16th November 2023

Adult Personality and Behaviour Psychopathology

Classification

The classification of disorders of adult personality and behaviour covers ICD-10 codes F60-F49. Where differences occur in DSM-5 terminology, this has been discussed in the appropriate sections below. There are also some significant changes in ICD-11 classification that will be discussed further throughout the chapter.

References

• International Statistical Classification of Diseases, tenth revision (ICD-10), Version:2016, https://icd.who.int/browse10/2016/en#/F60-F69
• International Statistical Classification of Diseases, eleventh revision (ICD-11), Version 01/2023, https://icd.who.int/browse11/l-m/en

Personality Disorder

Over the years, what was already a controversial (and confusing!) topic has changed drastically. By giving a diagnosis of personality disorder, we are effectively stating that someone’s personality is, in a way, ‘wrong’ or incompatible with societal norms, which has led to questioning whether it is appropriate to medicalise this patient group when issues arise are social. First, we will look at ‘normal personality’ before classifications of personality disorder.

Normal personality can be described in terms of traits and types. There are multiple theories and models that use varying numbers of traits to describe personality, ranging from Eysenk’s three-factor theory to Cattell’s 16-factor theory. To unify this, there is a general understanding that there are five fundamental traits – openness, extraversion, neuroticism, conscientiousness and agreeableness – certainly easier to remember than 16! When describing personality in terms of types, the aim would be to draw parallels with specific archetypes – this can be in broad or narrow terms. Ideographic methodologies, such as cognitive-behavioural, psychoanalytic and humanistic approaches, aim to take into account individuality and how previous experiences or development play a role in personality.

Classification

Let’s look at the characteristics of each PD split into the clusters used by DSM-5:

Cluster A – Odd or eccentric personality disorders:

• Paranoid – Distrust and suspicion of others and a tendency to interpret the motives of others as malicious.
• Schizoid – Pervasive detachment from social relationships and a restricted range of emotional expression.
• Schizotypal – Eccentric behaviour and unusual beliefs or appearance, uncomfortable around others.

Cluster B – Dramatic, emotional, or erratic personality disorders:

• Antisocial – Disregard for the rights of others and a lack of empathy, often irresponsible, irritable and aggressive. Associated with criminal behaviour with evidence of childhood conduct disorder.
• Borderline (ICD-10’s emotionally unstable – borderline type) – Unstable moods, self-image, and interpersonal relationships, and a tendency to engage in impulsive acts, threats or self-harm.
• Histrionic – Dramatic with shallow effect, egocentric and attention-seeking or manipulative behaviour.
• Narcissistic – Grandiose sense of self-importance, a need for admiration, and a lack of empathy for others.

Cluster C – Anxious or fearful personality disorders:

• Avoidant – Insecure and self-conscious with a fear of rejection, a tendency to avoid social situations.
• Dependent – Persistent need to be taken care of and a tendency to rely on others to make decisions.
• Obsessive-compulsive (ICD-10’s anankastic) – Preoccupation with order, control, perfectionism, and a tendency to be rigid and inflexible.

This leaves us with ICD-10’s emotionally unstable – impulsive type, characterised by the unpredictability of behaviour and mood, which is poorly controlled.

Predisposition, onset and maintenance

The aetiology of personality disorder is complex and multifactorial; the following factors may be implicated:

• Genetic – There is evidence that ‘normal’ personality traits are inheritable, and there are also familial links between certain PDs and disorders such as schizophrenia, affective and delusional disorders.
• Developmental – Traumas in childhood are known factors of developing PD; for example, a history of sexual abuse may predispose to borderline PD. Neglectful or inconsistent parenting styles may result in attachment difficulties and predispose to dependent or antisocial PD. Childhood conduct disorder and ADHD may also lead to the development of PD in later life.
• Neurophysiology – Studies suggest that there may be neurobiological differences in patients with PD. These include altered amygdala activity in certain processing functions and ‘immature’ EEG in psychopathy. As well as reduced serotonin levels in people who are impulsive or violent.
• Psychodynamic theories – Freud’s theory suggests that arrested development during different stages of childhood can lead to histrionic, obsessional and dependent PD. Whereas Kernberg suggested that a patient’s disorganised reactions to an event stops them from being able to respond rationally, therefore perpetuating further crises. Other theories include patients with PD displaying more primitive defence mechanisms or a lack of some aspects of superego (or morals).
• Cognitive-behavioural theories – Maladaptive patterns of thinking, affect and behaviour can lead to development of PD. These schemata are principles that are learned as a child in response to a combination of experiences and pre-existing behavioural patterns and responses.

The complexity of PD makes it difficult to fully understand prevalence. However, it is thought that in the UK, it affects 4.4% of the general population, 10-12% of primary care patients, and 33% of psychiatric outpatients, with the highest prevalence being in prisoners – 65% of males and 42% of females!

Focused history

A thorough assessment is essential, as there can be many pitfalls in diagnosing PD, and it is best to carry out multiple interviews before making a diagnosis. Everyone is allowed a bad day! A good personal history covering early childhood, education, employment and particularly relationships is key in identifying if PD is present. If the patient can’t recall aspects, then don’t be afraid to obtain collateral. It is important to consider not only information given by the patient but also their response to questioning (transference) and your response to them (countertransference). Enacted negative countertransference can occur when a diagnosis is made based on how the patient has made you feel rather than the assessment you just carried out.

Assessment and diagnosis of personality disorder

There are some tools that can be useful in diagnosis. However, none are really accepted as the gold standard measure. In general, focused interviews are more reliable than patient questionnaires. Assessment methods are broken down into structured categorical, structured dimensional and unstructured assessments. Often, patients will meet the criteria for multiple PDs and other comorbid mental health diagnoses.

Treatment

It is important that a consistent, boundaried approach is taken and to be aware disordered attachments may develop with staff. There is little benefit from long inpatient stays, but admission may be required in high-risk crises.

Biological treatments – Evidence is limited on the efficacy of medication in treating PD. However, it may be useful in comorbid diagnoses. Antipsychotics such as aripiprazole have been useful in managing impulses in borderline PD, antidepressants for managing low mood in borderline, avoidant or anankastic PD and mood stabilisers for patients who struggle with emotional dysregulation.

Psychological treatments – Two possible treatments stem from combined elements of psychodynamic and cognitive behavioural theories for developing PD. These are cognitive analytical therapy (CAT), which focuses on identifying and modifying maladaptive patterns of thinking and behaviour and dialectical behavioural therapy (DBT), which focuses more on developing skills to help regulate emotions and improve relationships with others. CBT can also be beneficial and is very similar to CAT; only it focuses on patterns of thought and behaviour in the present rather than delving into the past.

Psychosocial treatment – Therapeutic communities (if available) are specifically designed environments to help patients with PD to challenge difficult interpersonal behaviour. The aim is for them to be able to confront reality and learn to be democratic and tolerant of others in a supportive setting. Individual and group activities are offered.

Social treatments – Developing a supportive and understanding network of friends and family and educating those close to the patient can be helpful.

References

• Semple D; Smyth R. (2019). Oxford Handbook of Psychiatry, fourth edition.
• International Statistical Classification of Diseases, tenth revision (ICD-10), Version:2016, https://icd.who.int/browse10/2016/en#/F60-F69
• International Statistical Classification of Diseases, eleventh revision (ICD-11), Version 01/2023, https://icd.who.int/browse11/l-m/en#/http%3a%2f%2fid.who.int%2ficd%2fentity%2f37291724

Habit and Impulse Control Disorders

Habit and impulse disorders (ICD-10) or impulse control disorders (ICD-11) are a group of disorders where the patient engages in a certain irresistible impulse that has the potential to cause harm either to the patient or to others. The behaviours may impact interpersonal relationships, education, work and general functioning and lead to distress. For a diagnosis to be made, there must be evidence of repeated inability to resist the impulse. Episodes can be prefaced by an increase in tension or emotional arousal, with these feelings easing after carrying out the act.

• Pathological fire-setting or pyromania (ICD-10/11 and DSM-5) – May present with comorbidities which should be treated; following this CBT may be useful.
• Pathological stealing or kleptomania (ICD-10/11 and DSM-5) – Possible treatment options include SSRIs and psychotherapy.
• Trichotillomania (ICD-10/11 and DSM-5) and excoriation disorder (DSM-5 and ICD-11) – These two disorders are similar and can often be seen together. Characterised by recurrent pulling of the patient’s own hair and picking of the skin, respectively. Treatments may look to treat any complications alongside psychotherapy options; there is some evidence for medication.
• Intermittent explosive disorder (DSM-5 and ICD-11) – Characterised by disproportionate aggressive or violent outbursts in response to a situation. Treatments look to minimise aggression.
• Gambling and gaming disorder is also described in DSM-5 and ICD-11. Pathological gambling was the terminology used in ICD-10.

References

• Semple D; Smyth R. (2019). Oxford Handbook of Psychiatry, fourth edition.
• International Statistical Classification of Diseases, tenth revision (ICD-10), Version:2016, https://icd.who.int/browse10/2016/en#/F60-F69
• International Statistical Classification of Diseases, eleventh revision (ICD-11), Version 01/2023, https://icd.who.int/browse11/l-m/en#/http%3a%2f%2fid.who.int%2ficd%2fentity%2f826065555

Disorders of Sexual Preference and Paraphilic Disorders

There has been a lot of change in this category between ICD-10 and ICD-11 classifications, and although initially in the workings and still present in DSM-5, the categories fetishism and fetishistic transvestism are no longer included. This leaves exhibitionism, voyeurism, paedophilia, sadomasochism and frotteurism of the ICD-10 disorders of sexual preference, although again, these have been updated. Aetiological factors may be physiological, such as hormonal imbalance in utero, in adulthood and possibly underlying genetic causes. Psychological explanations also propose factors preventing normal sexual development or factors promoting deviant sexual behaviours or thoughts.

Assessment and diagnosis

Sexually deviant desires may be present as part of other psychiatric conditions. Therefore, thorough assessment and MSE is essential, particularly focussing on the psychosexual history. These patients may present of their own accord, on the request of a partner or even the court after an offence has been committed. Physical examination may be useful if there is comorbid sexual dysfunction, which will help to decide if investigations are required. The below are ways the patient achieves sexual arousal through thoughts, fantasies or behaviours. For disorder to be present, these must cause the patient discernible distress or risk of harm to themselves or others:

• Fetishistic disorder – Use of an inanimate object.
• Transvestic disorder – Dressing in the clothes of the opposite sex.
• Exhibitionistic disorder – Exposing the genitalia to an unsuspecting person or people.
• Voyeuristic disorder – Watching others have sexual relations, being without clothes or undressing.
• Paedophilic disorder – Sexual thoughts, urges or acts involving prepubescent children (<13 years).
• Coercive sexual sadism disorder – Inflicting mental or physical pain or humiliation. Previously, DSM-5’s sexual sadism disorder also alongside sexual masochism disorder, which is no longer included.
• Frotteuristic disorder – Rubbing against or otherwise touching an unsuspecting person.
• Other paraphilic disorders involving non-consenting individuals – These include necrophilia, zoophilia, klismaphilia and autoerotic asphyxia, among others.

Treatment

Treatment should not be offered unless the patient wants it and recognises that therapies will be labour intensive on their part. Aims can be altering the focus of the arousal or managing the distress associated.

Physical treatments – Historically, neurosurgery or castration have been used.

Biological treatment – There is evidence for the use of hormonal therapies (anti-androgens and progesterone) and SSRIs. Fluoxetine is mentioned in NICE guidance; however, studies are limited.

Psychological treatment – CBT and psychodynamic psychotherapy.

References

• Semple D; Smyth R. (2019). Oxford Handbook of Psychiatry, fourth edition.
• International Statistical Classification of Diseases, tenth revision (ICD-10), Version:2016, https://icd.who.int/browse10/2016/en#/F60-F69
• International Statistical Classification of Diseases, eleventh revision (ICD-11), Version 01/2023, https://icd.who.int/browse11/l-m/en#/http%3a%2f%2fid.who.int%2ficd%2fentity%2f2110604642
• National Institute for Health and Care Excellence. (20215). Hypersexuality: fluoxetine [Evidence summary ESUOM46]. https://www.nice.org.uk/advice/esuom46/chapter/Key-points-from-the-evidence

Gender Identity and Gender Dysphoria

Again, this is a category that has changed dramatically between ICD-10, DSM-5 and ICD-11. But first, let us look at what gender identity is. Gender identity relates to the perception of one’s own sex, whereas gender dysphoria describes distress due to a divergence from one’s biological sex. Because there is incongruence to biological sex, this does not mean gender dysphoria is present; this can be described as gender nonconformity. It is also important to separate dual role transvestism (ICD-10) – which is wearing the clothes of the opposite sex to temporarily belong to that gender without wishing for a permanent change – and fetishistic transvestism where cross-dressing results in sexual arousal. In ICD-10, transsexualism is associated with experiencing discomfort, distress or impaired functioning due to their assigned gender.

Assessment and investigations

Thorough medical, psychiatric and physical examination need to be undertaken. These can help to rule out differentials such as body dysmorphic disorder, intersex conditions, schizophrenia and other psychoses. Past medical and family history are also essential to identify potential risks of treatments such as cardiovascular risk factors and VTE. Investigations will also help to identify the same risks alongside any endocrine abnormalities, prostate, cervical or sexual health diagnoses.

Diagnosis

In ICD-11, gender incongruence sits in ‘conditions related to sexual health’ rather than ‘mental behavioural and neurodevelopmental disorders’. It covers gender incongruence in adolescence or adulthood (HA60) and in childhood (HA61). For adults and adolescents, there must be a strong wish to be able to transition to the sex they identify with and for children; there may be a desire to have the primary and/or secondary sexual characteristics of their preferred gender depending on developmental stage. These desires must be present for about two years.

Treatment

Treatment should be based on the individual’s unique needs and goals.

Non-medical / psychological treatment – There is a role for voice modulation, temporary or permanent methods of hair removal (particularly facial hair) and counselling for support.

Medical/endocrine treatment – Possible aims of therapy are the suppression of puberty or endogenous sex hormones and replacement with the sex hormones of the alternative gender at a physiological level. For biologically male patients, this would be suppression of androgens and giving synthetic oestrogen. For biologically female patients, this would be the administration of testosterone. Fertility preservation treatments should be offered. Patients must be counselled on potential side effects and red flags.

Surgical treatment – In the UK, there is a higher threshold for assessment and consent for reconstruction interventions. Chest or ‘top surgery’ is offered more readily than genital reconstruction or ‘bottom surgery’.

Social – In the time leading up to transition, it is important to consider the social surroundings and stigma a patient may face. It might not always be possible for a social transition to take place before medical or surgical interventions are undertaken. However, testing this out is no longer required before non-surgical treatments. Patients can be signposted to support groups. Legal support may be required in the process of changing names and gender on official documentation.

References

• Semple D; Smyth R. (2019). Oxford Handbook of Psychiatry, fourth edition.
• International Statistical Classification of Diseases, tenth revision (ICD-10), Version:2016, https://icd.who.int/browse10/2016/en#/F60-F69
• International Statistical Classification of Diseases, eleventh revision (ICD-11), Version 01/2023, https://icd.who.int/browse11/l-m/en#/http://id.who.int/icd/entity/411470068

Factitious Disorder

Under ICD-11, factitious disorder (Munchausen’s syndrome) is now in a category of its own and covers factitious disorder posed on self and posed on others. In this condition, patients, unmotivated by potential gains, feign psychiatric or physical conditions or impose them on others (factitious disorder by proxy). They may falsify signs and symptoms to seek out treatment for themselves or keep others dependent on their care. It is often seen in paramedical professionals and is closely linked with antisocial and borderline PDs. It is very similar to malingering, the crucial difference being that in malingering, there is some obvious gain for the individual, for example, compensation. Treatment is extremely difficult, as the patient will often be resistant to psychiatric assessment. However, iatrogenic harm due to over investigation must be minimised by either directly or indirectly challenging the patient about their intent to feign illness or passing on information to surrounding regions to prevent ‘hospital hopping’.

References

• Semple D; Smyth R. (2019). Oxford Handbook of Psychiatry, fourth edition.
• International Statistical Classification of Diseases, tenth revision (ICD-10), Version:2016, https://icd.who.int/browse10/2016/en#/F60-F69
• International Statistical Classification of Diseases, eleventh revision (ICD-11), Version 01/2023, https://icd.who.int/browse11/l-m/en#/http%3a%2f%2fid.who.int%2ficd%2fentity%2f430567349