Personality disorders

• Definition:

  • Enduring (starting in childhood or adolescence and continuing into adulthood)
  • Persistent
  • Pervasive (present or noticeable all the time)
  • Disorders of inner experience and behaviour that cause distress or significant impairment in social functioning
  • Manifests as problems with cognition, affect and behaviour
• Risk factors:

  • Traumatic events in early life - especially cluster B
  • Factors in childhood - difficult temperament, ADHD (antisocial), insecure attachment
  • Family history - no gene identified but is common for family history of mental disorders
• Epidemiology:

  • Common but estimated to be underdiagnosed
  • Most common are antisocial and borderline
  • Borderline PD is more common in females but antisocial PD is more common in males
• Clinical assessment:

  • A diagnosis of PD is usually made by a psychiatrist after a prolonged individual assessment
  • Several tools can be used to aid the diagnosis
  • Structures Clinical Interview for DSM-5 Personality Disorders (SCID-5-PD)
• There are some differences in the way PDs are classified depending on the classification system used.

  • DSM-V: 10 PDs into 3 clusters based on similar characteristics.
  • ICD-10: division of PDs into distinct types, but not into clusters.
  • ICD-11: a single diagnosis of PD based on central manifestations characterised of most previously categorised disorders and categorised into mild, moderate or severe PD
• ICD-11:

  • Outlines the central manifestations of PD as impairments in self-functioning and interpersonal functioning
  • Impairment in these two areas occurs in associated with maladaptive patterns of cognition, emotional experience, emotional expression and behaviour
  • Then applies specifiers to determine severity, personality train domains, and an additional borderline pattern specifier
  • This has not yet been implemented in clinical practice
• ICD-11 personality trait domain - negative affectivity:

  • Negative emotions
  • Emotional lability and poor regulation
  • Negativistic attitudes
  • Low self esteem and self confidence
  • Mistrustfulness
• ICD-11 personality trait domain - detachment:

  • Interpersonal distance
  • Emotional distance
  • Social detachment
  • Emotional detachment
• ICD-11 personality trait domain - dissociality:

  • Disregard for rights and feelings of others
  • Self-centredness
  • Lack of empathy
• ICD-11 personality trait domain - disinhibition:

  • Impulsivity
  • Distractibility
  • Irresponsibility
  • Recklessness
  • Lack of planning
• ICD-11 personality train domain - Anankastia:

  • Perfectionism
  • Emotional and behavioural constraint
• ICD-11 borderline trait:

  • Instability of interpersonal relationships
  • Identity disturbance
  • Act rashly in states of high negative affect
  • Recurrent episodes of deep self harm
  • Emotional instability
  • Chronic feelings of emptiness
  • Transient dissociative/psychotic like features
• Secondary personality change

  • Persistent personality disturbance that represents a change from previous characteristic personality pattern
  • Direct pathophysiological consequence of a physical health condition e.g. traumatic brain injury
  • Also called organic personality disorder
• ICD-10/DSM-5 paranoid PD:

  • Sensitive
  • Suspicious
  • Preoccupied with conspiratorial explanations
  • Self-referential
  • Distrust of others
• ICD-10/DSM-5 schizoid PD:

  • Emotionally cold
  • Detachment
  • Lack of interest in others
  • Almost always chooses solitary activities
• ICD-10/DSM-5 schizotypal PD:

  • Eccentric patterns of thinking and behaving - magical thinking
  • Ideas of reference is common
  • Interpersonal difficulties
• ICD-10 dissocial/ DSM-5 antisocial PD:

  • Callous lack of concern for others
  • Irresponsibility
  • Manipulation of others for personal gain
  • Irritability
  • Aggression
  • Inability to maintain enduring relationships
  • Disregard and violation of others rights
  • Evidence of childhood conduct disorder
• ICD-10 emotional unstable impulsive type:

  • Inability to control anger or plan
  • Unpredictable affect and behaviour
• ICD-10 emotionally unstable borderline type/DSM-5 borderline PD:

  • Unclear identity
  • Intense and unstable relationships
  • Unpredictable affect
  • Threats or acts of self harm
  • Impulsivity
• ICD-10/DSM-5 histrionic PD:

  • Self dramatization
  • Shallow affect
  • Egocentricity
  • Craving attention and excitement
  • Manipulative behaviour
• DSM-5 narcissistic PD:

  • Grandiosity
  • Lack of empathy
  • Need for admiration
  • Exploitation of others
• DSM-5 PD clusters:

  • Cluster A - odd or eccentric patterns of thinking or behaving with interpersonal difficulties - paranoid, schizoid, schizotypal
  • Cluster B - dramatic, emotional, impulsive with interpersonal difficulties - antisocial, borderline, histrionic, narcissistic
  • Cluster C - anxious fearful patterns with interpersonal difficulties - avoidant, dependent, obsessive compulsive
• ICD-10 anxious (avoidant)/DSM-5 avoidant:

  • Tension
  • Self-consciousness
  • Fear of negative evaluation by others
  • Timid
  • Insecure
• ICD-10 anankastic/DSM-5 obsessive compulsive PD:

  • Doubt
  • Indecisiveness
  • Caution
  • Pedantry
  • Rigidity
  • Perfectionism
  • Preoccupation with orderliness and control
• ICD-10/DSM-5 dependent PD:

  • Clinging
  • Submissive
  • Excess need for care
  • Feels helpless when not in a relationship
• ICD-11 severe personality disorder:

  • Severe disturbances in multiple areas of functioning of the self e.g. not having a sense of who they are
  • Problems with interpersonal functioning seriously affect virtually all relationships
  • Often associated with harm to self and others
  • Associated with severe impairment in all or nearly all areas of life
• Conduct disorder:

  • Usually begins in childhood or adolescence
  • Characterised by aggressive, rule-breaking behaviours that lead to conflict with adults and peers
  • Up to 50% may develop antisocial personality disorder
• Management:

  • Support - risk assessment, crisis management
  • Psychological therapy - mainstay of treatment - DBT is used to treat BPD
  • Pharmacotherapy - there are no licensed medications to treat PDs. Certain mood stabilisers or antipsychotics can be used if there is a co-existing mental health disorder
  • Promethazine (sedative antihistamine) is sometimes used for short term treatment in event of a crisis
• Complications:

  • Antisocial and borderline - increased morbidity and mortality
  • Obsessive compulsive and schizotypal traits are less likely to improve with age and may even get worse
  • Increased prevalence of substance misuse
  • Homicide
• Psychological therapies for BPD:

  • DBT - developed from CBT, focuses on acceptance of oneself and learn skills to reduce harmful maladaptive behaviours
  • Mentalisation based therapy (MDT) - recognise one's own thoughts, emotions, behaviours, and consider that others may perceive things differently
  • Cognitive analytical therapy (CAT) - focuses on relationship patterns