Personality Disorders

Lifelong, persistent, deeply ingrained maladaptive behaviour that characterizes an individual and deviates markedly from culturally expected or expected ‘normal’ range

Aetiology

• Developmental conditions that appear in childhood or adolescence and continue into adult life

• Genetic and environmental influences

• They are not secondary to another psychiatric disorder or brain disease, although they may precede or coexist with other disorders

• Cannot be explained as a manifestation or consequence of other adult mental disorders

Cluster 'A' personality disorders - odd and eccentric

Paranoid - 4 of:

• Excessive sensitivity to setbacks

• Tendency to bear grudges

• Suspiciousness and tendency to misconstrue the neutral/friendly actions of others as hostile/contemptuous

• A combative and tenacious sense of personal rights out of keeping with the actual situation

• Recurrent suspicions, without justification, regarding sexual fidelity of partner

• Persistent self-referential attitude, associated particularly with excessive self-importance

• Preoccupation with unsubstantiated 'conspiratorial' explanations of events in the world at large

Schizoid - 4 of:

• Few, if any, activities provide pleasure

• Emotional coldness, detachment, or flattened affectivity

• Limited capacity to express warm feelings for others as well as anger

• Indifferent to either praise or criticism of others

• Little interest in having sexual experiences with another person

• Almost always chooses solitary activities

• Excessive preoccupation with fantasy/introspection

• Neither desires, nor has, any close friends or confiding relationships (or only one)

• Marked insensitivity to prevailing social norms/conventions

Schizotypal - 5 of:

• Ideas of reference

• Odd beliefs or magical thinking, inconsistent with subcultural norms

• Unusual perceptual experiences, including bodily illusions

• Odd thinking and speech

• Suspiciousness or paranoid ideation

• Inappropriate or constricted affect

• Behaviour or appearance that is odd, eccentric, or perculiar

• Lack of close friends or confidants other than first-degree relatives

• Excessive social anxiety that does not diminish with familiarity and tends to be associated with paranoid fears rather than negative judgements about self

Cluster 'B' personality disorder - dramatic and emotional

Antisocial/dissocial - 3 of:

• Callous unconcern for feelings of others

• Irresponsible and disregard for social norms/rules/obligations

• Incapacity to maintain enduring relationships, though no difficulty establishing them

• Very low tolerance to frustration and low threshold for aggression/violence

• Incapacity to experience guilt, or to profit from adverse experience, particularly punishment

• Marked proneness to blame others

Emotionally unstable

• Tendency to act unexpectively, without consideration of consequences

• Quarrelsome behaviour and conflicts with others, especially when impulsive acts are thwarted/criticized

• Liability to outbursts of anger or violence

• Difficulty in maintaining any course of action that offers no immediate reward

• Unstable mood

• Disturbances in and uncertainty about self-image, aims and internal preferences (including sexual)

• Intense and unstable relationships, often leading to emotional crises

• Excessive efforts to avoid abandonment

• Recurrent threats or acts of self-harm

• Chronic feelings of emptiness

Histrionic - 4 of:

• Self-dramatization, theatricality, or exaggerated expression of emotions

• Suggestible

• Shallow/labile affectivity

• Continually seeks excitement and activities in which the subject is the centre of attention

• Inappropriately seductive in appearance or behaviour

• Overly concerned with physical attractiveness

Narcissistic - 5 of:

• Grandiose logic of self-importance

• Fixation with fantasies of infinate success, control, brilliance, beauty, or idyllic love

• Credence that he/she is extraordinary and exceptional and can only be understood by, or should connect with,other extraordinary or important people or institutions

• Desire for unwarranted admiration

• Sense of entitlement

• Interpersonally oppressive behaviour

• No form of empathy

• Resentment of others or a conviction that others are resentful of him or her

• Display of egotistical and conceited behaviours or attitudes

Cluster 'C' personality disorders - anxious and avoidant

Anankastic - 4 of:

• Excessive doubt and caution

• Preoccupation with details, rules, lists, order, organisation or schedule

• Perfectionism that interferes with task completion

• Excessive conscientiousness

• Undue preoccupation with productivity to the exclusion of pleasure/interpersonal relationships

• Pedantic, excessive adherence to social conventions

• Rigidity and stubbornness

• Unreasonable insistence that others submit to exactly his or her way of doing things, or unreasonable reluctance to allow others to do things

Anxious - 4 of:

• Persistent pervasive feelings of tension/apprehension

• Belief that oneself is socially inept/inferior to others

• Excessive preoccupation about being criticised/rejected in social situations

• Unwillingness to get involved with people unless certain of being liked

• Restrictions in lifestyle because of need of security

• Avoidance of social or occupational activities that involve significant interpersonal contact, because of fear of criticism, disapproval, or rejection

Dependent - 4 of:

• Encouraging or allowing others to make most of one's important life decisions

• Subordination of one's own needs to those of others on whom one is dependent, and undue complaince with their wishes

• Unwillingness to make even reasonable demands on the people one depends on

• Feeling uncomfortable or helpless when alone, because of exaggerated fears of inability to care for oneself

• Limited capacity to make everyday decisions without an excessive amount of advice/reassurance

Investigations

• Diagnosis is largely clinical

• Clinical assessment is complex, takes time, and requires more than one appointment

• There are several rating scales e.g. ZAN-BPD for borderline personality disorder, PAS, PDQ-4

Management

Avoidant PD

• Social skills training may be helpful

• Some evidence for antidepressants

Emotionally unstable PD

• The main psychological treatment is dialetical behavioural therapy

• Other therapy options include mentalization based therapy and STEPPS

• Inpatient care not usually considered however may be indicated when:
• Management of an acute increase in suicide risk
• Changes to medication cannot be managed in the communiy
• Clarification and treatment of comorbid diagnosis

Dissocial/antisocial PD

• Psychological interventions - group based cognitive and behavioural interventions

• Pharmacological interventions are not routinely used

Pharmacological treatment

• Pharmacological treatment is not recommended by NICE, but the short-term use of a sedative medication can be useful during a crisis as part of a longer care plan