37. Personality and Personality Disorders

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    V . Personality Disorders

    37. PERSONALITY AND PERSONALITYDISORDERSAlexis A. Giese, M D

    1 What is the difference between a personality trait and a personality disorder?Everyone has a distinct personality style including typical ways of perceiving the self and theworld, preferred coping mechanisms in response to stress, and values derived from cultural, familial,and individual experiences. Although personality development continues throughout life, most char-acteristic traits are formed by early adulthood.Personality disorders on the other hand, are distinguished by persistently inadequate adaptivecapacities affecting several realms of functioning, such a s social relationships o r occupational per-formance. People with personality disorders have chronic problems dealing with responsibilities,roles, and stressors; they also have difficulty understanding the causes of their problems or changingtheir behavior patterns.

    2. Give an example of each.A person with dependen t personality traits may be somew hat overreliant on others, but gener-ally functions fairly w ell. During a crisis such as an acute medical illness), he or she m ay exhibit ex-aggerated neediness in the healthcare setting or increase demands on family and friend s to makedecisions and provide care. How ever, when the illness is over, previous patterns of relating and func-tioning return. By contrast, som eone with dep endent personality disorder has trouble m aking evenroutine decisions without extensive support and advice, is underfunctioning socially and occupation-ally because of the inability to initiate things independently, and is submissive, clinging, and fearfulof loss of nurturan ce, even in everyday situations.3. What is the natural history of personality disorders?Early manifestations of personality disorders generally are evident in adolescence o r even child-hood. By young adulthood, m aladaptive traits cause major problems in social or occupational func-tioning or significant distress to the individual. Developmental tasks com mon to late adolescence orearly adulthood, such as completing an education, emancipation from the family of origin, obtainingemployment, and pursuit of romantic relationships, often are mishandled or delayed. Impairmentfro m a personality disorde r especially antisocial and borderline persona lity disorders) is usuallymost pronounced during the third and fourth decades and decreases thereafter. However, some per-sonality disorders, such as obsessive-compulsive and schizotypal, are less likely to remit with ageand m ay become more problematic in later life.4. Give examples of age-related manifestations.Borderline personality disorder m ay present first in the middle o r late teens with onset of self-mutilatory behaviors, eating disorder sym ptom s, depression, or suicide attemp ts. The twenties andthirties can be tumultuou s, with frequent crises and hospitalizations. By 40 years of age, however,the features of borderline personality disorder typically have attenuated, with decreased impulsive

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    86 Personality and Personality Disordersbehaviors, but with residual feelings of emptiness and identity disturbance. C rises that occur in mid-life e.g., loss of employment) may precipitate a recurrence of som e borderline symptoms such asself-mutilatory behavior, but such symptoms tend to be more limited than earlier because of somedegree of social stability and coping skills.

    Older adults may m anifest previously quiescent personality disorders, especially dependent andobsessive-compulsive, when faced with late-life stressors such as illness or loss of partner.5. Describe the clinical features that help distinguish an axis I disorder from an axis I1disorder.Axis I disorders clinical syndromes) are primarily focal disturbances affecting one mental di-mension, such as thought as in psychotic disorders) or mood as in mania). Axis I disorders may beepisodic, chronic, or progressive, but in general they represent a distinct departure from premorbidfunctioning. Many axis I disorders are highly amenable to specific pharmacotherapeutic and psy-chotherapeutic interventions.Axis I1 personality) disorders represent an impairment in baseline functioning, in which theperson generally f un ctio ns below the level expected fo r his or her intelligence, education, and re-sources. The impairment is most evident in self-percep tions and interpersonal relationships. By def-inition the personality impairment has an early onset and affects several realms of functioning.Clinical tip-offs to an ax is I1problem include atypical presentations hat do not fit readily intothe usual axis categories. For exam ple, a patient who com plains of mood sw ings and depressionthat are of insufficient severity and duration to meet criteria for bipolar disorder or cyclothymia mayhave histrionic or borderline person ality d isorder. Ano ther clue is the presence of multiple, conflict-ing psychiatric diagnoses. For ex am ple, a patient seen in several clinics and diagnosed variablywith schizophren ia, chronic depression , and social phobia may have schizotypal personality disor-der. A high degree of chaos and emotional response is som etimes a tip-off to personality disorder,especially the cluster B group see Question 6). In addition, failure to respond to appropriately ag-

    gressive treatment of an axis I disorder may suggest an underlying axis I1problem.The distinction between axis I and axis I sym ptom s often is made o nly after extensive longitu-dinal data are obtained. A thorough diagnostic evaluation fo r axis 1 disorders m ust precede or ac-company consideration of a personality d isorder diagnosis.6 Name the three clusters of personality disorders in DSM-IV.Cluster A is the odd or eccentric group, w hich includes paranoid, schizoid, and schizotypal per-sonality disorders. Cluster B is the dramatic, overly emotional, or erratic group, including antiso-cial, borderline, histrionic, and narcissistic personality disorders. Cluster C is the anxious or fearfulgroup, including avoidant, dependent, and obsessive-compulsive personality disorders.7 Describe the general characteristicsof cluster A.Th is group is characterized by a general distrust of others, misinterpretation of others ac-tions, odd or idiosyncratic beliefs, and a tendency toward social isolation.The assessment that be-liefs and behaviors are abnormal must take into account the patients cultural and religiousbackgro und. Som e religious and ethnic traditions may appear bizarre on the surface e.g., voodoo,dietary restrictions) but are pervasive in certain cultures. The distinction that the finding is patho-logic is strengthened by e vidence that the belief or b ehavior puts the patient at odds with his o r hersociety and interferes with social or occupational functioning.The initial presentation of cluster personality disorders often is hostility or conflict with others;

    the underlying mis t rus t and unusual ideas becom e apparen t over time. Only rarely do people with clus-ter A disorders self refer for mental health treatment. Referral for psychiatric evaluation may beprompted by primary m edical providers when depression or frank psychotic symptom s develop or whenthe odd beliefs interfere with treatment of a general medical cond ition. Occasionally, such persons cometo psych iatric attention through the legal system w hen idiosyncratic behaviors conflict with social con-vention or laws. For example, a person with schizotypal personality disorder may live an isolatedlifestyle with dozens of cats, ignoring hygiene and health codes; he or she m ay refuse to leave the homewhen it is condemned by authorities and ultimately be brought to mental health c are by the p olice.

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    Personality and Personality Disorders 187DSM IV Personality Disorder Clusters

    CLUSTER DESCRlPTlON PERSONALITY DlSORDERSA

    B

    C

    Oddteccentric

    Dramatiderratic

    Anxious/fearful

    ParanoidSchizoidSchizotypalAntisocialBorderlineHistrionicNarcissisticAvoidantDependentObsessive-compulsive

    Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Copyright1994 American Psychiatric Association.8. Describe individuals in clusterBSuch people often are characterized as labile, unpredictable, unlikable, and impulsive. Theinitial presentation typically is crisis-related and chaotic, often involving severe symptoms (that maydecrease after the crisis has passed), substance abuse, and conflicts with family members, employ-ers, or the healthcare system. Persons with cluster B disorders have difficulty establishing and main-taining interpersonal relationships (e.g., with medical providers) and often have a history ofdischarge against medical advice, doctor shopping, or failure to follow recommended treatment.9. What are the characteristicsof patients in cluster C?Patients often are anxious, timid, perfectionistic, and conflict-avoidant; presentation frequentlyis triggered by depression or somatic complaints. Although sometimes reluctant to engage in generalmedical or psychiatric treatment, they may become highly attached because they have few other im-portant relationships and have difficulty disengaging at the appropriate time.

    10. How frequently do personality disorders occur in the general and psychiatric populations?Standardized, structured diagnostic interviews estimate the lifetime prevalence of personalitydisorders in the general population at 10-13 . Schizotypal personality disorder is the most commoncluster A disorder in the general population, borderline personality disorder the most common incluster B, and dependent personality disorder the most common in cluster C.The prevalence of personality disorders in clinical psychiatric populations is, of course, muchhigher than in the general population. Psychiatric inpatients have prevalence rates of personality dis-orders ranging from 30-60 . In most studies, borderline personality disorder is the most frequentlyfound axis I disorder in hospitalized psychiatric patients (20-30 ). In outpatient psychiatric clinicsprevalence rates of personality disorder fall between those for the general population and inpatients,ranging from 20 40 in some estimates. Avoidant, dependent, and borderline personality disordershave been reported most frequently in psychiatric outpatient clinics.Many individuals meet criteria for more than one personality disorder. Multiple diagnoses ofaxis I1 disorders are allowed in DSM-IV, and the clinician should list all disorders in order of clinicalimportance.

    11. Describe common comorbid psychiatric disorders in persons with personality disorders.Mood disturbances, such as depression, anger, and anxiety, are frequent findings in people withpersonality disorders. Major depressive episodes and suicide attempts are more common in personswith a personality disorder than in those without. Anxiety disorders such as social phobia are frequentcomorbid diagnoses in the cluster C group, particularly avoidant personality disorder. Posttraumaticsymptoms (e.g., intrusive memories and flashbacks of traumatic events) are common i n borderline per-sonality disorder, although only a minority of cases meet full criteria for posttraumatic stress disorder.

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    I88 Personality and Personality DisordersSubstance abuse is a frequent comorbid diagnosis with personality disorders, especially in clus-ter B. Substance intoxication or withdrawal may contribute to som e of the presenting symptoms, andmay explain why so me of the sy mp toms are severe at presentation yet remit fairly quickly.Transient psychotic sym ptom s may lead to treatment, especially in the cluster A group and bor-

    derline personality disorder.People with personality disorders often present to primary medical providers w ith physical com-plaints, rather than seek mental health services. A personality disorder m ay comp licate or prolongmedical treatment and result in higher service utilization and costs if unidentified.12. What types of psychiatric treatment approaches are useful for treating personality disor-ders?By definition, personality disorders are chronic and relatively fixed and thus are not easilycured. In short-term treatments, adaptational approaches that help the patient to cop e with thecurrent crisis and solve problems more effectively are most helpful. Commonly used treatmentmodalities include crisis intervention, supportive psycho therapy, environm ental man ipulation suchas change in living situation), and treatment for substance abuse. Behavioral therapies such as as-sertiveness training or system atic desensitization) may be helpful for avoidant an d obsessive-com-pulsive personality disorders. Careful consideration of comorbid axis I disorders may lead to adiagnosis with specific treatment implications, including medications.Certain patients with personality disorders may benefit from long-term psychotherapy that at-tempts to restructure faulty coping m echanism s. Because of the intensity and complexity of the thera-peutic relationship, such treatment is best undertaken by professionals with specific expertise such asa psychiatrist, psychologist, or psychiatric social worker with psychodynamic training). This type oftreatment is not without its risks and should be recommended only to patients wh o are not i n crisis,who have som e degree of stability in their lives, and w ho have resolved substance abuse problems.13. What personality changes commonly are seen when underlying organic brain disease ispresent?Personality changes are a feature of many organic brain diseases, sometim es presenting as theearliest signs of illness or even its major m anifestation. Demen tias du e to Alzheimers disease andother neurodegenerative disorders often begin with subtle personality changes that are typically rec-ognized in retrospect after other findings, such as memory deficits, are evident. Structural damage tothe brain may result from tumors, trauma, or infarcts and cause significant, permanent personalitychanges-especially if the frontal and/or temporal lobes are involved. The abrup t and/or late onsetof personality changes sh ould no t be attributed to a personality disorder un til a thorough diagnosticinvestigation e.g., premorbid functioning, neurologic history, review of systems , physical exam) hasbeen condu cted.DisorderDementiase.g., Alzheim ers)

    Frontal lobe damag e

    Temporal lobe epilepsy

    Acquired immunodefi-Head traumaciency syndrome AIDS)

    Common personality changesEarly: apathy, narrowing of interests, loss of humor, poor socialLate: irritability, oppositionality, aggressive outbursts, suspicious-Apathy, indifferenceDepressionDisinhibition, excitementHeightened emotional toneRigidity, hypermoralisinCircumstantiality, loquaciousnessDissociative sym ptomsTemper o utburstsEarly: social withdrawal, apathy, agitationLate: progressive dem entia, paranoia, manic symp tomsImpulsivity, aggression, affective lability

    judgm ent, im pulsivity, imm aturityness

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    Personal i ty a n d Personal i ty D i s o r d e r s 18914 Are personality disorders caused by environmental or constitutional factors?The DSM-IV avoids the question by taking an empirical, atheoretical approach; the disordersare defined by descriptive criteria emphasizing observable behaviors. In the past, personality wastraditionally viewed as a product of upbringing, whereas the major mental illnesses were thought tobe related to biologic vulnerabilities. These issues are now understood to be much more complex,and a substantial body of evidence suggests that both biologic and environmental variables play im-portant interacting roles in personality development and disorders.A familial relationship may exist between schizophrenia and cluster A personality disorders, es-pecially schizoty pal personality disorder. Family studies also have sugges ted a hereditary com po-nent to antisocial personality disorder. Borderline personality disorder clusters in families, althoughthis is not clearly genetically determined. Some axis I illnesses such as depression are present at ele-vated rates in families of personality disordered probands, suggesting that in some cases personalitydisorder symptoms m ay be inherited subsyndromal form s of axis I problems.Data suppo rting the role of environmental factors are strongest in the cluster B g roup, includinghigh rates of childhood sexual and physical abuse as well as elevated rates of childhood stressorssuch as divorce, parental loss, inadequate parenting, frequent moves, and institutional placemen ts.Althoug h the association between b orderline personality disorder and childhood abu se is the moststrongly established (7680 prevalence in most studies), other personality disorders have been es-timated to have childhood abuse prevalence rates of approxim ately 50 compared with estimates of2040 in mixed psychiatric populations and 10-15 in the general population.15 Are psychotropic drugs useful in treating personality disorders?Mo st clinicians agree that psychotropic drugs have at least limited usefulness. If an axis I disor-der that usually responds to pharmacologic intervention is present, such as a major depression, treat-ment should be not be withheld because a personality disorder is suspected. Som e of the apparentpersonality disorder symptoms may remit with adequate treatment of depression and anxiety.Even in the absence of a formal axis I diagnosis, medications are sometimes moderately effec-tive for certain target symptoms in personality disorders. For example, the perceptual distortions andbrief psychotic sy mpto ms in paranoid or schizotypal personality disorders m ay respond to low dosesof antipsycho tics. Severe behavio ral dyscon trol as som etimes seen in antisocial and borderline per-sonality disorders) m ay respond to carbamazepine or beta blockers at high doses.16 Can psychotropic drugs be the mainstay of treatment?A treatment plan that focuses largely or exclusively on m edications probably will not meet theneeds of a patient with a personality disorder. Many such patients desperately want ame lioration of dis-tress, and seek pharm acologic intervention as a p anacea. Multidrug regimens carry the risk of com binedtoxicity and p rovide a ready m eans of su icide and drug dependence, particularly if substance abuse is acomorbid diagnosis. The definitive resolution of many problems faced by personality disordered pa-tients requires the development of new coping mechan isms and better social slulls; even with aggressivepharm acotherapy , such goals are usually best reached through psychotherapeutic processes.

    BIBLIOGRAPHY1. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 4th ed.Washington, DC, American Psychiatric Association, 1994.2. Andreasen NC, Black DW eds): Introductory Textbook of Psychiatry. Washington, DC, AmericanPsychiatric Press 1991.3 . Gorton G Akhtar S The literature on personality disorders, 1985-88: Trends, issues, and controversies.

    Hosp Community Psychiatry 41 :39-51, 1990.4. Hori A: Pharmacotherapy for personality disorders. [Review ] Psychiatry Clin Neurosci 52:13-19, 1998.5 . Oldham JM: Personality disorders: Current perspectives. JAMA 272: 1770-1776, 1994.6 . Oldharn JM, Skodol AE: Personality disorders and mo od disorders. In Tasman A, Riba MB eds): Review of7. Perry JC, Banon E, lanni F: Effectiveness of psychotherapy for personality disorde rs. [Re view] Am J8. Shea MT, Pilkonis PA, Beckham E, et al: Personality disorders and treatme nt outcome in the N I M H treat-

    Psychiatry, vol I Washington, American Psychiatric Press, 1992, pp 41 8 4 3 5.Psychiatry 156:1312-1 321, 1999.ment of depression collaborative research program. Am J Psychiatry 14 7:71 1-718, 1990.

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    190 Borderline Personality Disorders9. Siever LJ, Davis KL: A psychobiological perspective on the personality disorders.A m J Psychiatry 148:10 Turkat ID: The Personality Disorders: A Psychological Approach to Clinical Management. Elmsford,NY,

    1. Tyrer P: Personality Disorders. Management and Course. London, Butterworth, 1988.1657-1658, 1991.Pergamon Press, 1990.

    38. BORD ERLINE PERSONALITY DISO RD ERRobin A. McCann, P k D . , and Elissa M Ball, M . D

    1. What is borderline personality disorder?The key to recognizing borderline personality disorder BPD) is instability-instability inaffect interpersonal relationships and self-identity.The emotional instability of patients withB P D is characterized by vulnerability, intensity, and poor regulation. Emotions are quickly andeasily aroused and more intense than those of others; patients often experience difficulty soothingthemselves and returning to a stable emotional baseline. They are particularly vulnerable to per-ceived or actual abandonment and often react with rage, panic, and despair.As people with B P D have difficulty in soothing themselves, they may attempt to block the expe-rience of pain by experiencing, if not inducing, changes in consciousness, including feelings of dere-alization, depersonalization, and brief psychotic reactions with delusions and hallucinations.Substance use, gambling, overspending, eating binges, and/or self-mutilation, including suicidal

    threats, gestures, and attempts, are often used to escape intensely painful affect. People with BPDfrequently engage in self-injurious acts, ranging from minor scratches or self-inflicted cigarettebums to overdoses or other acts requiring ICU admissions; such nonfatal, intentionally self-harmfulacts are referred to as parasuicidal behaviors.2. What are the diagnostic criteria for BPD?The criteria for B P D were developed by consensus rather than empirical study and were firstpublished in 1980 in DSM 111 Specific DSM IV diagnostic criteria' for BPD are as follows:

    A pervasive pattern of instability of interpersonal relationships, self-image, and affects, andmarked impulsivity beginning by early adulthood and present in a variety of contexts, as indicatedby five (or more) of the following:1. Frantic efforts to avoid real or imagined abandonment. Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.2. A pattern of unstable and intense interpersonal relationships characterized by alternating be-tween extremes of idealization and devaluation.3. Identity disturbance: markedly and persistently unstable self image or sense of self.

    4. Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, sub-stance abuse, reckless driving, binge eating). Note: Do not include suicidal or self-mutilating behav-ior covered in Criterion 5 .5 . Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior.6. Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, ir-7. Chronic feelings of emptiness.8. Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper,constant anger, recurrent physical fights).9. Transient, stress-related paranoid ideation or severe dissociative symptoms.Reprinted with permiss ion from the Diagnostic and Statistical Manual of Mental Disorders, 4th ed.

    ritability or anxiety usually lasting a few hours and only rarely more than a few days).

    Copyright 1994 American Psychiatric Association.