Psychiatry - Personality disorders

Question 1

What are personality disorders?

Answer 1

These are characterised by rigid, long lasting patterns of thought, affect and behaviour. The attitudes of people with a personality disorder usually exaggerate part of their personality and result in behaviour at “odds” with normal expectation. These conditions must NOT be attributable to brain damage, organic disease or other psychiatric conditions.

Question 2

What criteria must be met for a diagnosis of personality disorder to be made?

Answer 2

1) Markedly disharmonious attitudes and behaviours, involving several areas of functioning - e.g. arousal, affectivity, impulse control and relationships
2) Prevailing, chronic, abnormal behaviour patterns not limited to discrete episodes, which are pervasive and maladaptive
3) Present in a broad range of social and personal situations
4) Manifestations appear <18 and continue into adulthood
5) There is considerable personal distress caused by these patterns of behaviour (although this may only become apparent later on)
6) Associated with occupational and social problems

Question 3

How are personality disorders classified?

Answer 3

Classification of personality disorders is categorical whereas personality is dimensional. Personality disorders are grouped into several traits to make diagnosis easier. But remember, everyone has a personality, but not all personalities are disordered. Avoid labels and engage with the person.

Question 4

How should personality disorders be managed?

Answer 4

There is very little evidence that psychiatry helps treating patients with personality disorders - essentially the disorder is one of social problems rather than a mental illness. Despite that, patients with personality disorders are at increased likelihood of premature death from a number of causes. In general:

• treat the individual
• reflect their goals
• help manage crisis
• treat cormorbid conditions
• consider patient/professional relationships

Medication plays NO part in treating personality disorders, so talking therapies are recommended:

• dialectal behavioural therapy (DBT) combines individual and group therapy using mindufulness, CBT and Eastern philosophy
• therapeutic communities
• mentalization

Question 5

What is the prognosis of personality disorders?

Answer 5

Poor. People diagnosed with personality disorder have higher rates of morbidity and mortality, worse outcomes for associated mental and physical illness, and lowered quality of life. Taking this into account, the prevalence of personality disorders decreases with age. This may be because older adults tend to be less impulsive and aggressive or maybe just better at hiding these traits.

Question 6

What disorders are found in cluster A personality disorders?

Answer 6

Research suggests that personality disorders fall into 3 groups, according to their emotional flavour (predominating characteristic).

Cluster A personalities are “odd or eccentric” and tend to be male dominated disorders.

They include:

i) PARANOID = suspicious, preoccupied with conspiracy, distrusts others
ii) SCHIZOID = emotionally “cold”, lacks interest in others, rich fantasy world
iii) DISSOCIAL = aggressive, easily frustrated, callous lack of concern for others, irresponsible and impulsive, criminal activity, unable to maintain relationships

Question 7

What are cluster B personality disorders?

Answer 7

Cluster B personalities are dramatic or emotional disorders. Aside from emotional subtypes, males are mostly affected by these disorders.

i) Emotionally unstable (2 types):
- BORDERLINE = feelings of emptiness, unclear identity, intense and unstable relationships, unpredictable affect, threats of self harm
- IMPULSIVE = inability to control anger or plan, unpredictable affect and behaviour

ii) HISTRIONIC = over dramatize, self centred, shallow affect, seeks attention, seductive, manipulative behaviour
iii) NARCISSISTIC (DMS-IV only) = high self importance, lacks empathy, grandiose, needs admiration
iv) ANAKASTIC (obsessive-compulsive) = worries and doubts, orderliness and control, perfectionism, sensitive to criticism, rigid and judgmental

Question 8

What are the cluster C personality disorders?

Answer 8

These are characterised by anxious or avoidant personality types.

i) ANXIOUS = men and women equally affected, patients are extremely anxious and tense, self conscious, insecure, fearful of negative evaluation by others
ii) DEPENDENT = females mostly affected; passive, clingy, submissive, excess need for care, feels helpless when not in a relationship

Question 9

What risk factors are associated with personality disorder?

Answer 9

Early adversities that are commonly reported by patients with personality disorder only lead to pathology in a minority of those in the population experiencing similar adversity. This suggests an underlying vulnerability in those who develop personality disorders. Early adversities that are commonly reported include social stressors, child abuse and dysfunctional families.

Question 10

How should personality disorders be investigated?

Answer 10

MRI may be indicated if organic causes of personality change are suspected - e.g frontal lobe tumour, or subdural haematoma.

Careful and thorough assessment should be undertaken. A collateral history is essential.

Psychometric testing such as the Millon Clinical Multiaxial Inventory may be useful.