16th November 2023

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