Psychiatric Disorders/Personality disorders

The personality disorders are not disorders in the same sense as the other psychiatric disorders, and to reflect this, the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) lists them under a separate axis, Axis II. For this reason, they are sometimes referred to as “Axis II Disorders.” Rather than discrete disorders in the sense of major depression or schizophrenia, they are more patterns of maladaptive behaviors. They are disorders, however, in the sense that they do represent somewhat consistent clusters of symptoms, have a predictable course, and predictable responses to treatment. In addition, the disruptions they can cause in a person’s social and/or occupational functioning legitimizes their status as true disorders.

Working Definitions

• Personality Trait. A stable, recurring pattern of human behavior.

• Personality Type. A constellation of personality traits recognizable as a frequent and familiar combination – e.g. the compulsive personality, characterized by preoccupations with work, detail, order, time, money, and cleanliness.

• Personality Disorder. A constellation of personality traits, which are inflexible and maladaptive. These traits lead to difficulties in work or interpersonal relations, and can cause subjective distress.

• Neurosis. An unfashionable term for a non-psychotic mental disorder that causes the patient unpleasant feelings (including anxiety, depression, pathological shame or guilt). Many disorders formerly called neuroses are now incorporated into more major mood disorders, such as generalized anxiety disorder, dysthymia, adjustment disorder, obsessive-compulsive disorder, etc.

Speculations on Etiology

Personality is formed through an interaction of genetic and developmental influences. Severe personality disorders generally imply a mood disorder, mild neurological abnormality (such as attention deficit disorder or learning disability), or a family history of alcoholism or personality disorder, plus some kind of early loss, trauma, or abuse. If the developmental history is apparently benign, the likelihood of an affective or organic factor is even greater.

Personality traits that are maladaptive in adulthood may have been more adaptive in childhood. In some cases, it is possible to see how troublesome personality traits were reinforced by the family environment. However, it may happen that initially adaptive behaviors become counterproductive in adulthood, particularly if the environment has changed. Appreciation of the Role of Early Trauma in Severe Personality Disorders

Several studies show increased prevalence of childhood abuse, incest, or neglect, early loss, or family alcoholism in hospitalized patients with severe personality disorders.

Chronic post-traumatic stress disorder may produce symptoms that aggravate the personality disorder. Developmental histories of patients with severe personality disorder must attend to potential trauma, abuse, and neglect. Specific therapeutic attention to traumatic events may be crucial to success of treatment.

Diagnosis

Making a Personality Diagnosis

Making a diagnosis of a personality disorder can be difficult. It generally requires observing an individual over time, and the reliability of cross sectional diagnosis of a personality disorder is poor. Under sufficient stress, most individuals have the capacity to “regress” to a less mature state. For example, a patient diagnosed with a serious mental illness, can begin to have difficulties coping with this new stress, and can appear at that time like a person with a personality disorder.

In addition to longitudinal evaluations, the reliability of a diagnosis is enhanced by interviewing collateral sources such as family members.

Taking a full history is important as well. It is tempting to rely on certain key behaviors (for example, wrist cutting) as if they were pathognomonic for a disorder, however this is rarely the case. Of greatest importance is a full and accurate social and development history, in order to demonstrate the individual’s behaviors over time and in different situations.

Personality tests, such as the Minnesota Multiphasic Personality Inventory complement the clinical interview and are a useful preventive against a clinician’s biases and blind spots. They are not in themselves diagnostic.

For the acute management of a patient with a suspected personality disorder, an assessment of current strengths and weaknesses is often more pertinent than precise categorical diagnosis.

Approaches to Describing Personality

• Categorical. In this approach, specific personality disorders are defined by diagnostic criteria in a manner similar to other mental. The advantages of such an approach are that this approach is consistent with the approach used by psychiatrists (in DSM-IV) to describe all other mental disorders. This approach is useful in research, as it presents a consistent approach to case identification, and thus is convenient for the types of empirical research that require large, homogeneous groups of patients (for example, treatment studies). There are disadvantages to approach, however. A categorical approach must draw a potentially arbitrary line between the normal and pathological: either people have the disorder or they do not. Furthermore, though groups of patients may be superficially linked by common symptoms, they may in fact have heterogeneous pathologies, in which case the diagnoses attached may not have predictive value. Finally, the use of these disorders in too superficial a manner can invite “labeling” and stigmatization of the individual.

• Dimensional. In the dimensional approach, personalities are seen on a continuum from “normal” to ‘deviant.” Generally, personality is divided into specific traits, which are then scaled. In this approach, a disorder is defined in terms of a statistical deviance from the normal range of behaviors. This approach may be more valid than a categorical approach, as it avoids seemingly arbitrary all-or-none decision. Furthermore, it has the capacity to permit a greater appreciation of individual differences. Disadvantages lie in the implementation of a dimensional approach. Defining normal behavior requires a normative sample; collecting a true normative sample that represents the actual range of adaptive behaviors can be illusory. Furthermore, the dimensional ratings obtained are based on standardized tests, which vulnerable to biases in design.

• Prototypical. Patients’ personalities are compared with typical examples of well-recognized personality types, such as the compulsive, the hysterical, the antisocial, etc. The advantage of such an approach is that this approach models the way the way that clinicians think about disorders (comparing an individual to idealized forms of health and disease). It also facilitates recognition of certain patterns. Disadvantages to this approach include is vulnerable to bias, the subjectivity of the approach which makes inter-rater reliability difficult. This in turn makes research on the disorders difficult.

• Structured Assessments Of Adaptive Strengths And Preferred Defense Mechanisms. This approach avoids defining a disorder altogether, and simply describes a persons personality in terms of t psychological strengths and weaknesses. The appraisal is done in a structured, albeit qualitative manner. This approach is useful as a complement to other forms of diagnosis, and can be helpful in planning a patient’s management and treatment. However, a person’s strengths and weaknesses may fluctuate with time, and may be less stable than the personality traits assessed by other approaches. Furthermore, strength and weakness assessments may depend greatly on the clinician’s interviewing skill

The DSM-IV Personality Disorders

The personality disorders are divided into three clusters, organized alphabetically: Types A, B and C. Type A is called the “Odd Cluster”, Type B the Dramatic Cluster, and Type C the Anxious Cluster.

A. The Odd Cluster

• Paranoid Personality. This is defined by the person’s high level of suspiciousness. Persons with disorder are mistrustful of everyone. This distrust does not reach the level of a delusion, however. More on this disorder

• Schizoid personality. This disorder is defined by the individual’s lacks of intimate relationships, and their tendency to be frightened by closeness. They seem to be virtually incapable of personal warmth, and are anxious when others try to be close (due to the fear of the intimacy of socialization). More on this disorder

• Schizotypal personality. This disorder is defined by the presence of odd and eccentric ideas. These ideas seem outside the norm, may influence daily behavior, but are not psychotic. More on this disorder

B. The Dramatic Cluster

• Antisocial personality. This disorder is defined by the individuals disregard for rules, laws and social conventions. Sometimes referred as “psychopaths” they are dishonest, and unconcerned about the effect of their behavior on others. More on this disorder.

• Narcissistic personality. Persons with this disorder are grandiose, needing constant attention. They have a lack of empathy for others, and an exaggerated sense of self-importance. They tend to act as if they are superior to unique from others. More on this disorder

• Borderline personality. These individuals are emotionally intense and unstable, with impulsive behavior, self-destructiveness, an inner emptiness and an intolerance of being alone.M ore on this disorder

• Histrionic personality. Individuals with this disorder are dramatic, with attention-seeking behavior. They often present as a caricature of femininity or masculinity. More on this disorder

C. The Anxious Cluster

• Avoidant personality. Persons with this disorder avoid social situations because of fears of rejection, criticism, or disappointment. They tend to avoid occupational or social challenges and are seen as “underachievers.” . More on this disorder

• Dependent personality. Persons with this disorder cling to a stronger person, sometimes submissively. They rely on that person for help and advice, and are anxious when faced with the need for an independent decision. More on this disorder

• Obsessive-compulsive personality. Persons with this disorder (sometimes called OCPD) have a preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility. They may be described as being preoccupied with work or duty, not enjoying life, and being rigid and inflexible. This disorder is different from Obsessive-Compulsive disorder (OCD), an Axis I diagnosis in that OCPD people do not have clear rituals or intrusive thoughts, and rarely see their habits as being alien to themselves (or “ego dystonic” which is common in OCD, but not OCPD). More on this disorder

How Personality Disorders Present

Personality disorders can be extremely challenging to deal with.

• In Medical Settings. Personality disordered patients are often very challenging for doctors. They are more likely to have interpersonal problems in the doctor-patient relationship. They may be more prone to being noncompliant with their medical care. They can have particular difficulty in coping with any restrictions on their normal function: hospitalization, disability or medical regimens (e.g. dietary restrictions) can be particularly trying for these patients. Professionals may find that these patients bring out the worse in them, and unprofessional behaviors are more likely with such patients.

• In The Family. Patients with personality disorders are more likely to have marital conflicts (including violent conflicts), and problems with child rearing. The risk of divorce is high in this group of patients.
• Within The Individual. Patients with personality disorders can experience multiple losses resulting from their behaviors: divorce, job losses are all common. Their difficulties in the medical setting can result in poorer outcomes from medical conditions. Specific personality disorders can have very particular difficulties when they are not able to live according to their usual style (for example, when a dependent person is removed from the object of their dependency).

Comorbidity

Personality disorders are often of high risk for various disorders. They have high rates of Axis I psychiatric disorders, particularly mood disorders, anxiety disorders and substance abuse. They may have higher rates of medical illnesses as well, for the reasons described above.

Some specific concerns:

• Antisocial, borderline, and histrionic personalities are vulnerable to alcohol and drug abuse.
• Borderline personalities are vulnerable to brief reactive psychosis and to major depression.
• Schizotypal and schizoid personalities are vulnerable to schizophrenia.
• Dependent personalities are vulnerable to agoraphobia.
• Compulsive personalities are vulnerable to obsessive-compulsive disorder.