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| ==[[Personality disorder overview|Overview]]== | | ==[[Personality disorder overview|Overview]]== |
| Personality disorders (PD) are described as unique, long-term pervasive patterns of expressing and manifesting emotions, thoughts, and behaviors in an inflexible and maladaptive manner leading to significant functional [[impairment]] in one's life. [[Personality traits]], in contrast, are specific patterns of thinking, perceiving, and responding to different situations in an adaptive and tenaciously stable way throughout life. The personality traits formulate an essential aspect in one's life in facing and dealing with contrasting situations as maladaptive [[personality]] can result in clinical distress and [[psychosocial impairment]]. In order to differentiate normal responses from abnormal or [[pathological]], the criterion employed requires behaviors displayed by a majority in the population as normal and [[pathological]] if they are rare or there is the absence of a sense of contentment and adaptability to the social environment or marked deviation from cultural expectations. Hence, these are relative terms, and therefore, the [[Diagnostic and Statistical Manual of Mental Disorders]] (DSM) has established a set criterion for diagnosing [[personality disorders]]. This is based on the presence of impaired personality functioning and pathological traits. The [[pathophysiology]] of PD remains unclear to date. There are countless complex [[psychodynamic theories]] explaining the development of the disorder. Both [[genetic]] and environmental factors interplay in the causation of PD. A decrease in [[monoamine oxidase]] (MAO), and [[serotonin]] levels are seen with multiple PD. Although mostly recognized and diagnosed in adults, PD is present and develops in youth and adolescence. About 1 in 10 adolescents meets the criteria for PD. There are ten personality traits classified into 3 clusters; A, B, and C, based on similar characteristics. A clinical criterion as set by DSM-V is used for the diagnosis after the exclusion of other similar conditions ([[mental health disorder]], [[substance use disorder]], structural [[central nervous system]] (CNS) disorder). For most personality disorders, an age greater than 18 years is required for the diagnosis. This disorder is retained throughout an individual's life; however, certain types become less intense with age. The presence of PD is associated with increased [[mortality]]. The increased [[mortality]] is associated with unnatural causes like [[suicide]], accidents, [[homicide]], [[substance abuse]], and [[depression]]. Natural death chances may also be enhanced in PD due to negative perspectives and emotions regarding health problems in life and the correlation of impaired mental health with physical health. [[Alcoholism]] and [[substance abuse]] contribute as precipitating factors and complications in PD. [[Psychotherapy]] remains the mainstay of treatment in both [[management]] and preventing complications. Medications are used as adjuncts. [[Cognitive-Behavioral therapy]], [[impulse control]], [[interpersonal psychotherapy]], self-help groups, and family therapy are required. Medical therapy is required to balance and restore the [[neurotransmitter]] abnormalities associated with PD. Among them, [[Selective serotonin reuptake inhibitors]](SSRIs) and newer [[antidepressants]] remain the hallmark. [[Antipsychotics]] and [[mood stabilizers]] also help. Despite individual and supportive [[psychotherapy]], treatment of PD remains challenging and difficult.
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| ==[[Personality disorder historical perspective|Historical Perspective]]== | | ==[[Personality disorder historical perspective|Historical Perspective]]== |
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| [[Personality]] defects were started to be recognized in the 18th century. Previously, all the diseases were a result of abnormalities with four bodily fluids; [[blood]], [[phlegm]], yellow [[bile]], and black [[bile]]. The changes in them were also considered responsible for variations in [[mood]]. However, by the 18th century, [[Phillippe Pinel]] described a group of people having impulsive, irrational ways and behaviors while maintaining understanding, perception, judgment, and memory of the actions. This was the birth of recognition of [[personality disorders]]. In the 18th century, the term [['phrenology']] was used to describe personality characteristics. It was believed that the origin of [[personality traits]] is from various [[facets]] in the [[cranium]]. Despite the discontinuation of the term, it remains significant as it laid the basis for the origin of PDs from the [[cerebral cortex]].
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| In the 19th century and early 20th century, different European psychologists started identifying and describing different personality traits and disorders. The term personality is derived from Greek word, [['persona,']] the mask worn in theatres in ancient times to denote a character or social role. It is now used to define that aspect of the person which is discerned by other individuals. In the 1920s and 1930s, [[Sigmund Freud]], known as the father of [[psychology]] and his colleagues, worked on the [[psychoanalytic]] classification and etiology of personality. They related personality traits with childhood characters. He presented the [[structural theory]] that unconscious mental conflicts influence the development of character and behavior. This comprises three components of the [[brain]]; the [[id]] (primitive urges at birth), [[ego]] (mediator that maintains a balance between id and reality), and [[superego]] (conscience and moral values). They develop at different stages in life, and the interplay among them is responsible for shaping the personality of a person. Any fixation at any stage is responsible for the improper balance of [[id]] and [[ego]] and leads to interference in the appropriate and timely development of the [[superego]]. A person is born with the id and develops ego and superego at last. This laid down the foundation for further theories and explanations of PDs; however, it lacks the interaction and influences of social, cultural, environmental, and [[genetic]] factors in posing the personality in an individual. In the late 1900s, statistics was utilized to group together different definitions of [[personality]] structures. It was pioneered by [[Bernard Cattell]]. This employs a different number of dimensions to delineate personality systems. These dimensional models lead to DSM characterization of personality disorders according to DSM classifications. [[DSM II]] was established in 1986 and listed 10 PDs. It differs from [[DSM I]] due to the recognition stage in life being adolescence, while the former states that these disorders exist lifelong. DSM II was based on concepts of [[psychoanalysis]] and [[neuroses]], while [[DSM II]]I described PDs scientifically and clinically. [[DSM IV]] was established in 1994 with an updated version, [[DSM IV-TR]], and uses a multiaxial approach to describe psychiatric illnesses with axis II reserved for personality disorder. This multiaxial system was abolished in [[DSM 5]] and categorized the various disorders with related disorders. It classifies PDs into three clusters, with each containing 3-4 disorders.
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| ==[[Personality disorder classification|Classification]]== | | ==[[Personality disorder classification|Classification]]== |
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| There are two approaches used to classify personality disorders; categorical and dimensional. [[Categorical]] classification is based on distinct operational criteria depending on behavioral characteristics. [[DSM-5]] and [[ICD-10]] both uses this approach. As compared to this, [[dimensional]] classification is based on the personality traits and using a quantitative distinction. It places normality at one end and disorder at other.
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| *DSM-5 classifies 10 personality disorders into three clusters due to similar characteristics:
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| **CLUSTER A: odd and eccentric
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| ***Paranoid-distrust and suspiciousness
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| ***Schizoid-detachment from social relationships
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| ***Schizotypal-distortion in interpersonal relationships and cognition, and behavioural eccentrism
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| **CLUSTER B: erratic and emotional
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| ***Antisocial-disregard and violation of rights of others
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| ***Borderline-instability in interpersonal relationships, and impulsivity
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| ***Histrionic-eccessive emotionality and attention-seeking behaviour
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| ***Narcissist-grandiosity and lack of empathy
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| **CLUSTER C: anxious and fearful
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| ***Avoidant-social inhibition and fear of criticism
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| ***Dependent-submissive and excessive need for reassurance
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| ***Obsessive-Compulsive-preoccupation with perfectionism and orderliness
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| *ICD-10 classifies into 3 clusters as well, which are as follows:
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| **A: Odd/eccentric
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| ***Paranoid
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| ***Schizoid
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| **B: Dramatic
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| ***Dissocial
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| ***Emotionally unstable borderline type
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| ***Emotionally unstable impulsive type
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| ***Histrionic
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| **C: Anxious/fearful
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| ***Anxious
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| ***Dependent
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| ***Anankastic
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| ==[[Personality disorder pathophysiology|Pathophysiology]]== | | ==[[Personality disorder pathophysiology|Pathophysiology]]== |
| Personality disorders are related to multifactorial causes. Throughout time, a multitude of theories has been developed to explain the origin of these disorders. However still, the [[pathophysiology]] of PDs remains enigmatic. The [[five-factor model]] of personality was developed in the 1980s and 1990s, which demonstrated that it comprises five distinct traits. These include [[extraversion]], [[Neuroticism]], openness to experience/intellect, [[Agreeableness]], and [[conscientiousness]]. A meta-analysis conducted by [[Saulsman]] and [[Page]] in 2004 reveals the association of personality disorders with the five-trait model. It concludes that [[extraversion]] is positively associated with disorders characterizing assertiveness or gregariousness like [[Histrionic]] and [[Narcissist]]. [[Neuroticism]] is positively associated with disorders causing emotional distress like [[Paranoid]], [[Schizotypal]], [[Borderline]], [[Dependent]], and [[Avoidant]]. [[Agreeableness]] is negatively associated with disorders characterized by interpersonal difficulties like [[Paranoid]], [[Schizotypal]], [[Antisocial]], [[Borderline]], and [[Narcissist]]. Those disorders which are distinguished by orderliness are positively associated with [[conscientiousness]], like [[Obsessive-compulsive disorder]]. [[Schizoid]] is negatively associated with [[extraversion]]. Hence, PDs are primarily the result of positive correlation with [[Neuroticism]] and negative association with [[Agreeableness]]. [[Extraversion]] is associated in both ways. It is a well-known fact that personality develops during childhood and interpersonal experiences and social interactions play a significant role in the development of PDs. Parental maltreatment, stress, and traumatic life events influence the personality adversely. In addition, genetic and [[prenatal]] factors also constitute a major role. Cluster-A PDs can have polymorphisms associated with the gene coding for [[dopamine 2-receptor]] (DRD2), [[catechol-0-methyltransferase]] (COMT), [[Dysbindin]] (DTNBP1), and [[D-aminoacid oxidase]] (DAAO). These genes are also associated with the development of schizophrenia, implying that both [[schizophrenia]] and schizotypal PD are related to [[dopaminergic dysfunction]]. Cluster B PDs have been found linked to polymorphisms in genes encoding serotonin transporter (5-HTTLPR), catabolic enzyme monoamine oxidase (MAOA), and [[tryptophan hydroxylase enzyme]] related genes [[TPH1]] and [[TPH2]]. This demonstrates the relation of the development of [[borderline]] personality and [[antisocial]] disorder with dysfunction in the [[serotonin system]]. Cluster-C PDs are linked with polymorphisms of the [[dopamine 3-receptor]] (DRD3) gene and [[COMT]], particularly [[obsessive-compulsive disorder]]. Perinatal injuries like trauma, infections like [[encephalitis]], and [[hemorrhage]] may also be contributing factors. Genetic factors interact with environmental stresses to result in PDs. Various parental behavior like excessive attachment, parental insensitivity or emotional neglect, physical and sexual abuse, and [[substance use disorders'' causes an essential impact on PDs development. Social bullying, racial discrimination, frequent dislocations during childhood, and lack of peer support are other risk factors.
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| ==[[Personality disorder causes|Causes]]== | | ==[[Personality disorder causes|Causes]]== |
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| ==Diagnosis== | | ==Diagnosis== |
| [[Personality disorder history and symptoms|History and Symptoms]] | [[Personality disorder physical examination|Physical Examination]] |[[Personality disorder laboratory findings|Laboratory Findings]] | [[Personality disorder other imaging findings|Other Imaging Findings]] |[[Personality disorder other diagnostic studies|Other Diagnostic Studies]]
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| ==Treatment== | | ==Treatment== |
| [[Personality disorder medical therapy|Medical Therapy]] | [[Personality disorder surgery|Surgery]] | [[Personality disorder primary prevention|Primary Prevention]] | [[Personality disorder secondary prevention|Secondary Prevention]] | [[Personality disorder cost-effectiveness of therapy|Cost-Effectiveness of Therapy]] | [[Personality disorder future or investigational therapies|Future or Investigational Therapies]] | | |
| | ==[[Personality disorder psychotherapy|Psychotherapy]]== |
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| | ==[[Personality disorder medical therapy|Medical Therapy]]== |
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| == Case Studies == | | == Case Studies == |