that can be difficult to control
    • Feelings of emptiness
    • Self-damaging acts (e.g., unsafe sex, substance abuse, reckless behavior)
    • Self-harm, suicidal behavior
    • Unstable self-image
    • Suspicion about what others think of them, even paranoid ideation and/or dissociative episodes
    • Unstable personal relationships
    • Fear of abandonment
• Other features: : splitting (psychiatry), a defense mechanism in which relationships are categorically good or bad
• Differential diagnoses
  • Bipolar disorder
  • Major depressive disorder
  • Schizophrenia, schizophreniform disorder
  • Side effects of medication
  • Substance abuse
  • Alcohol withdrawal
  • Hyperthyroidism
• Treatment: : dialectical behavior therapy

Histrionic personality disorder ^[2]

• Diagnostics: according to the DSM-5
  • At least 5 of the following criteria have to be met:
    • Attention-seeking: drawing attention to oneself by way of physical appearance
    • Uses dramatic speech
    • Exaggerated emotional expression
    • Not being the center of attention causes discomfort
    • Feelings are often shallow and unstable.
    • Exhibiting inappropriate, sexually provocative, and/or seductive behavior during interactions with others
    • Easily influenced by others or circumstances
    • Overestimating the degree of intimacy in relationships
• Differential diagnoses
  • Delusional disorder
  • Schizophrenia, schizophreniform disorder
  • Bipolar disorder
  • Substance abuse

Narcissistic personality disorder ^[2]

• Diagnostics: according to the DSM-5
  • At least 5 of the following criteria have to be met:
    • Excessive sense of self-importance (e.g., exaggerates achievements)
    • Fantasizes disproportionately about success, power, etc.
    • Believe in being special and a feeling of superiority
    • Great need for admiration
    • Expecting favorable treatment from others
    • Exploitation of others to achieve their own goals
    • Lack of empathy
    • Often envious of others
    • Often behaves arrogant and/or snobbish
  • Important to distinguish from manic or hypomanic episodes in bipolar disorder
• Other features: : difficulty dealing with criticism (e.g., reacts with anger and/or defensiveness), fragile self-esteem
• Classification: 3 subtypes
  • Grandiose, overt
  • High-functioning
  • Vulnerable/covert
• Differential diagnoses
  • Delusional disorder
  • Bipolar disorder
  • Schizophrenia, schizophreniform disorder
  • Substance abuse

References:^[3]

Overview

Avoidant personality disorder ^[2]

• Diagnostics: according to the DSM-5
  • At least 4 of the following criteria have to be met:
    • Avoidance of interpersonal contact due to fear of criticism or rejection
    • Only interacts with people if certain of being liked by them
    • Restrained in intimate relationships due to fear of being shamed
    • Preoccupation with and hypersensitivity to criticism
    • Feelings of inadequacy resulting in involuntary social withdrawal
    • Low self-esteem (sees themself as socially awkward, unappealing, or inferior to others)
    • Avoids taking risks and seldomly engages in new activities
  • Strong desire for social relationships (unlike schizoid personalities), but limited by extreme shyness and social anxiety
• Differential diagnoses
  • Generalized anxiety disorder
  • Adjustment disorder
  • Social anxiety disorder
  • Performance anxiety

Dependent personality disorder ^[2]

• Diagnostics: according to the DSM-5
  • At least 5 of the following criteria have to be met:
    • Disproportionate need for support
    • Difficulty making everyday decisions (often requiring others to assume responsibility)
    • Avoids disagreeing with others due to fear of losing their support
    • Difficulty initiating projects (e.g., applying for jobs) because of a lack of self-confidence
    • Makes extreme efforts to obtain support from others even if these efforts are unpleasant
    • Feelings of helplessness when alone
    • Urgently seeking new relationships when one fails
    • Both afraid of being abandoned and afraid to abandon their partner
• Other features
  • Often stuck in abusive relationships
  • Associated with an increased risk of suicide
• Differential diagnoses
  • Generalized anxiety disorder
  • Adjustment disorder
  • Social anxiety disorder
  • Performance anxiety
  • Major depressive disorder

Obsessive-compulsive personality disorder ^[2]

• Diagnostics: according to the DSM-5
  • At least 4 of the following criteria have to be met:
    • Excessive preoccupation with rules, lists, details, etc.
    • Obsession with work and productivity that often occurs 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 a vacation)
    • Perfectionism that often interferes with task completion
    • Unwillingness to delegate work or to collaborate with other people
    • Great conscientiousness and fastidiousness, inflexible about matters of morality or ethics
    • Cling to worn-out/worthless items (even if they have no sentimental value)
    • Often show miserliness (e.g., obsessed with saving money for future disasters)
    • Rigid routines
  • In contrast to obsessive-compulsive disorder (OCD), intrusive thoughts and repetitive behaviors are not present.
• Other features: Perfectionism and obsession with control are often egosyntonic.
  • Egosyntonic is a descriptor used in psychoanalysis for thoughts and behavior patterns that are in agreement with an individual's self-image
  • Opposed to OCD, which is typically egodystonic
• Differential diagnoses
  • Obsessive-compulsive disorder
  • Generalized anxiety disorder
  • Performance anxiety

Cluster C: avoidant people act Cowardly, some people are obsessive-Compulsive, and dependent people are Clingy.

References:^[3]

General principles ^[4][5][6]

• Personality disorders are associated with an increased risk of depression, suicide, substance use disorders, accidents, and physical illness. ^[7]
• Individuals with personality disorders may seek acute care for somatic and/or psychiatric concerns (e.g., self-harm).
• A physician-patient relationship may be particularly difficult to establish because:
  • Patients may be perceived as difficult, demanding, or self-destructive.
  • Acute stressors may result in increased maladaptive behavior.
  • Clinicians may feel overwhelmed by patient behavior and respond with withdrawal, aggression, or overinvolvement.

Beware of implicit biases when caring for patients with personality disorders.

Somatic presentations

Challenging patient encounters ^[5][6]

The following strategies may help to make patient encounters productive:

• Management of negative reactions
  • Maintain emotional distance while remaining empathetic.
  • Avoid reciprocating negative behaviors.
  • Recognize that countertransference is likely and may affect clinical judgment.
  • If necessary, leave the room to regain composure.
• Effective communication
  • Set expectations (e.g., regarding time limits, interruptions, behavior).
  • Use active listening and avoid passing judgment.
  • Validate the patient's concerns and emotions.
  • Gently redirect the patient if the conversation moves off-topic.
  • Try to ensure consistent messaging from all providers.

Beware of countertransference, listen actively, and set clear boundaries when interviewing and counseling patients with personality disorders.

Agitation or violent behavior ^[6]

See “Approach to the agitated or violent patient” for a complete approach.

• Identify potential for violence.
• Utilize deescalation techniques.
• If nonpharmacological interventions are ineffective, consider antipsychotics for agitation. ^[7]

Psychiatric presentations

The primary goals in acute settings are addressing suicidality and/or self-harm and stabilizing mental function. ^[7][8]

Management of suicidality and self-harm ^[9][10]

• Build a therapeutic relationship with the patient to accurately assess risks of suicide and/or self-harm.
• Evaluate suicide risk, e.g., using a suicide screening assessment.
• Gather collateral information (e.g., history from family or friends), if possible.
• If indicated, initiate acute management of suicidal behavior.
• Evaluate for nonsuicidal self-injury and perform acute wound management as indicated.

Be wary of conflating nonsuicidal self-injury with suicidal ideation, as this may result in unnecessary hospitalizations and/or emergency department visits. ^[9]

Supportive management and counseling ^[5][9]

• Showing support and validating the patient's feelings can help reduce anxiety and agitation.
• Attempt to reduce situational and environmental stressors as much as possible.
• If considering medication for symptomatic relief:
  • Prescribe only as needed to facilitate care (e.g., to enhance patient cooperation and communication). ^[9]
  • Avoid polypharmacy.
  • Avoid changing existing medication regimens while the patient is in crisis.
• Consider providing families and/or caretakers with resources to help with care.

Consults and disposition ^[5][9]

• Determine the need for psychiatric hospitalization and consult psychiatry for:
  • Significant risk factors for suicidal behavior
  • Elevated risk and inability to access follow-up
• If psychiatric hospitalization is not indicated:
  • Discuss the patient's care with their outpatient provider and/or support system members and arrange for close follow-up.
  • Refer patients without outpatient care to a suitable provider and/or case manager.
  • Provide the patient with return precautions.
  • Form a suicide safety plan with the patient including the following elements:
    • Ways to avoid future crises
    • Sources of help to contact
    • Suicide risk mitigation
    • Return precautions