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Mental Health

Personality disorders (PDs)

Manifestation of extreme personality traits that interfere with everyday life and contribute to significant suffering, functional limitations, or both.

Introduction

Manifestation of extreme personality traits that interfere with everyday life and contribute to significant suffering, functional limitations, or both.

History:

Temperament classification dates back as far as ancient Greece when Hippocrates proposed his humoral theory regarding the classifications of behavior. The postulated temperaments, consisting of sanguine, choleric, melancholic, and phlegmatic, were even in use as recently as the 20th century. Emil Kraepelin classified manic-depressive patients as depressive, hypomanic, or irritable, which in turn correlated with melancholic, sanguine, or choleric dispositions, respectively. These, in turn, evolved into the seven personality disruptions listed by the DSM-1, in 1952. The subsequent DSM II (1968), which was heavily influenced by psychoanalysis, elaborated further to distinctly separate personality disruptions from neuroses of the same name. Psychiatric conceptualization shifted away from the previously accepted psychoanalytic model to a categorical approach strongly correlating with the medical model originally proposed by Kraepelin. This new model was represented by the eleven personality disorders acknowledged in DSM III (1980). Eleven then became ten in the more condensed DSM IV (1994). During the production of the DSM 5 (2013), editors considered combining the novel dimensional five-factor model of behavior with psychoanalytic typological models of personality. However, the catalog ultimately remained unchanged. The ensuing ten disorders are classified within three clusters. Cluster A includes paranoid, schizoid, and schizotypal. Cluster B includes antisocial, borderline, histrionic, and narcissistic. Cluster C includes avoidant, dependent, obsessive-compulsive. These disorders are currently described as pervasive, maladaptive, and chronic patterns of behavior, thinking, and feeling, ultimately leading to distress and dysfunction.


Pathophysiology

Five-factor model:

There are literally hundreds of different personality traits. All of these traits can be organized into the broad dimensions referred to as the
Illustrative traits for both poles across Five-Factor Model personality dimensions. | Cristina Crego and Thomas Widiger: (2020) Personality Disorders | Noba. Retrieved December 09, 2020, from https://nobaproject.com/modules/personality-disorders

Clinical types

Most patients with personality disorders often have little to no insight in regards to their maladaptive behavior. They rarely voluntarily present with “personality disorder” or “personality issues” as their chief complaint. More often than not, the patient will present secondarily to psychiatric sequelae of personality disorders. Such sequelae include chronic depression, interpersonal relationship hardships, unsatisfactory academic history, and poor vocational performance.

Cluster A personality disorders (3.6%): Eccentric personality type

Includes paranoid, schizoid, and schizotypal. They generally appear suspicious, reclusive, and odd
  • Paranoid personality: Excessive sensitivity to setbacks, unforgiveness of insults, recurrent suspicions without justification regarding the sexual fidelity of the spouse or sexual partner, and a combative and tenacious sense of personal rights.
  • Schizoid personality disorder: Withdrawal from affectional, social, and other contacts, preference for fantasy, solitary activities, and introspection. Limited capacity to express feelings and to experience pleasure.
    • Schizotypal type: Avoid social interaction because of a deep-seated fear of people
    • Schizoid type: Feel no desire to form relationships, because they see no point in sharing their time with others.

Cluster B personality disorders (1.5%): Dramatic personalities

Includes antisocial, borderline, histrionic, and narcissistic
  • Antisocial personality disorder (ASPD): Disregard for social obligations, callous unconcern for the feelings of others. Behaviour not readily modifiable by adverse experience, including punishment. Low tolerance to frustration; low threshold for discharge of aggression, including violence; tendency to blame others, all leading to conflict with society.
  • Borderline personality disorder (BPD): Characterized by hypersensitivity to rejection and resulting instability of interpersonal relationships, self-image, affect, and behavior
  • Histrionic personality: Personality disorder characterized by a pattern of excessive attention-seeking behaviors, usually beginning in early childhood, including inappropriate seduction and an excessive desire for approval.
  • Narcissistic personality disorder: Long-term pattern of exaggerated feelings of self-importance, an excessive craving for admiration, and struggles with empathy

Cluster C personality disorders (2.7%):

Includes avoidant, dependent, obsessive-compulsive. These share a common theme of experiencing unfound anxiety, abnormal fears, and desire for untenable social relationships.
  • Obsessive-compulsive/Anankastic personality: Feelings of doubt, perfectionism, excessive conscientiousness, checking and preoccupation with details, stubbornness, caution, and rigidity.
  • Anxious [avoidant] personality: Feelings of tension and apprehension, insecurity and inferiority. A continuous yearning to be liked and accepted, hypersensitivity to rejection and criticism with restricted personal attachments, and a tendency to avoid certain activities by habitual exaggeration of the potential dangers or risks in everyday situations.
  • Dependent personality: Pervasive passive reliance on other people to make one’s major and minor life decisions, great fear of abandonment, feelings of helplessness and incompetence, passive compliance with the wishes of elders and others, and a weak response to the demands of daily life

Diagnosis

Diagnostic criteria:

The five personality disorder trait domains in the proposed International Classification of Diseases (ICD), 11th edition and the Diagnostic and Statistical Manual of Mental Disorders (DSM), 5th edition are comparable in terms of Negative Affectivity, Detachment, Antagonism/Dissociality and Disinhibition. However, the ICD-11 model includes a separate domain of Anankastia, whereas the DSM-5 model includes an additional domain of Psychoticism.
ICD-11 and DSM-5 Alternative Model of Personality Disorders classifications of personality disorders | Schema therapy conceptualization of personality functioning and traits in ICD-11 and DSM-5 – Scientific Figure on ResearchGate. Available from: https://www.researchgate.net/figure/ICD-11-and-DSM-5-Alternative-Model-of-Personality-Disorders-classifications-of_tbl1_328122601 [accessed 9 Dec, 2020]
Preliminary category to domain cross-walk for DSM-5 and ICD-11 personality disorder models. | ICD-11 and DSM-5 personality trait domains capture categorical personality disorders: Finding a common ground – Scientific Figure on ResearchGate. Available from: https://www.researchgate.net/figure/Preliminary-category-to-domain-cross-walk-for-DSM-5-and-ICD-11-personality-disorder_tbl3_319123080 [accessed 9 Dec, 2020]

Management

Personality disorders are one of the most difficult disorders to treat in psychiatry. The patient will not see his or her behavior as being maladaptive but instead will feel egosyntonic. Believing thus, the patient will have difficulty acquiescing to treatment. To make matters worse, even if a patient is agreeable to treatment, modern medicine is still lacking in available treatment modalities, as there are no medications currently approved to treat any personality disorder. The best strategy for a clinician to implement is to help the patient develop new behavior in the face of adversity.

Cluster A personality disorders:

  • Individual social skills training
  • Schizoid and schizotypal types: Augmentation with 2nd-gen antipsychotics
  • Group therapy (as they tend to be suspicious and distrustful)

Cluster B personality disorders:

Group therapy along with Individual social skills training
  • Antisocial personalities (reducing aggression): Lithium, valproic acid, and antipsychotics.
  • Histrionic personalities: Cognitive-behavioral therapy (CBT) (focusing on their need for attention)
  • Narcissistic personalities (difficult as they rarely come in, if at all, and will challenge all critiques and suggestions): Intensive psychodynamic psychotherapy
  • Borderline personality disorder: Dialectical behavior therapy (DBT)

Cluster C personality disorders:

  • Cognitive-behavioral therapy (CBT): Address assertiveness, independence, and attitude
  • Selective serotonin reuptake inhibitors (SSRIs): Address underlying anxiety
  • Avoidant personality disorder: Supportive psychotherapy, assertiveness, and social skills training, and psychodynamic psychotherapy
  • Obsessive-compulsive personality disorder: Psychoanalytic psychotherapy

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