Personality disorder

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Ayesha Anwar, M.B.B.S[2]

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.

Historical Perspective

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. 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 III 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.

Classification

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.

• DSM-5 classifies 10 personality disorders into three clusters due to similar characteristics:
  • CLUSTER A: odd and eccentric
    • Paranoid-distrust and suspiciousness
    • Schizoid-detachment from social relationships
    • Schizotypal-distortion in interpersonal relationships and cognition, and behavioural eccentrism
  • CLUSTER B: erratic and emotional
    • Antisocial-disregard and violation of rights of others
    • Borderline-instability in interpersonal relationships, and impulsivity
    • Histrionic-eccessive emotionality and attention-seeking behaviour
    • Narcissist-grandiosity and lack of empathy
  • CLUSTER C: anxious and fearful
    • Avoidant-social inhibition and fear of criticism
    • Dependent-submissive and excessive need for reassurance
    • Obsessive-Compulsive-preoccupation with perfectionism and orderliness
• ICD-10 classifies into 3 clusters as well, which are as follows:
  • A: Odd/eccentric
    • Paranoid
    • Schizoid
  • B: Dramatic
    • Dissocial
    • Emotionally unstable borderline type
    • Emotionally unstable impulsive type
    • Histrionic
  • C: Anxious/fearful
    • Anxious
    • Dependent
    • Anankastic

Diagnosis

History and Symptoms | Physical Examination |Laboratory Findings | Other Imaging Findings |Other Diagnostic Studies

Treatment

Medical Therapy | Surgery | Primary Prevention | Secondary Prevention | Cost-Effectiveness of Therapy | Future or Investigational Therapies

Case Studies

Case #1

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