Personality Disorders

A personality d/o is pervasive and constant, causing serious distress or impaired functioning. The individual's character traits deviate significantly from cultural norms.

Begins in adolescence or early adulthood. They lead to distress or impairment. The caveat to the diagnosis of personality disorders is that the features do not occur in the context of signs or symptoms that are part of a mood, anxiety, impulse control, or psychotic disorder, or any other psychiatric disorder as the primary underlying illness.

Personality traits are patterns of behavior or thinking about oneself and the environment that are relatively consistent over time, but they do not lead to a diagnosis of personality disorder unless they are maladaptive or cause functional impairment or distress.

Some personality d/o lessen with time, others continue throughout the patient's life. Personality d/o are Axis II diagnoses that fall into three clusters.

Cluster A Personality Disorders: Pts with cluster A personality d/o are eccentric or somewhat bizarre.

Paranoid personality disorder. Pt. have a pervasive pattern of interpreting actions and events as malevolent or demeaning. They are suspicious of the motives of others, fear exploitation or deceit, and scrutinize peers closely. Other traits include reluctance to share personal information, frequent misinterpretation of benign comments, unwillingness to forgive others, frequent angry reactions, and pathologic jealousy. Alcohol and substance abuse are common, brief psychotic episodes are not unusual and patients often develop MDD, agoraphobia, and OCD.

Schizoid personality d/o. These Pts are unable to form close relationships with others and have very restricted emotions. They do not attempt to achieve intimacy, prefer to be alone, and have no close friends, show little interest in sexual activity, and do not enjoy most activities. Approval or disapproval from others is unimportant. MDD may develop, and schizoid personality disorder may precede the development of delusional disorder or schizophrenia.

Schizotypal personality d/o. In addition to difficulty in maintaining close relationships, patients have odd or distorted behavior, cognition, or perception. Suspiciousness and ideas of reference are common, as are interests in superstitions or the paranormal. Eccentric speech, inappropriate affect and behavior , lack of close relationships, and social anxiety are other features of this disorder. Increased psychotic features may result in the diagnosis of a psychotic disorder.

These patients do not respond to antipsychotics. Psychotherapy is the preferred therapy.

Cluster B Personality Disorders. Involve dramatic or overemotional personality traits.

Antisocial personality disorder. Previously termed psychopath or sociopaths, individuals in this d/o show disregard for social norm and interests of others. They break laws, act aggressively, and deceitfully, and lack remorse for their actions. Other diagnostic features include failure to plan, reckless patterns of behavior, and lack of responsibility. Conduct d/o may be present before age 18 years. Several d/o, such as anxiety, depression, substance use, and somatization d/o, are associated. The majority of these patients are men.

Borderline personality disorder. Pt experience unstable relationships, self-esteem, and emotions. The desperately fear being abandoned and yet have a need to keep distant. Impulsivity, suicidal thoughts and actions, mood lability, uncontrolled anger, and feelings of boredom or emptiness are common features. Transient paranoid or dissociative sx may occur. Extreme idealization or devaluation. Splitting. Associated dx include mood d/o substance abuse, bulimia, PTSD, and ADHD. Approximately 75% of Pts are women.

Histrionic personality disorder. Labile emotions and attention-seeking patterns of behavior characterize this d/o. Pts want to be the center of attention and often use seductive behaviors or physical appearance to achieve this goal. Shallow or labile emotions, dramatic speech and behavior, easily influenced opinions, and inappropriately perceived intimacy are common. MDD, somatization, and conversion d/o may occur.

Narcissistic personality disorder. Pts are self-centered, have grandiose self-images, frequent fantasies of love and success, and a sense of entitlement. They expect admiration from others because they believe themselves to be superior. They lack empathy and may exploit, snub, or envy others. The majority of Pts are men. Anorexia, substance use, and mood d/o may occur.

Cluster C Personality Disorders. Anxiety and fear characterize cluster C personality disorders.

Avoidant personality disorder. Pt's avoid social situations for fear of rejection, and make friends only when they are certain of being accepted. Fears of embarrassment lead to a reluctance to be open or try new activities, a pattern of misinterpreting comments as critical, and the development of low self-esteem and feeling of inadequacy. Mood and anxiety disorders are common.

Dependent personality disorder. These patients are need, require support, advice and validation for everyday decisions and allow others to be responsible for their life choices. Conflict or disagreement is very difficult, as is personal motivation or initiative. Pts feel unable to take care of themselves, so they fear being alone and seek out close relationships. Pts constantly try to have others nurture them. Mood and anxiety disorders are common. Men and women have equal rates of this diagnosis.

Obsessive-compulsive personality disorder. Pt. tend to be perfectionist and controlling. They are micromanagers, overly conscientious to the point of missing deadlines. Their extreme devotion to work is accompanied by extreme preoccupation with petty details and rules and an inability to delegate tasks to others. Patients are inflexible and stubborn, miserly, and are often unable to discard old, unwanted objects. These patients do no typically meet criteria of OCD. Mood and anxiety disorders are common. Men have this diagnosis more frequently than women. Fluorodeoxyglucose PET consistently shows hypermetabolic activity in the caudate, anterior cingulate, and orbitofrontal cortex. DSM-5 states that the pathologic process of obsessive-compulsive disorder has a specific set of criteria. One requirement is that the pathologic process consume a considerable amount of time (1 hour) daily. Some patients with obsessive-compulsive disorder have associated depression and many will respond to SSRIs; however, according to the DSM-5, the amount of time spent on obsessions and compulsion is paramount when considering a diagnosis.