31st January 2024

Personality Disorders

Overview

The concept of personality has been explored since the dawn of human existence. The “4 humours theory” is probably the first known recognised categorisation, which is seen in Hippocrates’ teaching. This theory states that 4 bodily fluids/humours should be balanced for someone to be healthy. The 4 fluids are black bile, yellow bile, blood and phlegm. Galen, a disciple of Hippocrates, linked these 4 humours to personality. Later, Theophrastus described 30 characters to group people under.

By the end of adolescence and the beginning of adulthood, our personality reaches a level of stability. Someone with personality disorder is essentially characterised by a pervasive and chronic pattern of a set of behaviours and ideas leading to a certain level of rigidity in situations to which other people without a personality disorder can adapt to. Many factors contribute to the development and formation of one’s personality, including genetic, environmental and psychological factors. This indicates that both “nature” and “nurture” drive the formation of a personality disorder.

There is some evidence that some personality disorders may be associated with structural brain deficits. Antisocial personality disorder demonstrates reduction in the volume of prefrontal grey matter. Borderline personality disorder shows higher left amygdala activation to facial expressions of emotion compared controls. Some other studies showed that there is evidence of reduced volume in the frontal lobe, bilateral hippocampus, bilateral amygdala, left orbitofrontal cortex, right anterior cingulate cortex, and right parietal cortex and increased putamen volume in borderline personality disorder.

In terms of treatment, there are no drugs licensed for treatment of any of the personality disorders, so the main lines of treatment are psychological interventions and lifestyle modifications. However, medications can always be used in treating comorbidities of personality disorders. 

References

• Tyrer P, Mulder R. Personality disorder: from evidence to understanding. Cambridge University Press; 2022 Feb 24. 
• Raine A, Lencz T, Bihrle S, LaCasse L, Colletti P. Reduced prefrontal gray matter volume and reduced autonomic activity in antisocial personality disorder. Archives of general psychiatry. 2000 Feb 1;57(2):119-27.
• Donegan NH, Sanislow CA, Blumberg HP, Fulbright RK, Lacadie C, Skudlarski P, Gore JC, Olson IR, McGlashan TH, Wexler BE. Amygdala hyperreactivity in borderline personality disorder: implications for emotional dysregulation. Biological psychiatry. 2003 Dec 1;54(11):1284-93.
• Lis E, Greenfield B, Henry M, Guilé JM, Dougherty G. Neuroimaging and genetics of borderline personality disorder: a review. Journal of Psychiatry and Neuroscience. 2007 May 1;32(3):162-73.

Epidemiology

In a systematic review and meta-analysis of the adult population in Western countries, it was found that the prevalence of any personality disorder is 12.16%. Obsessive-compulsive personality disorder has the highest prevalence (4.32%), and dependent personality disorder has the lowest (0.78%). Prevalence of clusters of personality disorders (see below) has shown that cluster A disorders have 7.23% prevalence, followed by cluster C with prevalence of 6.70%, then cluster B with 5.53%. It is also noted that prevalence in community samples are less than those seen in clinical or forensic settings, where it ranges between 25% and 65%.

References

• Volkert J, Gablonski TC, Rabung S. Prevalence of personality disorders in the general adult population in Western countries: systematic review and meta-analysis. The British Journal of Psychiatry. 2018 Dec;213(6):709-15.

Types

There are 11 main personality disorders, but they are categorised under 3 clusters. The clusters are highlighted in the DSM classification, but they are not mentioned in the ICD classification. Nevertheless, the types of personality disorders are more or less the same in both diagnostic manuals as follows:

DSM-5:

• Paranoid
• Schizoid
• Schizotypal
• Antisocial
• Borderline
• Histrionic
• Narcissistic
• Avoidant
• Obsessive-compulsive
• Dependent

ICD-11:

• Paranoid
• Schizoid
• Schizotypal (reclassified as Schizotypal disorder, and it lies under “Schizophrenia and related disorders”)
• Dissocial 
• Emotionally Unstable, Impulsive type
• Emotionally Unstable, Borderline type
• Histrionic
• Anxious/Avoidant
• Anankastic
• Dependent

The 3 Clusters A, B & C are categorised as follows:*

Cluster A

It is mainly characterised by oddness and eccentricity, but following specific features are seen:

Paranoid Personality Disorder: 

• Mistrust and suspiciousness of others. 
• Sensitive to criticism.
• Preoccupied by conspiratorial explanations.

Schizoid Personality Disorder:

• Emotionally cold.
• Lack of interest in others.
  
• Doesn’t seek social relationships
  

Schizotypal Personality Disorder:

• Peculiar and eccentric appearance and ideas.
• Interpersonal discomfort.
• Perceptual and cognitive distortions.

Cluster B 

It is mainly characterised by unstable emotions, but following specific features are seen:

Antisocial Personality Disorder:

• Lack of concern for others.
• Violation of other’s rights.
• Irresponsibility.
• Inability to maintain relationships
• Childhood conduct disorder
  

Emotionally Unstable Personality Disorder, Impulsive Type (Not a cluster B disorder, not in DSM):**

• Difficulty in anger management.
• Emotional & behavioural unpredictability.

Emotionally Unstable Personality Disorder, Borderline Type:***

• Identity conflict.
• Unstable relationships.
• Impulsivity
• Emotional instability.
• Self-harm.

Histrionic Personality Disorder:

• Attention craving.
• Shallow affect.
• Easily suggestible.
• Seductive and provocative attitude
• Excessive dramatisation.
  

Narcissistic Personality Disorder:

• Grandiosity and sense of entitlement
• Lack of empathy
  
• Constant need for admiration
  
• Exploitive
• Fantasies of power

* ** ***Emotionally unstable personality disorder, borderline type, is an ICD term which is parallel to borderline personality disorder in DSM (Cluster B), whereas emotionally unstable personality disorder, impulsive type, is only referred to in ICD but not in DSM.

Cluster C

It is mainly characterised by anxiety and fear, but following specific features are seen:

Avoidant Personality Disorder:

• Fear of criticism
• Avoiding intimate relationship
• Feelings of inferiority
• Feelings of inadequacy
  
• Insecure
• Self-consciousness
  

Obsessive Compulsive Personality Disorder:

• Perfectionism
• Overconscientious 
  
• Preoccupation with orderliness and details
  
• Workaholic
• Inflexible
  

 Dependent Personality Disorder:

• Excessive need for care
• Constant need for reassurance
• Helplessness
• Submissiveness
• Clinginess

References

• Strahl NR. Clinical study guide for the oral boards in psychiatry. American Psychiatric Pub; 2011.

Comorbidities and Differential Diagnoses

In many instances, a comorbidity can be difficult to be distinguished from a differential diagnosis. Even the diagnostic criteria for some of the psychiatric disorders can cross over from one diagnosis to another, and personality disorders are no exception to this.

Mood Disorders

• Bipolar disorder, depression and dysthymia are thought to be the most commonly studied mood disorders in relation to a comorbid personality disorder. 
• Cluster A personality disorders are thought to be the least likely to be comorbid with mood disorders.
• Cluster C personality disorders are thought to be the most likely to be comorbid with mood disorders. 

Anxiety

Generalised anxiety disorder, PTSD, OCD, phobia and other anxiety disorders commonly present with different personality disorders. Cluster C is the most commonly seen cluster co-occurring with anxiety disorders.

ADHD

Antisocial and borderline personality disorders appear to be the most commonly co-occurring personality disorders with ADHD.

Eating Disorders

Both anorexia nervosa and bulimia nervosa have been reported to occur in similar rates in different personality disorders, especially in borderline and avoidant personality disorders. Only obsessive-compulsive personality disorder has shown higher incidence of anorexia nervosa than bulimia nervosa.

Schizophrenia and Psychotic Disorders

Cluster A has been linked to schizophrenia for years. In the ICD-11, the schizotypal personality disorder is referred to as schizotypal disorder and is no longer a personality disorder, but it comes under “Schizophrenia or other primary psychotic disorders”.

Alcohol and Substance Use

Antisocial and borderline personality disorders are frequently reported in individuals who have substance use disorder.

Complex PTSD (CPTSD)

This is a new ICD-11 diagnosis, which includes the already known symptoms of PTSD of re-experiencing trauma (flashbacks and nightmares), avoidance of stimuli that could act as reminders for the original trauma and hypervigilance. In addition to these, CPTSD has additional complex reaction in 3 main domains:  emotion regulation, self-identity and relational capacities. This new diagnosis has some similarities and overlap with borderline personality disorder, especially since both happen in people who experience traumatic events. A key difference between both is that an individual with CPTSD would have severe yet stable negative self-concept in contrast to someone with borderline personality disorder who would experience a shift in their self-image.

References

• Semple D, Smyth R. Oxford handbook of psychiatry. Oxford University Press; 2019 Jul 30.
• Dixon-Gordon KL, Conkey LC, Whalen DJ. Recent advances in understanding physical health problems in personality disorders. Current opinion in psychology. 2018 Jun 1;21:1-5.
• Friborg O, Martinsen EW, Martinussen M, Kaiser S, Øvergård KT, Rosenvinge JH. Comorbidity of personality disorders in mood disorders: a meta-analytic review of 122 studies from 1988 to 2010. Journal of affective disorders. 2014 Jan 1;152:1-1.
• Latas M, Milovanovic S. Personality disorders and anxiety disorders: what is the relationship?. Current opinion in psychiatry. 2014 Jan 1;27(1):57-61.
• Martinussen M, Friborg O, Schmierer P, Kaiser S, Øvergård KT, Neunhoeffer AL, Martinsen EW, Rosenvinge JH. The comorbidity of personality disorders in eating disorders: a meta-analysis. Eating and Weight Disorders-Studies on Anorexia, Bulimia and Obesity. 2017 Jun;22(2):201-9.
• Cloitre M. ICD-11 complex post-traumatic stress disorder: Simplifying diagnosis in trauma populations. The British journal of psychiatry. 2020 Mar;216(3):129-31.

Aetiology

Various factors contribute to the development of different types of personality disorder. 

Genetic factors

Studies have demonstrated the following genetic factors in the development of personality disorders:

• Borderline personality disorder has been linked to the presence of serotonin 1A and dopamine transporter gene variants. 
• Borderline personality disorder patients may have reduced nuclear expression of glucocorticoid receptors in blood mononuclear cells. 

Cluster A groups are said to have a link to schizophrenia; schizotypal personality disorder in the new ICD-11 is considered part of the “Schizophrenia or other primary psychotic disorders” and not a personality disorder and is called schizotypal disorder rather than being called a personality disorder.

Neurobiological factors

Various traits of personality disorders like impulsivity and emotional instability have been linked to dysfunction in neurotransmitters. It is believed that neurotransmitters such as Serotonin, Dopamine, and Glutamate/NMDA play a major role in the development of various traits of different personality disorders. Additionally, changes in the HPA axis have been linked to both borderline and antisocial personality disorders.

Psychological factors

Based on the psychodynamic theory, fixation at different stages can impede maturity/development with the individual stuck at this particular stage. Fixation at the oral stage could lead to dependent traits, and fixation at the anal phase can lead to having obsessive/compulsive traits. Also, attachment issues with parents can lead to development of traits of borderline personality disorder. 

Development and Adversities during Childhood

Physical and psychological traumas in early life are a major risk factor for developing personality disorders. Children who are victims of sexual abuse are at high risk of developing borderline personality disorder. Children with an ADHD diagnosis are at high risk of developing antisocial personality disorder.

References

• Joyce PR, Stephenson J, Kennedy M, Mulder RT, McHugh PC. The presence of both serotonin 1A receptor (HTR1A) and dopamine transporter (DAT1) gene variants increase the risk of borderline personality disorder. Frontiers in Genetics. 2014 Jan 7;4:313.
• López-Villatoro JM, MacDowell KS, Diaz-Marsá M, La Torre-Luque D, Prittwitz C, Galvez-Merlin A, Leza JC, Carrasco JL. Reduced glucocorticoid receptor expression in blood mononuclear cells of patients with borderline personality disorder. Frontiers in Psychiatry. 2022:1715.
• Gaebel W, Kerst A, Stricker J. Classification and diagnosis of schizophrenia or other primary psychotic disorders: changes from ICD-10 to ICD-11 and implementation in clinical practice. Psychiatria Danubina. 2020;32(3-4):320-4.
• Gurvits IG, Koenigsberg HW, Siever LJ. Neurotransmitter dysfunction in patients with borderline personality disorder. Psychiatric Clinics of North America. 2000 Mar 1;23(1):27-40.
• Moul C, Dobson-Stone C, Brennan J, Hawes D, Dadds M. An exploration of the serotonin system in antisocial boys with high levels of callous-unemotional traits. PloS one. 2013 Feb 15;8(2):e56619.
• Joyce PR, Stephenson J, Kennedy M, Mulder RT, McHugh PC. The presence of both serotonin 1A receptor (HTR1A) and dopamine transporter (DAT1) gene variants increase the risk of borderline personality disorder. Frontiers in Genetics. 2014 Jan 7;4:313.
• Friedel RO. Dopamine dysfunction in borderline personality disorder: a hypothesis. Neuropsychopharmacology. 2004 Jun;29(6):1029-39.
• Grosjean B, Tsai GE. NMDA neurotransmission as a critical mediator of borderline personality disorder. Journal of Psychiatry and Neuroscience. 2007 Mar 1;32(2):103-15.
• Aromäki AS, Lindman RE, Eriksson CP. Testosterone, aggressiveness, and antisocial personality. Aggressive Behavior: Official Journal of the International Society for Research on Aggression. 1999;25(2):113-23.
• Rausch J, Gäbel A, Nagy K, Kleindienst N, Herpertz SC, Bertsch K. Increased testosterone levels and cortisol awakening responses in patients with borderline personality disorder: gender and trait aggressiveness matter. Psychoneuroendocrinology. 2015 May 1;55:116-27.
• Strahl NR. Clinical study guide for the oral boards in psychiatry. American Psychiatric Pub; 2011.

Defence Mechanisms

These are subconscious mechanisms that all humans use to cope with anxiety and unwanted feelings. They can be useful, but they can also be pathological and maladaptive. Various defence mechanisms have been linked to different personality disorders:

• Splitting: Something or someone is either all good or all bad. This is most commonly seen in someone with borderline personality disorder.
• Projection: Attributing own feelings or thoughts onto someone else. This is most commonly seen in someone with paranoid, schizoid and borderline personality disorder.
• Projective Identification: When someone attributes their feelings or thoughts onto someone else, the other person unknowingly acts on these thoughts. This is most commonly seen in someone with borderline personality disorder.
• Fantasy: Imaginary life is created in one’s mind. This is most commonly seen in someone with schizoid and narcissistic personality disorder.
• Dissociation: Feeling disconnected from self or from a traumatic event. This is most commonly seen in someone with histrionic and borderline personality disorder. 
• Isolation of Affect: Separating emotions from thoughts. This is most commonly seen in someone with obsessive-compulsive personality disorder.
• Intellectualisation: Excessive use of abstract thinking and avoidance of any affective expression. This is most commonly seen in someone with obsessive-compulsive personality disorder.

References

• Bailey R, Pico J. Defense mechanisms. InStatPearls [Internet] 2020 Dec 9. StatPearls Publishing.
• Hentschel U, Smith GJ, Ehlers W, Draguns JG, editors. The concept of defense mechanisms in contemporary psychology: Theoretical, research, and clinical perspectives. Springer Science & Business Media; 2012 Dec 6.

Management

From a “Bio-Psycho-Social” perspective, managing disorders of the personality can be classified under 3 main strategies:

Psychotherapy

This is largely the treatment of choice for personality disorders. Psychotherapeutic interventions should be individualised to each patient. The main types of psychotherapeutic interventions are:

• Dialectical Behavioural Therapy (Marsha Linehan): Skills training and mindfulness.
• Cognitive Behavioural Therapy (Aaron Beck): Collaborative restructuring of unhelpful beliefs.
• Cognitive Analytical Therapy (Anthony Ryle): Combined CBT and analytic approaches.
• Mentalisation-Based Therapy (Antony Bateman): Mutual understanding of feelings and behaviour.
• Acceptance and Commitment Therapy (Steven Hayes and Robert Zettle): Structured acceptance and mindfulness.
• Schema-Focused Therapy (Jeffrey Young): Changing maladaptive patterns of feelings and behaviour.
• Transference-Focused Therapy (Otto Kernberg): Self-understanding in relationships.
• Systems Training for Emotional Predictability and Problem Solving “STEPPS” (Nancee Blum)
• Nidotherapy (Peter Tyrer): Environmental manipulation based on the fact that environment is critical in both helping and hindering the recovery of mental health illness.

Pharmacological Treatment

There are currently no licensed medications for treatment of any personality disorders. According to the UK NICE guidelines, drug treatment should be avoided except in crisis, and even then, it should only be for no more than a week. Despite that, in clinical practice, clinicians use a wide range of psychotropic medications for managing symptoms of personality disorders. It is, however, acceptable and, in fact, mandatory to use medications to treat comorbidities. The range of medications used for treatment of comorbid disorders are antidepressants, antipsychotics, mood stabilisers and anxiolytics.

Lifestyle Changes 

Like any other psychiatric (or physical health) disorder, lifestyle modifications are key to management and symptom control. 

• Physical exercises
• Sleep training/interventions
• Addressing smoking, alcohol and substance misuse
•  Maintaining a healthy and balanced diet

References

• Tyrer P, Mulder R. Personality disorder: from evidence to understanding. Cambridge University Press; 2022 Feb 24.
• Tyrer P. Nidotherapy: a cost‐effective systematic environmental intervention. World Psychiatry. 2019 Jun;18(2):144.
• Bozzatello P, Rocca P, De Rosa ML, Bellino S. Current and emerging medications for borderline personality disorder: is pharmacotherapy alone enough? Expert Opinion on Pharmacotherapy. 2020 Jan 2;21(1):47-61.
• National Institute for Health and Care Excellence. Borderline personality disorder: recognition and management [Internet]. [London]: NICE; 2009 [updated 2022 May; cited 2022 Oct 29]. (Clinical guideline [CG78]). Available from: https://www.nice.org.uk/guidance/cg78
• Firth J, Solmi M, Wootton RE, Vancampfort D, Schuch FB, Hoare E, Gilbody S, Torous J, Teasdale SB, Jackson SE, Smith L. A meta‐review of “lifestyle psychiatry”: the role of exercise, smoking, diet and sleep in the prevention and treatment of mental disorders. World Psychiatry. 2020 Oct;19(3):360-80.