10 – Personality Disorders




Abstract




At the turn of the twenty-first century, our understanding of personality disorders radically evolved as research on their biological characteristics and effective evidence-based treatments (EBTs) emerged to challenge preexisting notions of these syndromes as defensive, psychologically determined, and untreatable. Reflecting the turmoil of a paradigm shift, intense controversy raged in attempts to revise the diagnostic system for personality disorders in the transition from the DSM-IV to the DSM-V. Proposed changes included both the elimination of five of the ten existing DSM personality disorders (narcissistic, histrionic, schizoid, paranoid, and dependent) and the implementation of a complex diagnostic system involving the evaluation of both categorical prototypes and dimensional traits of personality. The extremity of these proposed changes in the diagnostic system provoked major opposition among prominent experts, ultimately leading to the retention of the existing set of personality disorder criteria and relegation of the proposed alternative model to a section calling for further research. One prominent change in the transition to the fifth edition of DSM was the elimination of the multi-axial system, ending the segregation of Axis II disorders from Axis I disorders.





10 Personality Disorders


Lois W. Choi-Kain , Ana M. Rodriguez-Villa , Gabrielle S. Ilagan , and Evan A. Iliakis



The Concept of Personality Disorders


At the turn of the twenty-first century, our understanding of personality disorders radically evolved as research on their biological characteristics and effective evidence-based treatments (EBTs) emerged to challenge preexisting notions of these syndromes as defensive, psychologically determined, and untreatable. Reflecting the turmoil of a paradigm shift, intense controversy raged in attempts to revise the diagnostic system for personality disorders in the transition from the DSM-IV to the DSM-5. Proposed changes included both the elimination of five of the ten existing DSM personality disorders (narcissistic, histrionic, schizoid, paranoid, and dependent) and the implementation of a complex diagnostic system involving the evaluation of both categorical prototypes and dimensional traits of personality. The extremity of these proposed changes in the diagnostic system provoked major opposition among prominent experts, ultimately leading to the retention of the existing set of personality disorder criteria and relegation of the proposed alternative model to a section calling for further research. One prominent change in the transition to the fifth edition of DSM was the elimination of the multi-axial system, ending the segregation of Axis II disorders from Axis I disorders. Consistent with research implications and treatment advances, the collapse of the multiaxial system overturned the perceived dividing lines between so-called conditions that may be the focus of clinical attention and the peculiar grouping of personality disorders with intellectual disability. What we know now is more about the importance of recognizing and treating personality disorders, which should eventually overturn the tradition of deferring their diagnosis.


A second significant change in the DSM-5 is that personality disorders are identified as primarily disorders of the self and interpersonal relationships. This is a valuable and overdue change that distinguishes personality disorders from all other major forms of mental illness. Personality disorders are prevalent, cause major morbidity and mortality, and contribute to a substantial economic burden on society (Soeteman et al., 2008; van Asselt et al., 2007). Personality disorders exist in approximately one-tenth of the general population, constitute up to half of the psychiatric population in hospital units and clinics, and are highly co-morbid with Axis I disorders (Lezenweger et al., 2007; Torgersen, 2009; Gunderson, 2011; Skodol & Gunderson, 2011; see Table 10.1). All clinicians are guaranteed to encounter patients with personality disorders and the failure to make a diagnosis may leave patients’ symptoms untreated in the best of cases and exacerbated or reinforced in the worst.




Table 10.1 Estimated prevalence in general population and heritability of personality disorders





















































Diagnosis Prevalence of disorder (percent) Heritability
Paranoid 0.4–5.1 .34
Schizoid 0.4–4.9 .43
Schizotypal 0.1–4.6 .61
Antisocial 0.2–4.5 .69
Borderline 0.7–5.9 .67
Histrionic 0.0–3.0 .63
Narcissistic 0.0–6.2 .71
Avoidant 0.7–5.2 .42
Dependent 0.1–1.8 .56
Obsessive-Compulsive 0.7–9.3 .60


The complex interaction of personality disorders with other psychiatric and medical conditions presents clinical challenges, since the symptoms of these disorders impact the therapeutic alliance and efficacy of treatment. Research confirms that the presence of co-morbid personality disorders lengthens time to remission, increases risk of relapse, and decreases response to otherwise effective treatments for other psychiatric illnesses. Individuals with personality disorders suffer from instabilities of behavior and interpersonal functioning, that is, tendencies of avoidance, dependence, mistrust, and impulsivity complicate treatment interactions, increasing the likelihood of poor compliance with prescribed treatments and recurrent conflicts with clinicians.


Considering the prevalence, co-morbidity, dysfunction, and therapeutic challenges associated with personality disorders, it is not surprising that they pose a significant economic burden to society. The costs associated with health care and lost productivity of individuals with personality disorders, particularly borderline personality disorder (BPD) and obsessive-compulsive personality disorder (OCPD), exceed such costs associated with major depressive (MDD) or generalized anxiety disorders (GAD; Soeteman et al., 2008). This finding suggests that the failure of both clinicians to diagnose and treat personality disorders as well as insurance companies to reimburse care for these disorders is costly to society.


The evaluation and treatment of these disorders sometimes require more time than a generalist practitioner can independently provide. However, once a clinician suspects a personality diagnosis, evaluations of interpersonal, behavioral, affective, and cognitive tendencies require only a simple review of diagnostic criteria. Personality disorders involve pervasive patterns in affect, behavior, cognition, and interpersonal functioning that cause significant distress or dysfunction. Generally, clinicians can quickly construct a concise differential diagnosis when they evaluate the degree to which a person’s thoughts and emotions become dysregulated – that is, either constricted or exaggerated – in addition to their tendencies toward interpersonal preoccupation or avoidance (see Figure 10.1). Making a treatment plan for any major psychiatric disorder without considering the differential diagnosis and common co-morbidities that involves personality disorders can lead to misdiagnosis, the prescription of ineffective treatments, and sometimes even iatrogenic outcomes.





Figure 10.1 DSM-5 personality disorders according to their affective, cognitive, and interpersonal features


In general, the treatment of personality disorders is both simple and complex. While some evidence for the efficacy of pharmacologic treatments for personality disorders exist, medications tend to target only manifest symptoms, not underlying mechanisms or personality traits. For example, mood stabilizers may mitigate mood swings or improve depressive symptoms, but do not change intolerance of aloneness or deep mistrust of others. Furthermore, few medication trials have been conducted and results are inconsistent (see Choi-Kain et al., 2017 for review).


The gold standard of treatment for personality disorders is psychotherapy. Psychotherapy increases the rate of remission of symptoms significantly in this group of disorders (Perry, Banon, & Ianni, 1999). When the patient is seeking treatment and is motivated to change, both individual and group psychotherapy are effective for many of these disorders. In relationships with therapists and with other patients in group therapy, individuals with personality disorders are able to see and hear feedback about how they interact with others. More recently, generalist approaches to treating BPD have been developed and proven as effective as more intensive specialized psychotherapies (see Choi-Kain et al., 2017 for review). These approaches prioritize diagnosis, psychoeducation, and clinical management, rather than psychotherapy, which might render them more accessible for psychiatrists and other clinical professionals who either do are not psychotherapists, or cannot implement lengthy and more time-intensive interventions. Table 10.3 summarizes treatment approaches.




Table 10.2 Common differential diagnoses and co-morbidities of personality disorders





















































Diagnosis Differential diagnosis Common co-morbidities



  • Paranoid



  • (PPD)




  • Delusional Disorder, Persecutory Type



  • Schizophrenia, Paranoid Type



  • Mood Disorder with Psychotic Symptoms



  • Schizotypal PD



  • Schizoid PD



  • Narcissistic PD



  • Antisocial PD



  • Borderline PD



  • Avoidant PD



  • Core Distinguishing Features ➜mistrust and suspicion




  • PTSD



  • Social Phobia



  • Schizophrenia



  • Alcohol Use Disorders




  • Schizoid



  • (SzPD)




  • Schizophrenia



  • Depression



  • Autism and Asperger’s Disorder



  • Schizotypal PD



  • Avoidant PD



  • Core Distinguishing Features ➜disinterest in others

MDD



  • Schizotypal



  • (StPD)




  • Schizophrenia



  • Schizoid PD



  • Paranoid PD



  • Core Distinguishing Features ➜eccentric ideas and behavior




  • MDD



  • Substance Use Disorders




  • Antisocial



  • (AsPD)




  • Substance Use Disorders



  • Bipolar Disorder



  • ADHD



  • Intermittent Explosive Disorder



  • Autistic Spectrum Disorder



  • Narcissistic PD



  • Core Distinguishing Features ➜social irresponsibility, disregard, and secondary gain




  • Impulse Control Disorders



  • Borderline PD



  • ADHD



  • Substance Use Disorders




  • Borderline



  • (BPD)




  • Bipolar Disorder



  • Antisocial PD



  • Core Distinguishing Features ➜intolerance of aloneness, emotional dysregulation




  • MDD/Dysthymia



  • Substance Related Disorders



  • Eating Disorders



  • PTSD



  • ADHD



  • Narcissistic PD



  • Antisocial PD




  • Histrionic



  • (HPD)




  • Dependent PD



  • Borderline PD



  • Narcissistic PD



  • Core Distinguishing Features ➜attention seeking




  • MDD/Dysthymia



  • Somatization Disorder



  • Conversion Disorder



  • Borderline PD



  • Antisocial PD




  • Narcissistic



  • (NPD)




  • Bipolar Disorder



  • Histrionic PD



  • Antisocial PD



  • Core Distinguishing Features ➜ dysregulated, fragile self-esteem




  • MDD/Dysthymia



  • Anorexia Nervosa



  • Substance Related Disorders (esp. cocaine)



  • Histrionic PD



  • Borderline PD



  • Paranoid PD




  • Avoidant



  • (APD)




  • Social Phobia



  • Schizoid PD



  • Core Distinguishing Features➜ avoidance, rejection sensitivity




  • MDD/Dysthymia



  • Social Phobia



  • Panic Disorder



  • OCD




  • Dependent



  • (DPD)




  • Mood Disorders



  • Panic Disorder



  • Agoraphobia



  • Borderline PD



  • Histrionic PD



  • Avoidant PD



  • Core Distinguishing Features ➜ submissiveness, dependency




  • MDD/Dysthymia



  • Anxiety Disorders



  • Alcohol Use Disorders



  • Borderline PD



  • Histrionic PD




  • Obsessive-Compulsive



  • (OCPD)




  • OCD



  • Schizoid PD



  • Avoidant PD



  • Narcissistic PD



  • Core Distinguishing Features ➜ need for control, perfectionism, rigidity, obstinacy




  • MDD/Dysthymia



  • Alcohol Use Disorders



  • OCD



ADHD = attention deficit hyperactivity disorder, MDD = major depressive disorder, OCD = obsessive-compulsive disorder, PD = personality disorder, PTSD = post-traumatic stress disorder




Table 10.3 Treatment of personality disorders: Pharmacologic and psychotherapeutic interventions





















































Diagnosis Pharmacology Psychotherapy



  • Paranoid



  • (PPD)

Antidepressants


  • Supportive



  • CBT




  • Schizoid



  • (SzPD)




  • Supportive



  • Social Skills Training




  • Schizotypal



  • (StPD)

Antipsychotics


  • Supportive



  • Social Skills Training



  • CBT for anxiety management




  • Antisocial



  • (AsPD)




  • Antidepressants (SSRIs)



  • Mood stabilizers (lithium, valproate)




  • Early Intervention



  • CBT for impulsivity and behavioral shaping



  • *controversy over treatability*




  • Borderline



  • (BPD)




  • Mood symptoms, impulsivity, anxiety



  • Mood stabilizers (lamotrigine, topiramate)



  • Transient psychotic symptoms, anger problems



  • Atypical antipsychotics



  • Not harmful but limited efficacy



  • Antidepressants



  • Minimize due to risk of dependency



  • Benzodiazepines



  • Stimulants




  • Generalist approaches



  • GPM, SCM, and other structured clinical



  • management approaches



  • Supportive



  • Specialist approaches



  • DBT



  • MBT



  • TFP



  • SFT



  • STEPPS




  • Histrionic PD



  • (HPD)

Psychodynamic psychotherapy



  • Narcissistic



  • (NPD)




  • Psychodynamic psychotherapy



  • DBT



  • MBT



  • TFP




  • Avoidant



  • (APD)




  • Antidepressants (MAO-Is, SSRIs)



  • Anxiolytics




  • Psychodynamic psychotherapy



  • Supportive psychotherapy



  • CBT




  • Dependent



  • (DPD)




  • Antidepressants (MAO-Is, SSRIs)



  • *may have increased risk for benzodiazepine dependency




  • Psychodynamic psychotherapy



  • CBT




  • Obsessive-Compulsive



  • (OCPD)

Antidepressants (SSRIs)


  • Psychodynamic psychotherapy



  • CBT



CBT = cognitive-behavioral therapy; GPM = general psychiatric management; SCM = structured clinical management; DBT = dialectical behavioral therapy; MBT = mentalization based treatment; SFT = schema-focused therapy; SSRI = Selective Serotonin Reuptake Inhibitor; STEPPS = Systems Training for Emotional Predictability and Problem Solving; MAO-I = Monoamine oxidase inhibitors; TFP = transference based psychotherapy


The following chapter will review the current literature on the classification, epidemiology, etiology, longitudinal course, differential diagnosis, evaluation, and treatment of personality disorders. While there is burgeoning empirical literature on some disorders (e.g., borderline, schizotypal, antisocial) there is a paucity of research on others (e.g., paranoid, schizoid, histrionic). This chapter will integrate clinical theories and approaches with relevant empirical bases where available.



Cluster A: Paranoid, Schizoid, and Schizotypal Personality Disorders


Cluster A disorders, referred to as the “odd, eccentric” cluster of personalities, are characterized primarily by the social withdrawal and cognitive-perceptual distortions or eccentricities seen in more psychotic proportions in schizophrenia and its related disorders. Historically, in the earliest efforts toward the classification of major mental illnesses, the subtypes coined as descriptors of what was thought to be variations of schizophrenia, such as “pseudoquerulant type,” “shut-in personality,” and “borderline schizophrenia,” recognizably represent these Cluster A disorders. The overlap of the Cluster A disorders with major thought disorders has led to conceptions of a schizophrenia spectrum where the personality diagnoses represent shared underlying biological vulnerabilities phenotypically expressed in more muted forms or as pre-morbid precursors to more severe symptoms. Akin to schizophrenia, symptoms in this cluster range from “positive” or psychotic-like symptoms (e.g., paranoia and disorganized thinking in paranoid and schizotypal personality disorder) to “negative” or deficit symptoms (e.g., constricted affect and social apathy in schizoid personality disorder). Shared tendencies of interpersonal mistrust and detachment lend toward the low prevalence of patients with these disorders seeking treatment, as well as subjects willing to engage in research.


There is an overall dearth of academic literature, but of the three, research on schizotypal personality disorder is most robust, showing both strong evidence of familial aggregation and shared genetic vulnerabilities with schizophrenia as well as distinctive structural brain abnormalities and impaired areas of performance on cognitive tasks in common with schizophrenia. Nonetheless, very little is known about response to treatment and longitudinal course of these disorders. Further investigation is needed to assess the validity of both the paranoid and schizoid diagnoses, as they uncommonly exist by themselves and the schizotypal diagnosis so strongly overlaps with features of both.


For individuals with Cluster A disorders, their tendencies may be ego-syntonic and not cause distress. Oftentimes, these patients will present with chief complaints of depression or anxiety or because concerned family members insist on treatment. Clinicians should determine the chronicity, severity, and bizarreness of symptoms and interpersonal functioning to contrast these disorders to their “Axis I” (DMS-IV) cousins. One can then evaluate the function or core mechanisms underlying the symptoms to differentiate these disorders from other personality diagnoses (Table 10.2). Treatment of these individuals is impeded by their paranoia, social cognitive deficits, and phobic or disinterested attitudes toward others. Individual therapy with Cluster A patients works best when not overly probing or confrontational, but rather supportive and structured. These individuals are often unable to tolerate or navigate more open-ended group therapy approaches as their understanding of themselves and others is grossly impaired. However, individuals with these disorders can sometimes benefit from cognitive-behavioral or psychoeducational skills-based groups.



Paranoid Personality Disorder (PPD)


Clinical Features

The hallmark of paranoid personality is pervasive and unwarranted suspicion and mistrust of others as bearing malevolent motives. Individuals with PPD assume that others intend to harm or deceive them. They are hypervigilant and hypersensitive to any signs that confirm their suspicions and remain socially aloof out of fear of being exploited or betrayed by those with whom they get close. They are quarrelsome and litigious, bearing grudges persistently. Persons with paranoid personality are therefore prone to self-fulfilling prophecies, where their prediction of others acting unfavorably toward them is often realized when others are provoked by their suspicious hostility.


The prevalence of PPD is estimated between 0.4 to 5.1 percent of the general population (Lenzenweger et al., 2007) and 9.7 percent of the clinical population (Triebwasser et al., 2013). Of all personality disorders, PPD ranks among the top diagnoses associated with a reduction in functioning and quality of life (Triebwasser et al., 2013). Clinical theories implicate feelings of anger and inadequacy developed from early experiences of excessive parental rage and recurrent humiliation. The primary defense mechanism at hand is projection, where intolerable emotions or thoughts within one’s self are split off and attributed to others. The limited empirical literature confirms a significant association between PPD and childhood emotional and physical abuse and victimization (Triebwasser et al., 2013). While literature on the biological features of this illness is sparse, there are patterns of familial aggregation that are unlikely to be caused by shared environmental effects and more likely to arise from gene-environment interactions. PPD’s estimated heritability ranges from .28 to .66 (Triebwasser et al., 2013). Limited evidence indicates that first-degree relatives of individuals with delusional disorder are at greater risk for developing PPD, suggesting these two disorders may be genetically related.



Treatment

Given their pervasive mistrust, individuals with PPD tend not to seek clinical help. The evaluation of PPD is complicated given the ego-syntonic nature of its features. Patients with PPD are unlikely to see their problems as internal and instead rigidly blame others. Since their symptoms limit the scope of their interpersonal world, the accessibility of family members or spouses to provide collateral information is often lacking. When clinicians detect global suspiciousness without frank psychosis, they might inquire about close relationships and how the patient interacts with others. The differential diagnosis includes paranoid schizophrenia; delusional disorder, paranoid type; and schizotypal, schizoid, borderline, narcissistic, antisocial, and avoidant personality disorders. Both schizophrenia and delusional disorder differ from PPD in the persistence, prominence, and proportion of their paranoid beliefs, which are exclusively interpersonal, less bizarre, and harder to disprove in PPD. Individuals with PPD often meet criteria for other personality diagnoses, but these persons can be distinguished by the pervasiveness of their paranoia regarding others (as opposed to the more transient paranoia characteristic of borderline personality) and by its organizing core of mistrust of others as opposed to disinterest (schizoid), dependency (borderline), grandiosity (narcissistic), exploitation (antisocial), or fear of rejection (avoidant). Discerning the differences between these diagnoses is complicated by the high rate of co-morbidity with other psychiatric disorders ranging from thought disorders to anxiety disorders (PTSD, social phobia) to other personality disorders (BPD). Rarely is PPD the sole diagnosis.


No controlled studies have been completed for the treatment of PPD. In approaching treatment, whether medical or psychiatric, a non-confrontational, respectful, straightforward manner should be used to minimize the aggravation of symptoms so that enough trust can be generated for the patient to cooperate in treatment. Efforts to appreciate any validity in the patient’s suspicions may facilitate an alliance between patient and treater. This alliance may then enable the patient to make use of cognitive-behavioral treatments or atypical antipsychotics, which may work to decrease anxiety for individuals with PPD. However, mistrust often interferes with adherence to such measures, and their sensitivity to criticism and perceiving slights interferes with what is, in the best-case scenario, a long course of treatment. Little is known about PPD’s longitudinal course, but considering the low likelihood that individuals with PPD will seek treatment, and endure relationships long enough to change core beliefs about others, their paranoia seems likely to sustain itself for life.

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Jul 27, 2021 | Posted by in PSYCHIATRY | Comments Off on 10 – Personality Disorders

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