Clinical Pearl Series Edited from Yale-G First Aid: Crush USMLE Step 2CK & Step 3 by Yale Gong, MD, Sr. Medical Advisor at www.medicine.net (Copyrighted)

Personality Disorders  

(ICD-10: Disorders of Adult Personality and Behavior)

Definition: These are disorders of personality patterns that are pervasive, inflexible, and maladaptive causing impaired social-behavioral functions. They are a group of common psychiatric disorders that lack proper care but we frequently encounter. They are also tough because most individuals refuse to admit their problems and decline treatment.

General Features of Personality Disorders

(1) They can be classified into three clusters (“3 Ws”: A—Weird, B—Wild, C—Worried); (2) Long history dating back to childhood; (3) Recurrent maladaptive behavior and major difficulties with interpersonal relationships or society; (4) Low self-esteem and lack of confidence; (5) Minimal introspective ability with a tendency to blame others for all problems; (6) Depression with anxiety when maladaptive behavior fails.

Etiology: Unknown. It may be associated with genetic factors, original family, and childhood experiences.

Prevalence: More males have antisocial and narcissistic personality disorders, and more females have borderline and histrionic personality disorders.

Onset: Late adolescence or early adulthood.

Course: It’s usually chronic over decades and very difficult to treat because the patient is not willing to seek treatment. Mostly symptoms of paranoid, schizoid, and narcissistic personality disorder worsen with age, whereas symptoms of antisocial and borderline personality disorder usually ameliorate.

Principles of treatment: Psychotherapy is the mainstay of therapies, mostly long-term, intensive psychodynamic and cognitive therapy.

Specific Types and Clinical Features

I.  Cluster A Personality Disorders — “Weird”

The so-called odd-eccentric cluster, is composed of schizoid, schizotypal, and paranoid personality disorders. This cluster is mainly characterized by peculiar thought processes and inappropriate affect.

Schizoid personality disorder

Socially isolated “loners” with restricted and distant emotions and friendship; lack of desire for intimate human connection; disinterested in others and indifferent to joy, praise, or criticism. Patients who have more awareness of their interpersonal needs are more likely to form a therapeutic relationship.

Schizotypal personality disorder

Odd thought, behavior, appearance, and perceptions; socially isolated and uncomfortable with others. It’s differentiated from schizoid personality disorder by magical or weird thinking and affect, ideas of reference and persecution, and brief psychotic episodes. Patients may be wishing for a close, special or romantic relationship with therapists while simultaneously feeling aggressive or negative toward them.

Paranoid personality disorder

Pervasively distrustful/mistrustful, suspicious, taking other’s motivation as malevolent, socially isolated, and emotionally cold. Individuals are irrationally alert for threats that others do not see. They also frequently defend an extremely fragile self-concept. Challenges to build up a therapeutic relationship are pronounced due to “confrontation”.

Clinical strategy for Cluster A

Cluster A patients are suspicious and distrustful of physicians and rarely seek treatment unless dealing with acute problems such as substance use. Even they seek treatment they usually have great difficulty establishing a therapeutic relationship. Therapists should be clear, honest, non-controlling and non-defensive. Maintain emotional distance and avoid humor.

II. Cluster B Personality Disorders — “Wild”

These are mainly characterized by mood lability, dissociative symptoms, and preoccupation with rejection.

Histrionic personality disorder

Colorful, exaggerated behavior, emotions and appearance to draw attention; extremely self-centered; theatrical and sexually seductive. It’s mostly seen in female.

Management: Psychotherapy is the main treatment. Attention-seeking attributes can be helpful in establishing a preliminary therapeutic relationship. However, the clinician must be prepared to manage dramatic acting-out. 

Borderline personality disorder

Unstable affect, mood, relationships, and self-image; chronic feelings of emptiness, impulsivity, recurrent suicidal behaviors, and inappropriate anger. Psychotic symptoms may be present with stress. The main defense mechanism is splitting.

Management: Psychotherapy is the main treatment. Patients and families need education about the disorder. For patients who experience symptoms of emotional dysregulation (lability, inappropriate anger, and dysphoria), impulsivity and aggression, or cognitive-perceptual problems despite evidence-based psychotherapy, additional pharmacotherapy—an antipsychotic, mood stabilizer, or antidepressant—is suggested.

Antisocial Personality Disorder (ASPD)

Definition and diagnosis: A pervasive personality pattern of disregard for, or violation of, the rights of others; with continuous antisocial or criminal acts, inability to conform to social rules, marked impulsivity, violation of the rights of others, deceitfulness, and lack of remorse. There may be a history of crime, legal problems, and impulsive and aggressive behavior. It usually starts around 15 y/a as conduct disorder and is diagnosed after the age 18.

Etiology: It may include hormones and neurotransmitters (high testosterone, low 5-HT), limbic neural maldevelopment, head trauma, cultural influences, and environment.

Management: ASPD is considered to be among the most difficult personality disorders to treat. Because of their very low or absent capacity for remorse, patients usually lack sufficient motivation and fail to see the costs associated with antisocial acts. Therapeutic techniques should be focused on rational and utilitarian arguments against repeating past mistakes. (1) For children, early intervention with group parent training may help prevent antisocial personality in adolescence. (2) Cognitive-behavioral therapy is for persons with mild disorder who possess some insight and reason to improve. (3) For patients with ASPD and severe aggression who are willing to take medication, a second-generation antipsychotic (risperidone or quetiapine) is indicated.

Narcissistic personality disorder

Sense of self-importance, grandiosity, and entitlement; in need of admiration and lack of empathy; jealousy and improper rage with criticism. It occurs mostly in low-educated patients.

Management: Patients pose significant challenges in establishing a therapeutic relationship. The clinician may have to tolerate a lengthy period of time of vulnerability and self-protection before trust develops.

Clinical strategy for Cluster B

Cluster B patients are associated with testing and pushing the limits of the treatment relationship. They are manipulative and demanding (attention), and tends to change the rules. Clinicians should be firm (stick to the treatment plan), fair (not punitive or derogatory), and consistent in rules and boundaries in a quest to build a relationship.

III. Cluster C Personality Disorders — “Worried”

These are mainly characterized by anxiety and preoccupation with criticism or rigidity.

Avoidant personality disorder

Patients are socially inhibited, feeling inadequate or inferior, shy and lonely, hypersensitive to criticism, preoccupied with rejection, and unwilling to get involved with people. Some patients may be similar to vulnerable narcissists and/or social anxiety disorder. It is important to understand underlying self, interpersonal and emotional schemas to optimize treatment alliance.

Dependent personality disorder

Submissive and clinging, feeling inadequate and helpless; avoiding responsibility and making decisions; always in need of care.

Management: Psychotherapy is the main treatment. The clinician must be alert to the potential for the patient to withdraw emotionally and psychologically. Additional challenges may occur when the clinician attempts to encourage more independence.

Obsessive-compulsive personality disorder (OCPD)

Preoccupied with details, orderliness, perfectionism, and control; often consumed by the details of everything and lose the efficiency (goals); inflexible morals and values. It is different from obsessive compulsive disorder (OCD), an anxiety disorder. OCD is manifested by the patient’s experience of obsessive thoughts and compulsive behaviors. There is only modest co-occurrence between OCPD and OCD. Both disorders are mainly treated with cognitive-behavioral therapy (CBT). OCD may also need SSRIs.

Passive-aggressive (negativistic) personality disorder

This diagnosis was initially included in Cluster C, but shifted to disorders in need of further study in DSM-IV, and deleted altogether in DSM-5.

Clinical strategy for Cluster C

Patients are worried but controlling, and their words may be inconsistent with actions. These may ruin the treatment. Therapists should give clear recommendations, but not force the patient into decision. Be caring, sympathetic, and patient. Building a therapeutic relationship with patients with Cluster C disorders is facilitated because these patients are willing to take responsibility for their problems and more readily engage in a dialogue with the clinician to try to solve them in comparison to patients with more severe Cluster A or B disorders.