A personality disorder, as defined in the Diagnostic and Statistical Manual of the American Psychiatric Association, Fifth Edition (DSM-5) is an enduring pattern of inner experience and behavior that differs markedly from the expectations of the individual's culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment. (See Prognosis and Presentation.)
Although the most common etiologies for personality disorders are multifactorial, these conditions may also be secondary to biologic, developmental, or genetic abnormalities. Stressful situations may often result in decompensation, revealing a previously unrecognized personality disorder. Indeed, personality disorders are aggravated by stressors, external or self-induced. Individuals may have more than 1 personality disorder. (See Pathophysiology and Etiology.)
Ten personality disorders, grouped into 3 clusters (ie, A, B, C), are defined in the DSM-5.[1] Cluster A disorders include the following (see Prognosis and Treatment):
Cluster B disorders include the following:
Cluster C disorders include the following:
A concept has emerged that personality may be expressed in terms of the following 5 basic dimensions:[2]
This model is termed the 5-factor model, and it has developed a significant amount of acceptance among personality psychologists.
The model has been used to describe the different accepted types of personality disorders. Most current research suggests that personality disorders may be differentiated by their interactions among the 5 dimensions rather than differences on any single dimension.
In patients with personality disorder, abnormalities may be seen in the frontal, temporal, and parietal lobes. These abnormalities may be caused by perinatal injury, encephalitis, trauma, or genetics. Personality disorders are also seen with diminished monoamine oxidase (MAO) and serotonin levels. However, the relationships of anatomy, receptors, and neurotransmitters to personality disorders are purely speculative at this point.
Frequently, a history of psychiatric disorders is present. In some cases, the patient has developmental abnormalities secondary to abuse or incest.
The origin of personality disorders is a matter of considerable controversy. Traditional thinking holds that these maladaptive patterns are the result of dysfunctional early environments that prevent the evolution of adaptive patterns of perception, response, and defense. A body of data points toward genetic and psychobiologic contributions to the symptomology of these disorders; however, the inconsistency of the data prevents authorities from drawing definite conclusions.[5]
A genetic contribution to paranoid traits and a possible genetic link between this personality disorder and schizophrenia exist. Psychosocial theories implicate projection of negative internal feelings and parental modeling.
Support for the heritability of this disorder exists.
This disorder is genetically linked with schizophrenia. Evidence for dysregulation of dopaminergic pathways in these patients exists.
A genetic contribution to antisocial behaviors is strongly supported. Low levels of behavioral inhibition may be mediated by serotonergic dysregulation in the septohippocampal system. There may also be developmental or acquired abnormalities in the prefrontal brain systems and reduced autonomic activity in antisocial personality disorder. This may underlie the low arousal, poor fear conditioning, and decision-making deficits described in antisocial personality disorder.[6]
Psychosocial formulations point to the high prevalence of early abuse (sexual, physical, and emotional) in these patients, and the borderline syndrome is often formulated as a variant of posttraumatic stress disorder. Mood disorders in first-degree relatives are strongly linked.
Biologic factors, such as abnormal monoaminergic functioning (especially in serotonergic function) and prefrontal neuropsychological dysfunction, have been implicated but have not been well established by research.[7, 8]
Little research has been conducted to determine the biologic sources of this disorder. Psychoanalytic theories incriminate seductive and authoritarian attitudes by fathers of these patients.
No data on biologic features of this disorder are available. In the classic model, narcissism functions as a defense against awareness of low self-esteem. More modern psychodynamic models postulate that this disorder can arise from an imbalance between positive mirroring of the developing child and the presence of an adult figure who can be idealized.
This personality disorder appears to be an expression of extreme traits of introversion and neuroticism. No data on biologic causes are available, although a diagnostic overlap with social phobia probably exists.
No studies of genetics or of biologic traits of these patients have been conducted. Central to their psychodynamic constellation is an insecure form of attachment to others, which may be the result of clinging parental behavior.
Modest evidence points toward the heritability of this disorder. Psychodynamically, these patients are viewed as needing control as a defense against shame or powerlessness.
Personality disorders affect 10-15% of the adult US population. The following are prevalences for specific personality disorders in the general population, across five studies from 2001 to 2010:[9]
Variance in prevalence rates across studies mostly reflects different thresholds of severity adopted by investigators.
Because the DSM-5 criteria are heavily bound to North American cultural definitions, epidemiologic data about personality disorders in other countries are notoriously unreliable.
As previously mentioned, personality disorders, grouped into 3 clusters (ie, A, B, C), as defined in the DSM-5.[1] Sex-related demographics for disorders within these clusters include the following:
Personality disorders generally should not be diagnosed in children and adolescents because personality development is not complete and symptomatic traits may not persist into adulthood. Therefore, the rule of thumb is that personality diagnosis cannot be made until the person is at least 18 years of age. Because the criteria for diagnosis of personality disorders are closely related to behaviors of young and middle adulthood, DSM-5 diagnoses of personality disorders are notoriously unreliable in the elderly population.
Personality disorders are lifelong conditions, although attributes of cluster A and B disorders tend to become less severe and intense in middle age and late life. Individuals with a personality disorder are at risk for the following:
Patients with a cluster B personality disorder are particularly susceptible to problems of substance abuse, impulse control, and suicidal behavior, which may shorten their lives. Cluster C characteristics tend to become exaggerated in later life
In patients with a personality disorder, risk of death is usually related to conditions or behaviors resulting from the disorder. Consequently, death may result from suicide, substance abuse, trauma from motor vehicle accidents, or injuries from fighting.
Patients with personality disorders are at higher risk than the general population for many (axis I) psychiatric disorders. Mood disorders are a particular risk across all personality diagnoses. Some comorbidities are more specific to particular personality disorders and clusters.
Cluster A
Cluster A disorders and their morbidities include the following:
Cluster B
Cluster B disorders and their morbidities include the following:
Cluster C
Cluster C disorders and their morbidities include the following:
Patients should be advised that their patterns of perception and response result from some combination of inheritance and personal history and that recovery is therefore likely to be a prolonged process, requiring effort and attention. The relevance of ongoing psychotherapy to long-standing vulnerabilities requires frequent reemphasis by the physician.
Alcoholism and drug abuse are not merely complications of personality disorders, they are also aggravating factors. Patients need constant reminding that yielding to the temptation to drink or use drugs is likely to make their emotional distress worse and is certain to increase the risk of complications, including suicide.
With the patient's permission, education can be provided to the family to alert them to the possibilities of disruptive and destructive behavior and can provide guidelines for limit setting and safety.
Family support groups exist in some communities, and family support resources, such as Borderline Personality Disorder Family Groups and Stigma, are available online.
The National Institute of Mental Health provides a fact sheet on borderline personality disorder that may be of use to families of persons with that condition.
A resource for patients and families dealing specifically with borderline personality disorder is the National Educational Alliance for Borderline Personality Disorder.
In general, patients with personality disorders have wide-ranging problems in social relationships and mood regulation that usually been present throughout adult life. In these patients, patterns of perception, thought, and response are fixed and inflexible, although the behavior of these patients is often unpredictable. Moreover, these patterns markedly deviate from the expectations of the patient’s culture.
To meet the DSM-5 threshold for clinical diagnosis, the pattern must result in clinically significant distress or impairment in social, occupational, or other important areas of functioning. Note that the disorder will occur in all settings (eg, social as well as vocational) and will not be limited to 1 sphere of activity.[1, 11]
Paranoid personality disorder
Individuals with this disorder display pervasive distrust and suspiciousness, with a tendency to attribute malevolent motives to others, to be preoccupied with unjustified doubts, and to persistently bear grudges. Common beliefs include the following:
Schizoid personality disorder
This type of personality disorder is uncommon in clinical settings. A person with this disorder is markedly detached from others and has little desire for close relationships, choosing solitary activities. The person's life is marked by little pleasure in activities and little interest in sexual relations. People with this disorder appear indifferent to the praise or criticism of others and often seem cold or aloof.
Schizotypal personality disorder
People with this disorder exhibit marked eccentricities of thought, perception, and behavior. Typical examples are as follows:
Antisocial personality disorder
Individuals with antisocial personality disorder display a pervasive pattern of disregard for and violation of the rights of others and the rules of society. Although the formal diagnosis of antisocial personality disorder is made only after one is aged at least 18 years, the following features must start to be exhibited by age 15 years or earlier:
Borderline personality disorder
The central feature of borderline personality disorder is a pervasive pattern of unstable and intense interpersonal relationships, self-perception, and moods. Impulse control is markedly impaired. Transiently, such patients may appear psychotic because of the intensity of their distortions. Diagnostic criteria require at least 5 of the following features:
Borderline personality disorder is, however, one of the most commonly overused diagnoses in DSM-5.
Histrionic personality disorder
Major traits of this condition include the following:
Narcissistic personality disorder
Narcissistic patients are grandiose and require admiration from others.[12] Particular features of the disorder include the following:
Avoidant personality disorder
Avoidant patients are generally very shy. They display a pattern of social inhibition, feelings of inadequacy, and hypersensitivity to rejection. Unlike patients with schizoid personality disorder, they actually desire relationships with others but are paralyzed by their fear and sensitivity into social isolation.
Major traits include the following:
Dependent personality disorder
While many people exhibit dependent behaviors and traits, people with dependent personality disorder have an excessive need to be taken care of that results in submissive and clinging behavior, regardless of consequences. Diagnosis requires at least 5 of the following features:
Obsessive-compulsive personality disorder
People with obsessive-compulsive personality disorder display the following traits:
These are disorders of personality functioning that do not meet the criteria for any specific personality disorder. Major traits include the following:
No specific physical findings are associated with any personality disorders. Physical examination, however, may reveal findings related to the consequences and sequelae of these disorders.
Patients (particularly those with cluster B disorders) may show signs of prior suicide attempts, such as scars from self-inflicted wounds, or stigmata from alcoholism or drug abuse.
In emergent care settings, the examination should include the following:
Few relevant mental status findings are obtained through direct questioning of the patient; they are instead gathered through careful observation of the patient while the clinician is eliciting the history.
Thought process is generally normal in persons with personality disorders, and cognitive functions, including memory, orientation, and intelligence, are usually unimpaired. Insight is often limited, as patients attribute their suffering to uncontrollable influences outside themselves. Judgment can be inferred by the presenting circumstances.
Mental status findings include the following:
The following tests can be used in the diagnosis of personality disorders:
Psychological testing may support or direct the clinical diagnosis.[11, 9] The Minnesota Multiphasic Personality Inventory (MMPI) is the best-known psychological test. The Eysenck Personality Inventory and the Personality Diagnostic Questionnaire are also used. None of these has been reliably validated against DSM-5 diagnoses.
The Structured Clinical Interview for DSM-5 (SCID-5) can also be used to aid in diagnosis.
Caregivers should be vigilant about suicidal potential and should document their assessments in the medical record at each visit.
Poor impulse control in patients with a personality disorder, particularly those with a cluster B disorder, places some degree of legal responsibility on the physician. If a patient threatens someone else with injury, the physician may have a duty to warn the intended victim, either directly or through legal authorities, under the Tarasoff ruling.
Medications are in no way curative for any personality disorder. They should be viewed as an adjunct to psychotherapy so that the patient may productively engage in psychotherapy.
If patients without a true psychotic condition are treated with antipsychotic agents, serious neurologic effects, such as tardive dyskinesia or neuroleptic malignant syndrome, can result. The physician should carefully document the indication for the use of such agents, and these drugs should be discontinued as soon as possible.
These patients rarely seek treatment. When treatment is sought, the physician should be respectful and honest and should provide clear explanations.
Antisocial personality disorder
Set behavioral limits when necessary. Portray a streetwise approach without being punitive.
Borderline personality disorder
Explain care truthfully and simply. Remove anxiety. Frequently, these patients use the defense mechanism of "splitting," describing individuals as all good or all bad. In the emergency department (ED), such patients may be expert at manipulating staffers and may divide caregivers against each other. Be especially sure to have clear communication lines among ED caregivers.
Be aware that emotional volatility in the patient may be precipitated by the news that a requested treatment or disposition is not possible or appropriate. Involve the patient in his or her evaluation by asking the patient to specify the treatment results that he or she expects or hopes to achieve.
With complaints that are hard to characterize, such as weakness, headaches, or dizziness, it may be helpful to ask the patient to keep a diary of his or her symptoms, including date, time, and precipitants. The goal is to have the patient take ownership of his or her presenting symptoms, rather than transferring the responsibility for all solutions to the health care provider.
Histrionic personality disorder
Provide emotional support to the patient but resist a close, interpersonal relationship.
Narcissistic personality disorder
The health care provider must deal with emotional transitions by the patient, from overidealizing the provider to devaluing him or her. The provider must avoid being defensive about mistakes. There has been work done suggesting that a narcissistic personality may have qualities similar to those of an antisocial personality. The main difference appears to be in the degree of grandiosity, with narcissistic patients tending to exaggerate their talents.
Avoidant personality disorder
Avoid criticism of the patient. Establish the physician-patient relationship.
Dependent personality disorder
Set limits with the patient concerning the care being provided.
Obsessive-compulsive personality disorder
Share control of treatment with the patient, allowing the individual to actively participate in decisions regarding his or her care. In addition, avoid being defensive and authoritarian with the patient.
Psychotherapy is at the core of care for personality disorders. Because personality disorders produce symptoms as a result of poor or limited coping skills, psychotherapy aims to improve perceptions of and responses to social and environmental stressors.[13]
Psychodynamic psychotherapy examines the ways that patients perceive events, based on the assumption that perceptions are shaped by early life experiences. Psychotherapy aims to identify perceptual distortions and their historical sources and to facilitate the development of more adaptive modes of perception and response. Treatment is usually extended over the course of several years at a frequency ranging from several times a week to once a month; it makes use of transference.[14, 15]
Cognitive therapy (also called cognitive behavior therapy [CBT]) is based on the idea that cognitive errors stemming from long-standing beliefs influence the meaning attached to interpersonal events. It deals with how people think about their world and with their perception of it. This very active form of therapy identifies the distortions and engages the patient in efforts to reformulate perceptions and behaviors. CBT is typically limited to once-weekly treatments over a period of 6-20 weeks. In the case of personality disorders, such episodes of therapy are repeated often over the course of years.[16]
Interpersonal therapy (IPT) is based on the idea that patients' difficulties result from a limited range of interpersonal problems, including such issues as role definition and grief. Current problems are interpreted narrowly through the screen of these formulations, and solutions are framed in interpersonal terms. Therapy is usually weekly for a period of 6-20 sessions. Though empirically validated for anxiety and depression, IPT is not widely practiced, and therapists conversant in the technique are difficult to locate.[17]
Group psychotherapy allows interpersonal psychopathology to display itself among peer patients, whose feedback is used by the therapist to identify and correct maladaptive ideas, communication, and behavior. Sessions are usually once weekly over a course that may range from several months to years.
Dialectic behavior therapy (DBT), a skills-based therapy (developed by Marsha Linehan, PhD) that can be used in individual and group formats, has been applied to borderline personality disorder. The emphasis of this manual-based therapy is on the development of coping skills to improve affective stability and impulse control and on reducing self-harmful behavior. This treatment is also being used with other cluster B personality disorders to reduce impulsive behavior.[9]
Criteria for hospitalization of patients with personality disorders are generally the same as for patients with axis I psychiatric disorders: imminent danger to self or others, inability to care for basic needs, or psychosocial stressors overwhelming the patient's capacity to cope.
Because the underlying disorder remains basically unchanged by inpatient interventions, length of stay should be minimized to avoid dependency that subverts recovery from the circumstances prompting the hospitalization.
Short stays may be used to stabilize environmental factors, adjust medication regimen, and/or implement short-term psychotherapeutic intervention.
Patients observed in the ED or admitted to the medical-surgical unit of a hospital without a psychiatric service may require transfer to a hospital that provides such service. Psychiatric consultation can provide guidance about whether the patient would benefit from such transfer.
Some patients hospitalized in the psychiatric units of general hospitals, where stays are generally shorter than 2 weeks, may require transfer to psychiatric hospitals that can provide long-term care. Such cases are unusual, being limited to patients with personality disorders whose coping capacities are so grossly impaired that they cannot maintain adequate function in the community or in a less restrictive environment.
The primary care physician should usually consider psychiatric consultation for patients with personality disorders, because the ongoing psychiatric care that patients require is not readily provided in the primary care setting.
If a patient is discharged from an ED to a safe environment, follow-up with a psychiatrist in 24-48 hours should be arranged. Developing a verbal or written contract with the patient that reflects follow-up concerns and eventualities, with expectations for the patient, is frequently helpful.
All patients hospitalized for manifestations of personality disorders should be referred for follow-up psychotherapy or counseling.
Within the limits of contemporary medical knowledge, personality disorders cannot be prevented, although steps can be taken to prevent or deter some of the consequences and complications of personality disorders.
Frequent inquiries about suicidal ideation are warranted, regardless of whether the patient spontaneously raises the subject. The physician need not fear instilling the idea of suicide in a patient who is not already entertaining it. Subsequent inquiry about firearms, lethal medications, and other available means of suicide point to avenues of preventive behavior.[10]
Benzodiazepines, narcotic analgesics, and other drugs with potential for dependency should be used rarely and with great caution. Nearly all personality disorders are marked by impaired impulse control and consequent risk of addictive behavior. Patients with personality disorders are prone to benzodiazepine abuse.
Patients with personality disorder who have children should be asked frequently and in detail about their parenting practices. Low frustration tolerance, a tendency to externalize blame for psychological distress, and impaired impulse control in patients with a personality disorder put their children at risk for neglect or abuse.
Medication is rarely necessary to treat personality disorders. Indeed, differentiating personality disorders from pure mood disorders is important because patients with mood disorders will benefit from medication, particularly selective serotonin reuptake inhibitors (SSRIs). Patients with personality disorders and manifesting comorbid mood disorder require close medical supervision in terms of initiation and following of medication therapy.
Medications are in no way curative for any personality disorder. They should be viewed as an adjunct to psychotherapy so that the patient may productively engage in psychotherapy.
The focus is on the treatment of symptom clusters such as cognitive-perceptual symptoms, affective dysregulation, and impulsive-behavioral dyscontrol. These symptoms may complicate almost all personality disorders to varying degrees, and all of them have been noted in borderline personality disorder.[18, 19, 20, 21, 22, 23]
The assumption is that neurotransmitter abnormalities that transcend the concepts of axis I and axis II disorders underlie these symptom clusters. The strongest evidence for the efficacy of pharmacologic treatment of personality disorders has been for borderline personality disorder, but even this is based on a fairly small database of studies.
Clinical Context: This agent selectively inhibits presynaptic serotonin reuptake.
Clinical Context: Paroxetine is a potent selective inhibitor of neuronal serotonin reuptake. Also has weak effect on norepinephrine and dopamine neuronal reuptake.
Clinical Context: Fluoxetine selectively inhibits presynaptic serotonin reuptake with minimal or no effect on the reuptake of norepinephrine or dopamine.
Clinical Context: This agent is an SSRI and an S-enantiomer of citalopram that is used for the treatment of depression. Escitalopram enhances serotonin activity because of selective reuptake inhibition at the neuronal membrane. Its mechanism of action is thought to be the potentiation of serotonergic activity in the central nervous system (CNS) through the inhibition of CNS neuronal reuptake of serotonin. The onset of depression relief may occur after 1-2 weeks, which is faster than the relief obtained from other antidepressants.
Clinical Context: An antagonist at the 5-HT2 receptor, nefazodone inhibits the reuptake of 5-HT. In addition, this agent has a negligible affinity for cholinergic and histaminergic receptors.
Clinical Context: Mirtazapine increases the availability of serotonin and norepinephrine.
Because of overdose risk, tricyclic antidepressants and monoamine oxidase inhibitors (MAOIs) are usually not prescribed for patients with personality disorders. The selective serotonin reuptake inhibitors (SSRIs) and newer antidepressants are safe and reasonably effective. However, because the depression of most patients with personality disorders stems from their limited range of coping capacities, antidepressants are usually less effective than in patients with uncomplicated major depression.
Antidepressants are most often prescribed for a limited time in patients with serious depressive episodes lasting longer than a few weeks.
Clinical Context: Valproic acid is the most widely used agent in its class. It is modestly effective and generally well tolerated. It is chemically unrelated to other drugs that treat seizure disorders. Although its mechanism of action is not established, its activity may be related to increased brain levels of gamma-aminobutyric acid (GABA) or enhanced GABA action. It also may potentiate postsynaptic GABA responses, affect potassium channels, or have a direct membrane-stabilizing effect.
These agents are useful for stabilizing the affective extremes in patients with bipolar disorder, but they are less effective in doing so in patients with personality disorders. They have some demonstrated efficacy in suppressing impulsive and particularly aggressive behavior in patients with personality disorder.
Clinical Context: Risperidone binds to the dopamine D2 receptor with an affinity that is 20 times lower than it is for the 5-HT2 receptor. This agent improves negative symptoms of psychoses and reduces the incidence of extrapyramidal adverse effects.
Clinical Context: Olanzapine may inhibit the effects of serotonin, muscarine, and dopamine.
Clinical Context: Quetiapine may act by antagonizing the effects of dopamine and serotonin. Its efficacy is similar to that of risperidone and olanzapine. This agent causes fewer dose-dependent adverse effects and less concern regarding weight gain.
Some personality disorders (especially borderline personality disorder) produce transient psychotic periods, while others (eg, schizotypal personality disorder) feature chronic idiosyncratic ideation of nearly psychotic proportions.
Response to antipsychotics in patients with a personality disorder is less dramatic than it is in true psychotic axis I disorders, but symptoms such as anxiety, hostility, and sensitivity to rejection may be reduced. Antipsychotics are typically used for a short time, while the symptoms are active.
The atypical antipsychotics have almost completely replaced the traditional neuroleptics because of their safety margin, but neurologic risks (including tardive dyskinesia and neuroleptic malignant syndrome) are never absent. Risperidone and olanzapine are described here; however, quetiapine and ziprasidone may also be used. No evidence indicates that any of these has superior efficacy, and each one may have advantages and disadvantages with regard to adverse effects.