Personality Disorders

 Definition:

Clinically significant deviation of normal personality development.  Personality disorders must have the following features:

• Marked deviations in behavior and attitudes from the expected cultural norm
• The abnormal behavior and attitude are enduring and consistent across a range of experiences
• The abnormal behavior and attitudes have their origin in childhood and adolescence
• The disorder causes distress to the subject or to others, and creates problems in areas of personal and social functioning.

Personality does not change except:

• Organic personality disorder: secondary to a general medical cause such as encephalitis
• Enduring personality change: occurs following either a prolonged experience where life at risk (PTSD due to torture, natural disaster) or recovery from a severe mental illness.

Epidemiology:

Range from 6 to 10% (very common). Population with PD have a higher rate of mental illness, depending on the type.

Aetiology:

• Genetic Predisposition (30%-60%)
• Attachment Experience
• Traumatic events (causing connection ‘failure')
• Family constellation and dysfunction
• Socio cultural and political factors.

All the above function in a complex fashion

• v Cluster A (The Eccentric) or The Weird:

1. Schizoid Personality Disorder:

• Emotional coldness and lack of warmth displayed towards others, few activities provide pleasure.
• Prefers to be alone, little interest in social relationships or sexual experience.
• Indifferent to social conventions, personal criticism.
• Excessively introspective preferring solitary activities.

2. Paranoid Personality Disorder:

• Distrust and suspiciousness of others, extreme sensitivity to criticism plus a tendency to misconstrue the remarks or actions of others
• Incapacity to forgive others and tendency to bear grudges
• Excessive sense of self-importance and personal rights

3. Schizotypal Personality Disorder:

• Similar to the above but with more prominent eccentric behavior, overvalued ideas, and non-hallucinatory perceptual abnormality (related to schizophrenia genetically).
• v Cluster B (The Dramatic) or The Wild:

4. Dissocial (Antisocial) Personality Disorder:

• Low tolerance to frustration with tendency to react aggressively
• Excessive irresponsibility and rejection of social norms; tendency for impulsive, short-term gains without fear of potential consequences
• Others are blamed for their behavior
• Inability to experience guilt or remorse
• Inability to form long term relationship

5. Borderline Personality Disorder:

• Emotionally unstable with excessive mood fluctuation usually lasting a few hours but occasionally several days. Containing feelings of anger and are particularly difficult
• Recurrent suicidal threat or attempts, such as overdosing or self-mutilation
• Other impulsive behavior such as substance misuse or promiscuity which could be dangerous for the individual
• Tendency to form intense and volatile relationships
• Disturbance of self image with characteristic feelings of emptiness, boredom and fear of being abandoned by others.

 6. Histrionic Personality Disorders:

• Prone to self-dramatization particularly through activities where they are centre of attention
• Emotionally shallow, suggestible, exaggerated expression, and over concern with their appearance.
• Self-indulgence and manipulation of others for their needs.
• v Cluster A (The Fearful) or The Worried:

7. Dependent Personality Disorder:

• Excessive submissiveness and subordination to others with reduced capacity to take responsibility for their own actions and make decisions
• Excessive fears of being abandoned by those they are dependent on, going to great length to engender support and reassurance from others
• Preoccupation with feelings of incompetence and inability to care for themselves.

8. Anxious (Avoidant) Personality Disorder:

• Preoccupation with feelings of inadequacy and inferiority
• Feeling of tension and apprehension
• Avoidance of personal relationships and social situations for fear of rejections or negative criticism
• Reluctance to take risk or take part in new activitie

9. Anankastic (Obsessive-Compulsive) Personality Disorder:

• Preoccupation with details and rules
• Excessive perfectionism, single- mindedness and inflexibility in behavior and attitudes to the extent that task completion and decision-making are impaired
• Excessive doubt, caution, and self-criticism
• Insistence that others conform to their own standards
• Although intrusive thoughts or impulses may occur, the disorder is distinct from obsessive-compulsive disorder in that obsession and compulsions do not occur and is ego-syntonic

Prognosis and treatment:

• Integrative (i.e. medication and psychotherapy). Stronger evidence for psychotherapy.
• Cluster A most resistant to treatment, reward dependence à Noradrenalin
• Cluster B most amenable to treatment, Novelty seeking àDopamine
• Cluster C intermediate, Harm avoidanceàSerotonin

Previously PD was assumed to reduce with age, however recent evidence suggests that this view is unrealistic and the traits may be more rigid and transform.

References:

• 1. Stevens L, Rodin I. Psychiatry: An illustrated colour text, Churchill Livingstone 2001
• 2. Steple D. Oxford Handbook of Psychiatry, Oxford University Press, 2006
• 3. Guthrie E & Creed F. Seminars in Liaison Psychiatry. Royal college of Psychiatrist 2007
• 4. World Health Organization (WHO). ICD-10 Classification of mental and behavioural disorders. Churchill Livingstone
• 5. American Psychiatric Association (APA). DSM-IV-TR. Fourth Edition Text Revision. APA Publication
• 6. King D. Seminars in clinical psychopharmacology. Second Edition 2004. Royal College of Psychiatrists