15th February 2025

Personality Disorders and Psychosis

Personality disorders

Classification of personality disorders

The ICD (International Classification of Diseases)-11 describes personality disorder as ‘a marked disturbance in personality functioning, which is nearly always associated with considerable personal and social disruption. The central manifestations of personality disorder are impairments in functioning of aspects of the self (e.g. identity, self-worth, capacity for self-direction) and/or problems in interpersonal functioning (e.g. developing and maintaining close and mutually satisfying relationships, understanding others’ perspectives, managing conflict in relationships).’

Precise definitions for personality disorder have been historically both mutable and controversial, and the ICD diagnostic requirements for personality disorder have recently been updated. Once a diagnosis of personality disorder has been established, the new ICD-11 guidelines state that it should be described in terms of level of severity.

Classification	Severity of effect on personality	Impact on relationships and occupational/social roles	Impact on functioning	Risk of harm to self or others
Mild personality disorder	Disturbances affect some areas of personality functioning but not others.	Problems in many interpersonal relationships and/or expected occupational and social roles. Some relationships and/or roles are maintained.	May be associated with substantial distress or with impairment in … important areas of functioning that is either limited to circumscribed areas or present in more areas but of milder severity.	Typically not associated with substantial harm to self or others.
Moderate personality disorder	Disturbances affect multiple areas of personality functioning, though some may be relatively less affected.	Marked problems in most interpersonal relationships, which are likely to be characterised by conflict, avoidance, withdrawal, or extreme dependency. The performance of most expected occupational and social roles is compromised to some degree.	Associated with marked impairment in … important areas of functioning, although functioning in circumscribed areas may be maintained.	Sometimes associated with harm to self or others.
Severe personality disorder	Severe disturbances in personality functioning.	Problems in interpersonal functioning affect virtually all relationships. The ability and willingness to perform expected occupational and social roles is absent or severely compromised.	Associated with severe impairment in all or nearly all areas of life.	Often associated with harm to self or others.

Table 1 Severity classifications in personality disorder (ICD-11).

As per the ICD-11, personality disorder can then be further described using five trait domain specifiers. These describe characteristics of the individual’s personality that are most prominent and contribute to the personality disturbance:

Train domain	Core features
Negative affectivity	A tendency to experience a broad range of negative emotions (e.g. emotional lability and poor emotion regulation; negativistic attitudes; low self-esteem and self-confidence; mistrustfulness).
Detachment	Tendency to maintain interpersonal and emotional distance.
Dissociality	Disregard for the rights and feelings of others, encompassing both self-centeredness and lack of empathy.
Disinhibition	Tendency to act rashly based on immediate external or internal stimuli (i.e. sensations, emotions, thoughts), without consideration of potential negative consequences.
Anankastia	A narrow focus on one’s rigid standard of perfection and of right and wrong, and of controlling one’s own and others’ behaviour and controlling situations to ensure conformity to these standards.

Table 2 Trait domains in personality disorder (ICD-11)

‘Borderline pattern’ can also be used as an optional additional specifier as per the ICD-11. It may be applied to individuals whose pattern of personality disturbance is characterised by a pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity.

Management of personality disorders

Management plans should be agreed with the patient, be tailored to the individual and set clear expectations. There has been a movement away from prolonged inpatient stays or those involving psychiatric ICUs.

Psychotherapy

Psychotherapy is the first-line treatment for personality disorders. In particular, dialectical behaviour therapy (DBT) is recommended by NICE for women with borderline personality disorder who self-harm. DBT is a long-term intervention lasting 1-2 years. Brief psychological interventions (<3 months) should be avoided.

Pharmacological management

NICE recommends that drug treatment should not be used for borderline personality disorder or its symptoms (e.g. emotional instability, repeated self-harm), although drug treatment can be utilised in treating comorbid conditions. For concurrent depression, a combination of antidepressant medication (first line usually an SSRI) and a psychological treatment can be considered, depending on the patient’s preference (NICE notes that the evidence base is limited).

Where medications are used, NICE recommend the following:

Consider side effects, addiction risk and safety in overdose.
Avoid polypharmacy where possible.
Antipsychotics should not be used as medium- or long-term treatment.
Short-term sedatives may be used in crisis but for no longer than one week.

References

Casey P and Kelly B. Personality Disorders. In Fish’s Clinical Psychopathology: Signs and Symptoms in Psychiatry. 4th ed. Cambridge: Cambridge University Press; 2020. Pp. 109-123
ICD-11. Personality Disorders. Online [cited 17 December 2023]. Available at: https://icd.who.int/browse11/l-m/en#/http%3a%2f%2fid.who.int%2ficd%2fentity%2f37291724
Management of Personality Disorder. In: Oxford Handbook of Psychiatry. 4th ed. Ed. Semple D and Smyth R. Oxford: Oxford University Press; 2019. Pp. 517-540
Mind. Personality Disorder: Why is it Controversial? [Internet] [cited 21 January 2024]. Available from: https://www.mind.org.uk/information-support/types-of-mental-health-problems/personality-disorders/why-is-it-controversial
National Institute for Health and Care Excellence. Borderline personality disorder: recognition and management [Internet]. NICE. 28 January 2009 [cited 16 January 2024]. Available from: https://www.nice.org.uk/guidance/cg78
National Institute for Health and Care Excellence. Depression in adults: treatment and management [Internet]. NICE. 29 June 2022 [cited 21 January 2024]. Available from: https://www.nice.org.uk/guidance/ng222/chapter/Recommendations#depression-in-people-with-a-diagnosis-of-personality-disorder
Personality Disorders. In DSM-5. Washington, DC: American Psychiatric Publishing; 2013. Pp. 645-684]
ICD-11. Personality Disorders. Online [cited 17 December 202]. Available at: https://icd.who.int/browse11/l-m/en#/http%253a%252f%252fid.who.int%252ficd%252fentity%252f37291724

Primary psychotic disorders

Overview of psychosis

Psychosis makes it difficult for people to differentiate between what is real and what is not. Psychotic disorders include but are not limited to: schizophrenia, schizoaffective disorder, delusional disorder and drug-induced psychosis.

Schizophrenia

Epidemiology of schizophrenia

Genetic and environmental factors both play a role in whether someone develops schizophrenia. Possible environmental factors include but are not limited to: complicated pregnancy and birth, early social services contact, neurodevelopmental difficulties, and cannabis use, especially in adolescence.

Schizophrenia is more common among males. Age of onset varies between genders, with more men experiencing the onset of symptoms in their early-to-mid twenties, and more women experiencing onset of symptoms in their late twenties. Early onset schizophrenia is typically associated with a poorer prognosis (as are presentations with mainly negative symptoms).

Clinical features of schizophrenia

Onset of schizophrenia may be acute or insidious. A prodromal phase often precedes the onset of psychotic symptoms, which may include negative symptoms, social withdrawal, self-neglect, inversion of sleep cycles, anxiety or depression.

As per the ICD-11, for a diagnosis of schizophrenia, symptoms must be present for at least one month. At least two symptoms are needed for diagnosis. At least one of the two symptoms must come from the following list:

Persistent delusions
Persistent hallucinations
Formal thought disorder (e.g. tangentiality, ‘knight’s move thinking’, ‘word salad’)
Experiences of influence, passivity, or control (e.g. thought withdrawal/broadcasting)

The second of the two symptoms can come from either the above list or from the following symptoms:

Negative symptoms (e.g. flat affect, poverty or paucity of speech, lack of motivation, social withdrawal and anhedonia)
Grossly disorganised behaviour that impedes goal-oriented activity
Psychomotor disturbances (e.g. catatonic restlessness or agitation, posturing, waxy flexibility, negativism, mutism or stupor)

Management of schizophrenia

There is no first-line antipsychotic drug suitable for all patients, and drug choice is shaped by individual circumstances and choices, as well as minimisation of side effects.

There are two main classes of antipsychotic medication:

First-generation (typical) antipsychotics:
- D2 antagonists (+ other receptors)
- E.g. haloperidol, chlorpromazine, fluphenazine
- Extrapyramidal side effects (EPSEs) are more common
Second-generation (atypical) antipsychotics
- 5HT2A/D2 antagonists (+ other receptors)
- E.g. aripiprazole, olanzapine, quetiapine, paliperidone, risperidone, lurasidone and clozapine
- Metabolic side effects more common

Key considerations for maintenance therapy include:

Establishing the minimal effective dose in order to reduce side effects
Depots (e.g. paliperidone, olanzapine, zuclopenthixol) may help ensure compliance
Encourage psychotherapy, e.g. CBT, family therapy and psychoeducation

Side effects of antipsychotics

Common side effects of antipsychotics include:

Extrapyramidal symptoms:

Includes parkinsonian symptoms (bradykinesia and tremor), akathisia (restlessness) and tardive dyskinesia (abnormal involuntary movements of the lips, tongue, face and jaw that can continue after drug discontinuation).
Also includes dystonia (uncontrolled muscle spasms). This can be very acute in onset. Presentations include but are not limited to: oculogyric crisis (prolonged ‘rolling upwards’ of the eyes), torticollis (neck twisting causing the head to tilt), buccolingual crisis (protruding or pulling sensation of tongue), opisthotonic crisis (whole body spasm causing an arched back, flexed arms and extended lower limbs), scoliosis or lordosis, blepharospasm (eyelid spasm preventing eye opening) and torticopelvic crisis (abdominal pain or rigidity). Laryngeal dystonia causes throat pain, shortness of breath and difficulty talking and is rare but potentially life-threatening.

Consider procyclidine to reduce medication side effects and for acute dystonic reactions.

Metabolic symptoms:

Weight gain, hypercholesterolemia and diabetes.

Cardiovascular:

QTc-interval prolongation, postural hypotension.

Neuroleptic malignant syndrome:

Rare but potentially fatal side effects.
Presents with hyperthermia, sweating, muscle rigidity (‘lead-pipe rigidity’), hyporeflexia, tachycardia, labile blood pressure and fluctuating consciousness.
Management includes stopping the antipsychotic, giving IV fluids, cooling, and considering bromocriptine and dantrolene.

Hyperprolactinaemia:

May cause loss of libido, sexual dysfunction, galactorrhoea and infertility in both sexes. In men may cause oligospermia, reduced ejaculation volume and gynaecomastia. In women may cause oligomenorrhea or amenorrhea, reduced vaginal lubrication, dyspareunia, acne and hirsutism.
First-line treatment is stopping or reducing the antipsychotic and changing to another medication. If this is not feasible, low-dose aripiprazole can also be used as an add-on medication to treat symptomatic hyperprolactinaemia.

Sexual dysfunction.


Clozapine is a second-generation antipsychotic. It can be very effective, but needs careful titration and monitoring due to side effects. It is trialled when two different antipsychotics have failed. Common side effects include: Anticholinergic: constipation, difficulty urinating, dry mouth (consider hyoscine hydrobromide) and blurred vision Anti-adrenergic: hypotension and sexual dysfunction Other: sedation, weight gain, nausea, headaches, fatigue, dizziness, hypersalivation, tachycardia and hypertension Rare but potentially life-threatening side effects include: Agranulocytosis or thrombocytopaenia Arrhythmias, cardiomyopathy, peri/myocarditis, pericardial effusions Thromboembolism Intestinal obstruction, ileus, hepatitis, cholestatic jaundice, pancreatitis, fulminant hepatic necrosis Neuroleptic malignant syndrome Interactions include: Smoking decreases clozapine levels; caffeine increases them Clozapine has various interactions, including lithium (increases seizure, confusion and dyskinesia risk) Clozapine is contraindicated with previous blood dyscrasias, severe cardiac disease (including a history of myocarditis, pericarditis or cardiomyopathy), severe renal disease, or severe/progressive liver disease. People taking clozapine are managed in secondary care. Frequent monitoring of FBC for neutropenia or agranulocytosis is required, especially during titration.

Clozapine is a second-generation antipsychotic. It can be very effective, but needs careful titration and monitoring due to side effects. It is trialled when two different antipsychotics have failed.

Common side effects include:

Anticholinergic: constipation, difficulty urinating, dry mouth (consider hyoscine hydrobromide) and blurred vision
Anti-adrenergic: hypotension and sexual dysfunction
Other: sedation, weight gain, nausea, headaches, fatigue, dizziness, hypersalivation, tachycardia and hypertension

Rare but potentially life-threatening side effects include:

Agranulocytosis or thrombocytopaenia
Arrhythmias, cardiomyopathy, peri/myocarditis, pericardial effusions
Thromboembolism
Intestinal obstruction, ileus, hepatitis, cholestatic jaundice, pancreatitis, fulminant hepatic necrosis
Neuroleptic malignant syndrome

Interactions include:

Smoking decreases clozapine levels; caffeine increases them
Clozapine has various interactions, including lithium (increases seizure, confusion and dyskinesia risk)

Clozapine is contraindicated with previous blood dyscrasias, severe cardiac disease (including a history of myocarditis, pericarditis or cardiomyopathy), severe renal disease, or severe/progressive liver disease.

People taking clozapine are managed in secondary care. Frequent monitoring of FBC for neutropenia or agranulocytosis is required, especially during titration.

Box 1 Key facts about clozapine

Monitoring of antipsychotics

There are specific guidelines on monitoring for different antipsychotics, but NICE recommends the following as a guide, in addition to baseline measurements:

Criteria	Initiation	3 months	6 months	Annually	Additional info
Prolactin			Yes	Yes	Not needed for aripiprazole, clozapine, quetiapine & <20 mg OD olanzapine
U&Es, FBC, LFTs				Yes	FBC is frequently monitored for patients on clozapine, especially during titration
Lipids, glucose, HbA1c		Yes		Yes	Needed at one month for clozapine & olanzapine
BMI	Weekly for the first 6 weeks	Yes		Yes
HR & BP	After dose changes				Not needed for amisulpride, aripiprazole, trifluoperazone & sulpride
ECG	After dose changes			Yes

Table 3 NICE guidelines for monitoring with antipsychotics.

Schizoaffective disorder

As per the ICD-11, schizoaffective disorder is ‘an episodic disorder in which the diagnostic requirements of schizophrenia and a manic, mixed, or moderate or severe depressive episode are met within the same episode of illness, either simultaneously or within a few days of one another.’ Psychomotor disturbances, including catatonia, may be present. Symptoms must have been present for at least one month.

General management is the same as for schizophrenia. However, manic or depressive episodes are managed as in bipolar disorder. The condition tends to have a non-deteriorating course, with prognosis being better than for schizophrenia, although generally worse than for primary mood disorders.

Delusional disorder

Delusional disorder is defined by the ICD-11 as the ‘presence of a delusion or set of related delusions, typically persisting for at least 3 months or often much longer, in the absence of a depressive, manic or mixed episode.’ Delusions are ‘variable in content across individuals, while showing remarkable stability within individuals, although they may evolve over time.’

Characteristic symptoms of schizophrenia (e.g. persistent hallucinations, formal thought disorder, negative symptoms, and experiences of influence, passivity or control) will be absent. However, specific hallucinations typically related to the delusion may be present. Affect, speech and behaviour are typically unaffected, apart from when directly related to the delusions.

Eponymous and miscellaneous delusional conditions

Syndrome	Description
Othello	Delusions of infidelity and paranoid jealousy
Cotard’s	Delusions that the person is dead, does not exist, is decaying, or that body parts are missing
Capgras	Delusions that someone close to them has been replaced by an identical imposter
de Clerambault	Delusions that somebody, especially of higher social status, desires or loves them
Folie à deux	Delusions (and sometimes hallucinations) are transmitted from one person to another

Table 4 Eponymous and miscellaneous delusional conditions (Sims’ Symptoms in the Mind)

References

British National Formulary. Psychoses and related disorders. Online [cited 16 January 2022]. Available from: https://bnf.nice.org.uk/treatment-summary/psychoses-and-related-disorders.html
ICD-11. Schizophrenia. Online [cited 17 December 2023]. Available at: https://icd.who.int/browse11/l-m/en#/http%3a%2f%2fid.who.int%2ficd%2fentity%2f1683919430
ICD-11. Schizoaffective Disorder. Online [cited 17 December 2023]. Available at: https://icd.who.int/browse11/l-m/en#/http://id.who.int/icd/entity/106339515
National Institute for Health and Care Excellence. Psychosis and schizophrenia: what monitoring is required? [Internet]. NICE. September 2021 [cited 17 December 2023]. Available from: https://cks.nice.org.uk/topics/psychosis-schizophrenia/prescribing-information/monitoring/
Oyebode F. Delusions and Other Erroneous Ideas. In: Sims’ Symptoms in the Mind. Edinburgh: Elsevier; 2018. Pp. 105-128
Schizophrenia and Related Psychoses. In: Oxford Handbook of Psychiatry. 4th ed. Ed. Semple D and Smyth R. Oxford: Oxford University Press; 2019. Pp 179-241

Psychosis secondary to other conditions

Medical causes of psychosis

It is important to rule out medical causes of psychosis before diagnosing it as a psychiatric condition, as these likely need different, time-sensitive management. A CT or MRI head is generally recommended in the first episodes of psychosis.

Factors suggesting a medical cause of psychosis include:

Acute onset
Onset at >40 years
Non-auditory hallucinations (e.g. visual, olfactory, tactile)
No family history of psychosis and no premorbid or prodromal symptoms

Key medical causes are summarised in Table 5.

Table 5 Key medical causes of psychosis and associated clinical features and investigations

Condition	Clinical features	Investigations
Delirium	Cognitive decline, behavioural change, reversed night-day sleep-wake cycle and altered consciousness. Acute onset with fluctuating course. Common medications implicated in delirium include anticholinergic drugs, benzodiazepines, antihistamines, dihydropyridine calcium channel blockers, diuretics, and opioids.	Determine underlying cause, including pain, infection, nutrition, constipation, hydration, medication, environment (‘PINCH ME’). First line: haloperidol.
Structural brain problems, e.g. tumour, stroke	Symptoms depend on the territory affected. E.g. peduncular hallucinosis, a relatively rare neurological disorder that causes vivid visual hallucinations following damage to the midbrain. There may be Lilliputian hallucinations featuring smaller-than-life people or animals.	Neuroimaging.
Epilepsy	Ictal psychosis: associated with non-convulsive status epilepticus. Postictal: develops following a lucid phase, up to 7 days following cessation of a seizure; associated with temporal lobe epilepsy and generalised tonic-clonic seizures. Interictal: not related to the timing of seizures; typically associated with partial epilepsy; may indicate the presence of small brain tumours.Psychosis may also be caused by seizure medications.	Clinical history of two seizures is needed for a diagnosis of epilepsy. EEG may help confirm the diagnosis. Insomnia is usually the first sign of postictal psychosis, so preventative antipsychotic treatment may be started.
Neurodegenerative, e.g. dementia, Parkinson’s, CJD	Progressive cognitive decline, memory loss, functional difficulties, language deficit, personality changes. Can cause anxiety/depression and psychosis. With Parkinson’s: tremor, rigidity, bradykinesia, postural instability, hyposomnia, sleep disorders. With CJD: muscle weakness, involuntary movements, poor co-ordination, peripheral neuropathy, visual disturbance.	Neuroimaging and neurocognitive testing. More specialised tests if prion disease is suspected.
Demyelinating disease, e.g. MS	Fatigue, visual disturbance, peripheral neuropathy, muscle spasms, mobility problems. Associated with psychosis, some MS medications also induce/exacerbate psychosis.	Neuroimaging, evoked potential test, LP.
Inflammatory, paraneoplastic or infectious CNS disease	Fever and rapid progression. Encephalitis: flu-like symptoms may progress to seizures, weakness/paralysis and cognitive deficits. HSV commonest cause.	Neuroimaging and LP or rheumatology investigations if indicated.
Wilson disease	Liver and kidney disease and, more rarely, cardiomyopathy. Kayser-Fleischer rings. Neuropsychiatric symptoms include Parkinsonian features, dystonia, cognitive disorders (frontal lobe disorders and subcortical dementia) and psychosis.	Caeruloplasmin (low), 24 h urine copper (high), serum copper (low, except in acute liver failure).
Acute porphyria (cutaneous porphyrias do not affect CNS)	Abdominal pain, chest pain, peripheral neuropathy, nausea, bowel changes, red or brown urine, hypertension, tachycardia, seizures and cognitive defects.	Urine porphyrin precursor porphobilinogen (PBG). Genetic testing.
Lead poisoning	Tremor, headache, abdominal pain, bowel changes, muscle pain/weakness, memory problems, fatigue, cognitive defects and delirium. Burton’s line: blue tinge around the gums. Acute lead poisoning may progress to encephalopathy, seizure and death.	Heavy metal screen. Blood film may show basophilic stippling, microcytosis and hypochromia.
Vision loss	May trigger visual hallucinations, often with insight (Charles Bonnet syndrome).	Ophthalmology investigations.

Substance and alcohol-induced psychosis

Prescription drugs and illicit substances (e.g. cannabis, spice, meth, MDMA, LSD [lysergic acid diethylamide]) can cause symptoms of psychosis, but can also worsen underlying mental health conditions. Alcohol can also cause psychosis and is perhaps most dangerous during withdrawal. Delirium tremens affects approximately 5% of people in alcohol withdrawal and can be fatal.

Alcohol withdrawal

The general timeline of alcohol withdrawal is as follows:

6-12 hours: anxiety, shaking, nausea, headaches, sweating and insomnia
12-48 hours: hallucinations and seizures
48-72 hours: delirium tremens (hallucinations, confusion, seizures, sweating, tachycardia and hypertension)

Management of alcohol withdrawal includes CIWA (clinical institute withdrawal scale) scoring to assess severity, consideration of benzodiazepine or carbamazepine, and thiamine to prevent Wernicke’s encephalopathy.

For delirium tremens, first-line management is with oral lorazepam; second-line options include IV lorazepam or haloperidol. Ideally, the patient should be managed in the ICU in a well-lit room.

References

Ellul M, Solomon T. Acute encephalitis – diagnosis and management. Clinical Medicine. April 2018. 18(2):155–159
Epilepsy Foundation. Psychosis. Online [cited 28 January 2022]. Available from: https://www.epilepsy.com/learn/challenges-epilepsy/moods-and-behavior/mood-and-behavior-101/psychosis
Fordham S. RCEM Learning. Delirium in the Elderly. Online [cited 28 January 2022]. Available from: https://www.rcemlearning.co.uk/reference/delirium-in-the-elderly
Liaison Psychiatry. In: Oxford Handbook of Psychiatry. 4th ed. Ed. Semple D and Smyth R. Oxford: Oxford University Press; 2019. Pp. 839-880.
Marder S. Psychosis in adults: Epidemiology, clinical manifestations, and diagnostic evaluation [Internet]. Stein M, Friedman M, editors. UpToDate. 2021 [cited 18 January 2022]. Available from: https://www.uptodate.com/contents/psychosis-in-adults-epidemiology-clinical-manifestations-and-diagnostic-evaluation
National Institute for Health and Care Excellence. Alcohol-use disorders: diagnosis and management of physical complications [Internet]. NICE. 2017 [cited 16 January 2022]. Available from: https://www.nice.org.uk/guidance/cg100
Orrin Devinsky. Postictal Psychosis: Common, Dangerous and Treatable. Epilepsy Currents. March 2008. 8(2):31-34.
Epilepsy Society. Seizure types. Online [cited 5 November 2022]. Available from: https://epilepsysociety.org.uk/about-epilepsy/epileptic-seizures/seizure-types

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