Specific Types of Personality Disorder
José Luis Carrasco
Dusica Lecic-Tosevski
Cluster A personality disorders
Paranoid personality disorder
Pervasive suspiciousness, mistrust, hypersensitivity to criticism, and hostility are the essential features of paranoid personality disorder. These individuals live a restricted emotional and interpersonal life because they fear the malevolent intent of others. As a rule, paranoid people are ready to counter-attack, provoking repeated confrontations. In this way, they induce hostility and resentment in others.
The term paranoia may lead to some confusion if it is not properly delimited. Paranoid had been used as an adjective to label various delusional representations or syndromes. Kraepelin(1) differentiated paranoia as a distinct condition characterized by chronic and highly systematized delusional ideas (see Chapter 4.4). Schneider(2) described people with this paranoid personality as fanatic psychopaths, stressing their intensity, and rigidity in confrontation with others. He denied any relationship with paranoia. Freud(3) and other psychoanalysts construed the paranoid character as a pattern of mistrust and feeling of being attacked, based on distortions and externalization of the person’s inner world.
Paranoid personality disorder was included in DSM-III with criteria of suspiciousness, mistrust, hypersensitivity, and restricted affectivity. This last criterion does not appear in DSM-IV and ICD-10, since restricted affectivity is neither necessary nor specific for paranoid personalities. Instead, emphasis is placed on mistrust and sensitivity to setbacks. The DSM-IV criteria for paranoid personality disorder are shown in Table 4.12.3.1.
(a) Epidemiology
The prevalence of paranoid personality disorder is estimated at about 0.5 to 1 per cent in the general population and at 10 to 20 per cent among psychiatric patients. The disorder is more commonly diagnosed in males.
(b) Aetiology
This personality disorder has a familial relationship with delusional disorders and with schizophrenia,(4) and has been included in the so-called schizophrenic spectrum.(5) Deficits in cortical dopamine activity may be associated with a poor conceptual organization that could in turn be responsible for suspiciousness and distorted interpretations.(6)
Mistrust and lack of confidence may reflect deficits arising in early developmental stages and resulting in a lack of basic selfconfidence.(7) Lack of protective care and affective support in childhood could perhaps facilitate the development of paranoid features.
(c) Clinical picture
Paranoid individuals do not often ask for help from psychiatrists. They have no wish to be cured; instead, they believe that they have to be protected from other people’s hatred and attacks. Subjects with this personality disorder suspect that others are acting to harm, exploit, or deceive them. These suspections are based not on objective evidence, but on internal conviction and an attempt to find a rational explanation for the supposed wrongs.
Table 4.12.3.1 DSM-IV diagnostic criteria for paranoid personality disorder | ||||||||||||||||||||||||||||||
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Paranoids are reluctant to confide in others; they tend to feel that others are plotting against them, and that the enemy may be found in unexpected places. They do not readily tell others about their suspicions. The disorder may be manifested by irritability, unusual defensive or self-protective behaviours (e.g. locking doors and closing windows and curtains to avoid being spied on, and hiding papers or documents), or emotional detachment.
Paranoid people lack confidence in others. They doubt the loyalty or trustworthiness of friends and partners, and check their behaviour repeatedly for evidence of malevolent intentions. They assume that others are not trustworthy, to the extent that they cannot believe it when friends demonstrate their loyalty. They withhold personal or significant information from friends, fearing that it will be used maliciously against them. They do not form close friendships and are often isolated. When in trouble, paranoids do not expect help from friends or others close to them; instead, they expect to be attacked or ignored.
Many of the suspicious and distrustful attitudes of paranoids are perpetuated by their intense interpersonal sensitivity. They react intensely to any comment or event that may relate to them. Hidden meanings that are demeaning and threatening may be read into benign events or the remarks of others. Unintended errors by colleagues or public servants are taken as deliberate attempts to harm or deceive them. Humorous remarks or jokes may be interpreted as attacks on their character. Paranoids are easily hurt, and their pride is easily damaged by minor critical comments or questioning. They are excessively preoccupied with attacks on their reputation or character, and minor slights may arouse major hostility and a
counter-attack. They bear grudges and harbour hostile feelings for a long time, and are unwilling to forgive the insults, injuries, or slights that they think they have received.(8)
counter-attack. They bear grudges and harbour hostile feelings for a long time, and are unwilling to forgive the insults, injuries, or slights that they think they have received.(8)
Pathological jealousy is a common presentation of paranoid individuals. They have unreasonable doubts about the loyalty and faithfulness of their partners, based on little or no evidence. They may try to gather trivial and circumstantial facts to justify their beliefs. To avoid betrayal they attempt to gain complete control of intimate relationships, continuously questioning, and challenging partners about their whereabouts and intentions.
The interpersonal world of paranoids is a consequence of their suspiciousness and distrust. They have difficulty in relating to others, especially with close relationships. Hostility is always present and can be manifested as excessive argumentativeness, recurrent complaint and confrontation, or hostile aloofness.(8) Although they may appear rational, unemotional, and cold, the affect of paranoids is labile and oversensitive and they may be hostile, stubborn, and sarcastic. This mixture of secretive, cold, hostile, and sarcastic behaviours often elicits a hostile response in others, which confirms the paranoid person’s beliefs.
Paranoids blame others for their shortcomings. They are querulous and quick to counter-attack, so that they may become involved in frequent litigation. Since they do not confide in others, paranoids need self-confidence and a sense of autonomy and independence. They need to control people who might be harmful. While they do not accept criticism, they are highly critical.
One group of paranoids are close to Schneider’s ‘fanatics’.(2) They have hidden grandiose fantasies of power and negative views of other people, especially those belonging to another group who come to be considered as natural enemies. They simplify issues and avoid any ambiguous perspective. Some form cults or other tightly knit groups with people who share their paranoid belief systems.
(d) Course
Paranoid features may be present in childhood and early adolescence in the form of hypersensitivity, social anxiety, poor peer relationships, and eccentricity. These features sometimes elicit teasing from other children, which in turn may aggravate the paranoid attitudes.
In situations of stress, individuals with paranoid personality disorder may respond with brief psychotic episodes. During these episodes, they may have frank delusional ideas or distorted perceptions. Some paranoid personality disorders are the premorbid state for a delusional disorder or even schizophrenia.
Individuals with this personality disorder may be at increased risk for agoraphobia, obsessive-compulsive disorder, and substance abuse or dependence. This personality disorder is often co-diagnosed with schizoid, schizotypal, narcissistic, and avoidant personality disorders.
(e) Differential diagnosis
Paranoid personality disorder should be distinguished from suspicious attitudes towards examination among immigrants, ethnic groups, or political groups. Members of these groups may display defensive and mistrustful behaviours owing to lack of familiarity with the language or the rules of a society, or in response to perceived neglect or rejection. Their behaviour may elicit further rejection from the majority, thus reinforcing the defensive behaviours.
Paranoid personality disorder is distinguished from delusional disorder, paranoid schizophrenia, and depression with psychotic symptoms, all of which are characterized by periods of persistent psychotic symptoms. Paranoid personality disorder present before the occurrence of these syndromes should be diagnosed as ‘premorbid’.
People with schizotypal personality disorder are suspicious, have paranoid ideas, and keep their distance from others. However, they also experience perceptual distortions and magical thinking, and are usually odd and eccentric. Schizoid personality disorder is characterized by aloofness, coldness, and eccentricity, but these individuals usually lack prominent suspiciousness or paranoid ideation. Individuals with avoidant personality disorder are hypersensitive and do not confide in others. However, their lack of confidence is based on fear of being embarrassed or found inadequate rather than fear of other people’s malicious intentions. Some antisocial behaviour by paranoid individuals originates in a wish for revenge or counter-attack, rather a desire for personal gain as in antisocial personality disorder. Paranoid features are often present in narcissistic individuals who fear that their imperfections could be revealed. The differential diagnosis should be based on the predominance of persistent need of praise versus persistent suspiciousness and distrust.
(f) Treatment
Antidepressant and anxiolytic treatment may be useful for anxiety and depression resulting from a paranoid response to stressful situations. Low-dose antipsychotics may be indicated during brief psychotic episodes or when ideas of reference are present.
Psychological treatment is difficult owing to the lack of insight. The approach is to attempt to gain the patient’s confidence, avoiding early confrontation of distorted ideas, followed by a slow gentle attempt at cognitive restructuring.
Schizoid personality disorder
Schizoid personality disorder is characterized by a persistent pattern of social withdrawal. Schizoid individuals show discomfort in social interactions and are introverted. They are seen by others as eccentric, isolated, or lonely. DSM-IV diagnostic criteria are shown in Table 4.12.3.2.
This type of personality became recognized in the first two decades of the twentieth century. August Block’s description of the shut-in personality and Eugen Bleuler’s description of autism distinguished between shy and lonely persons and those who engage in relationships only in fantasy. Psychoanalysts included this term in their writings and developed an approach based on deficient object relations and individuation.(9) Some schizoid personalities have probably been sweet children who were very easy to care for, although giving less joy to their parents and eliciting less stimulation and fewer expressions of emotion than more expressive children.(7)
(a) Epidemiology
The epidemiology of schizoid personality disorder is not clearly established. Recent studies give a median prevalence of 0.5 to 1 per cent (see Chapter 4.12.5).
(b) Aetiology
A familial association may exist between schizotypal personality disorder and schizophrenia.
Table 4.12.3.2 DSM-IV diagnostic criteria for schizoid personality disorder | ||||||||||||||||||||||||||||||
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(c) Clinical picture
People with schizoid personality disorder appear cold, reserved, distant, and unsociable. They lack involvement in everyday events and in the concerns of others. They rarely tolerate eye contact, usually give short answers, and appear uneasy when asked about emotions or feelings. However, they may invest much energy in abstract ideas such as those of mathematics or philosophy.
There is a characteristic lack of emotional expression and low energy. Speech is typically slow and monotonous, and seems to lack associated emotion. Affect is excessively serious or constrained, although some inner fear may be detected by an experienced clinician. If they try to be humorous, they usually give a child-like impression. Psychomotor activity tends to be lethargic, lacking gesture, and rhythmic movement. They may seem absorbed in insignificant matters, keeping quiet and not annoying anybody, as if in their own world. They do not express joy, anger, sadness, or other emotions. Interpersonal communication tends to be formal and impersonal, although not irrational. Threats, real or imagined, are dealt with by fantasized omnipotence or resignation. Aggressive acts are infrequent.
People with schizoid personality disorder characteristically seem to lack interest in the lives and concerns of others. When in a group, they stay unnoticed and detached, seeming indifferent to criticism or praise or to the reactions of others. Schizoids are attracted to solitary hobbies, and may be successful in lonely jobs that others find difficult to tolerate. Many prefer working at night. Usually, they do not seem to suffer because of this detachment and they have no desire for closeness or intimacy. They seldom have close friends or relationships, except with immediate relatives. Their sexual lives may be poor or exist only in fantasy, and some postpone mature sexuality indefinitely. They do not usually marry, although some, especially schizoid women, may passively agree to marriage. However, schizoid individuals may make emotional attachments with animals or inanimate objects.
Schizoid personalities lack insight, and generally have a poorly developed sense of identity and a poor capacity for evaluating interpersonal events. They may appear to be self-absorbed and engage in excessive daydreaming. However, some schizoid individuals have original and creative ideas.
(d) Differential diagnosis
Schizoids have better occupational functioning than patients with schizophrenia or schizotypal personality disorder, and, although isolated, can have successful careers. Schizophrenic patients exhibit delusional thinking or hallucinations and psychotic episodes. Schizotypal individuals show greater eccentricity and oddness than schizoids, and also have perceptual and thought disturbances including magical thinking.
People with paranoid personality disorder may also show social detachment and lack close relationships. However, they show more social engagement than schizoids and may have a history of aggressive behaviour.
Emotional constraint is also present in obsessive-compulsive personality disorder, but obsessional patients are more involved in everyday life and concerns, and may be worried by criticism. People with avoidant personality disorder are also detached and aloof. However, although they actively avoid interpersonal contact because of fear of rejection or being found inadequate, they have an intense desire for close relationships.
(e) Course
Schizoid personality disorder is usually apparent in early childhood. As with all personality disorders, it is usually long-lasting; however, it is not necessarily lifelong although there is seldom any rapid or profound change. If their deficits are moderate and social circumstances are favourable, some schizoids achieve social and vocational adaptation.
Although this personality disorder is sometimes a precursor of schizophrenia, the number of schizoid patients who go on to develop schizophrenia is unknown.
(f) Treatment
Because they lack insight and have little motivation for change, schizoids seldom seek treatment. Motivation for change may depend on life circumstances and external pressures.
Low-dose antipsychotic medication is useful in some situations. Antidepressants and psychostimulants have also been used with some positive effects.
The psychotherapy of patients with schizoid personality disorder must be based on gaining a therapeutic alliance. Unlike paranoid patients, they may become involved in therapy and reveal fantasies, imaginary friends, and fears of unbearable dependency. Ambivalence may appear because of fear of dependence on the therapist, who must keep the necessary distance to allow a tolerable relationship for the patient.
Social skills training is sometimes useful in improving their awareness of social cues.
Schizotypal personality disorder
Schizotypia is a controversial term in psychiatry. The term was used by Kretschmer(10) to denominate the phenotypic characters that antedated the development of schizophrenia. Nevertheless, the term schizotypal personality disorder was not included in psychiatric classifications until the publication of DSM-IIIR in 1987.(11) Before
that date, schizotypal individuals were allocated either with schizoids or with schizophrenics, and were usually labelled as latent schizophrenics or pseudoneurotic schizophrenics. However, the validity of this nosological entity is still controversial and, despite its acceptance in DSM-IV, ICD-10 does not recognize it as a separate personality disorder. Instead, ICD-10 includes the schizotypal syndrome among the psychotic disorders and not as a personality disorder, based on the biological affinities of schizotypal individuals with other schizophrenic patients. DSM-IV diagnostic criteria are shown in Table 4.12.3.3.
that date, schizotypal individuals were allocated either with schizoids or with schizophrenics, and were usually labelled as latent schizophrenics or pseudoneurotic schizophrenics. However, the validity of this nosological entity is still controversial and, despite its acceptance in DSM-IV, ICD-10 does not recognize it as a separate personality disorder. Instead, ICD-10 includes the schizotypal syndrome among the psychotic disorders and not as a personality disorder, based on the biological affinities of schizotypal individuals with other schizophrenic patients. DSM-IV diagnostic criteria are shown in Table 4.12.3.3.
Table 4.12.3.3 DV-IV diagnostic criteria for schizotypal personality disorder | ||||||||||||||||||||||||||||||||||||
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(a) Epidemiology
Schizotypal personality disorder is present in 0.5 to 3 per cent of the general population, with no demonstrated differences between sexes. It is more commonly diagnosed in relatives of schizophrenic patients, and the incidence is much higher in monozygotic than in dizygotic twins (33 per cent versus 4 per cent).(4)
(b) Clinical picture
The essential feature of schizotypal individuals is a pattern of peculiarity and oddness in interpersonal relationships with resulting social detachment and lack of close relationships. Because of their distorted reality processing schizotypal individuals feel intensely uncomfortable in the presence of others. Conversely, others feel uneasy in the presence of schizotypals because of their unusual ways of thinking and expressing emotions.
Like schizoids, schizotypals have a decreased desire for intimate contacts, although they may sometimes express unhappiness about their lack of relationships. As a consequence they do not have close friends or confidants other than relatives. They experience intense anxiety in social situations with unfamiliar people. They can interact if necessary, but they prefer to keep aloof because they feel different and are not interested in the concerns of others. Their anxiety in these situations is not based on feelings of inadequacy or fear of humiliation. Rather, it is due to suspicion of the motivation of others, and therefore it is not alleviated as time passes and the situation becomes more familiar. Thus schizotypals feel progressively worse and more reluctant to confide in other people.
Individuals with schizotypal personality disorder often have ideas of reference that is interpretations of casual events as having specific and unusual meanings related to themselves. However, these ideas do not achieve the pathological conviction of delusions. Similarly, these individuals may be preoccupied with superstitions or paranormal phenomena. They may feel that they may read other people’s thoughts or influence their behaviour by the power of thought. Their magical thinking is often manifested by ritualized behaviours aimed at avoiding harmful events.
Perceptual disturbances are frequent in schizotypal personality disorder. An experience of a sixth sense is typical, with the ‘ability’ to notice someone’s presence. Distorted perceptions are present in the form of sounds perceived as calling voices or shadows transformed into figures and faces.
Thought processing and speech are characteristically affected. Speech may be constructed in an unusual and idiosyncratic way-generally loose, digressive, or vague, but without actual derailment or incoherence. Responses may be either excessively concrete or far too abstract, and words may be used in unusual ways.
The interpersonal relationships of schizotypal individuals are primarily affected by paranoid and suspicious ideation. They may believe that colleagues at work want to damage their reputation. In addition to the social anxiety of these individuals, this leads to a stiff and constricted contact and affect. They are considered odd and eccentric by others: they have peculiar mannerisms, dress in an unusual and unkempt manner, adopt extravagant postures and clothing combinations, do not obey normal social conventions, and generally avoid eye contact.
(b) Course
Schizotypal features may be present in childhood and adolescence in the form of solitariness, academic underachievement, hypersensitivity, and bizarre fantasies. Schizotypals do not seek treatment because of their personality disorder, but rather because of the presentation of associated depression, dysphoria, and anxiety. In response to stressful situations, these patients may experience transient psychotic episodes lasting from minutes to hours. In some cases, clinical symptoms and duration reach the degree of brief psychotic disorder, schizophreniform disorder, or schizophrenia, with the schizotypal personality disorder as the premorbid state. The prevalence of major depressive episodes is notoriously high, as is co-diagnosis with paranoid, schizoid, avoidant, and borderline personality disorders.
(c) Differential diagnosis
Delusional disorder, schizophrenia, and mood disorder with psychotic symptoms have to be excluded based on the greater intensity and persistence of psychotic symptoms.
In childhood, it can be difficult to distinguish schizotypal personality disorder from other forms of disorders characterized by odd behaviour, isolation, eccentricity, and peculiarities of
language. These include autistic disorder, Asperger’s disorder, and some language disorders. The differentiation with communication disorders is based on the prominence of language symptoms in these children and the compensatory efforts to communicate by gesture and other means. Autism and Asperger’s disorder present an even more intense social isolation and indifference, stereotyped behaviours and interests.
language. These include autistic disorder, Asperger’s disorder, and some language disorders. The differentiation with communication disorders is based on the prominence of language symptoms in these children and the compensatory efforts to communicate by gesture and other means. Autism and Asperger’s disorder present an even more intense social isolation and indifference, stereotyped behaviours and interests.
Paranoid and schizoid personality disorders lack the perceptual and speech impairment of schizotypal personality disorder, as well as the marked eccentricity and oddness. Avoidant personality disorder, while including social anxiety and isolation, differs from schizotypal personality disorder in that avoidants have an intense desire for closeness, which is constrained by fear of rejection. Schizotypals do not have a desire for relationships. Borderline personality disorder has a high rate of co-occurrence with schizotypal personality disorder and frequently the two disorders cannot be differentiated. Brief psychotic episodes in people with borderline personality disorder are more dissociative-like and generally follow affective shifts in response to stress or frustration. Social isolation in borderline personality patients is generally due to repeated interpersonal failures rather than a persistent lack of desire for relationships and intimacy.
Finally, schizotypal personality disorder must be diagnosed in the cultural context of the patient. It should be noted that some perceptual peculiarities and magical beliefs may be due to culturally determined characteristics. For example, mind reading, voodoo, shamanism, evil eye, and so on should not be considered as personality disorders in some cultural areas.
(d) Treatment
Low-dose antipsychotic medication may be useful for ideas of reference, perceptual disturbances, and other psychotic-like symptoms. Antidepressants are effective when depressive states are associated.
The psychological management of schizotypals should include a prolonged period of gaining the confidence of the patient. However, a particularly careful approach must be adopted owing to the peculiar thought processing of these patients.
Cluster B personality disorders
Antisocial personality disorder
Antisocial personality disorder is characterized by a pattern of disregard for the safety and the rights of others, without feeling remorse. Individuals with this disorder are unreliable, manipulative, incapable of lasting relationships, and unable to conform to social norms. The disorder starts early (before the age of 15), is pervasive, and manifests in variety of contexts. Although social deviance is one of the core features of antisocial personality disorder, it is not synonymous with criminality. Antisocial personality disorder uncomplicated by other disorders is not often met in clinical settings, except forensic psychiatry. However, owing to its impact on family and social environment, it has major public health significance and has been extensively studied in academic psychiatry, psychoanalysis, law, sociology, theology, and literature.
The description of antisocial personality in the last 1970s was mainly based on criminal behaviour(12) and the disorder was conceptualized as synonymous of criminality. Later classifications modified this approach and focused on the personality traits and emotional patterns described in classic descriptions included the classic personality traits leading to the current DSM-IV and ICD-10 classification criteria for antisocial personality disorder. (Tables 4.12.3.4 and 4.12.3.5).
Table 4.12.3.4 SM-IV diagnostic criteria for antisocial personality disorder | |||||||||||||||||||||||||||||||||
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(a) Epidemiology
A prevalence rate of about 3 per cent is consistently found in the general population, and it is more frequent in males than females, with sex ratios ranging from 2:1 to 7:1. It is more common among younger adults, people living in urban areas and lower socio-economic groups.(13)
Table 4.12.3.5 ICD-10 diagnostic criteria for disocial personality disorder | ||||||||||||||||||||
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(b) Aetiology
The aetiology of antisocial personality disorder is complex and multifactorial, involving biological, early developmental, and social determinants.
Twin, adoption, and family studies have demonstrated that genetic factors strongly contribute to the development of antisocial personality.(14) Antisocial personality in males is often associated with hysteria in women of the same family which suggests that the two conditions might be alternative expressions of the same genetic endowment, belonging to ‘spectrum conditions’.(15) Longitudinal studies of hyperactive children have reported high rates of later (adult) antisocial behaviour, and have suggested a ‘developmental’ relationship between antisocial behaviour and childhood hyperactivity.
Aggression in antisocial personality disorder is associated with indexes of reduced brain serotonin activity such as low levels of the serotonin metabolite 5-hydroxyindole-acetic acid in the cerebrospinal fluid and(16,17) low platelet monoamine oxidase activity. Reports on minimal brain dysfunctions resulting on frontal-lobe deficiencies and lack of inhibition have also been described.
Parental deprivation, inconsistent maternal care, family violence, and severe childhood physical) abuse have been reported as strong predictors for development of antisocial personality disorders.(12,18)
Social disintegration and chronic criminality can cause episodic antisocial behaviour, reflecting a normal adaptation to an abnormal social environment.(19) However, the multifactorial origin of the antisocial personality disorder and its early onset and manifestations indicate that it cannot be attributed to cultural conflicts and social determinants.
(c) Clinical features and diagnosis
Patients with antisocial personality disorder often appear quite normal, charming, and understanding. However, their history reveals disturbed functioning in the domains of behaviour and self-concept, love and sexuality, interpersonal relations, and cognitive style.(20)
Reckless behaviour unaffected by punishment is typical of antisocial individuals, who are also exploitative, manipulative, demanding, and lacking in a sense of responsibility. An easy-going hedonistic attitude may be interrupted by rage, cruelty, and violence. The absence of internalized moral values is manifested by lying, truancy, running away from home, thefts, fights, substance abuse, and illegal activities may be typical experiences, beginning in early childhood.
An impaired control of impulses and a reduced ability to anticipate the negative consequences of behaviour is typical associated to a marked intolerance to anxiety. Antisocial individuals are egocentric, and unable to feel genuine guilt and remorse. They exhibit intense and persistent anger usually expressed as hostility towards others and they have an incapacity for reflective mourning or sadness. Frequent suicide threats and attempts are also common, as is somatic preoccupation.
Interpersonal relationships of antisocial subjects are characterized by manipulation, exploitation, instability and incapacity for love, and comprehension. Sexual perversions, abuse, and paedophilia are frequent. They display deficient parenting and social dysfunction, and resistance to authorities is pronounced.
The cognitive style of antisocial subjects is characterized by glibness, superficiality of knowledge, and paranoid view of reality.
(d) Comorbidity and differential diagnosis
Antisocial personality disorder is frequently comorbid with depression, which usually has atypical features. Bipolar disorder (manic phase) and mental retardation (learning difficulties) should be excluded. Substance abuse may be comorbid from childhood, and antisocial behaviour may be secondary to premorbid alcoholism type 2. Atypical schizophrenic disorder (pseudopsychopathic schizophrenia), temporal-lobe epilepsy, or a limbic-lobe syndrome should also be excluded.
The presentation of antisocial and criminal behaviour in borderline personality disorder is frequent. However, borderline behaviours are marked by intense affective instability and reactivity and may show some remorse or guilt. Unlike antisocial patients, borderline personality disorders do not lack the capacity for intimacy and emotional investment of others and do not show sadistic behaviours. Self-aggression and suicide attempts are much more prevalent among BPD than in antisocial personality.
Aggressive and defiant behaviours are often present in histrionic personality disorder. Although some aetiologic relationship among both disorders might be possible, as described above, histrionic patients are more impulsive and emotionally driven than antisocial and display intense emotions related with attachments and losses.
(e) Course and prognosis
Antisocial behaviour is most pronounced in early adult years, and gradually decreases with age. Professional motivation and establishing a stable couple or partnership may have beneficial effects. Maturation of the personality might also take with depression or hypochondriasis emerging when rage and aggression are abandoned. Substance abuse and promiscuity are risky behaviours for developing HIV infection.
(f) Treatment
Medication is used to deal with incapacitating symptoms, such as anxiety, rage, depression, and somatic complaints. Selective serotonin reuptake inhibitors, lithium, carbamazepine, clonazepam, and other anticonvulsants have been used to control aggressive behaviour but the effects are much less pronounced than in borderline personality disorder or intermittent explosive disorder. Psychostimulants such as methylphenidate may be useful if there is evidence of attention-deficit hyperactivity disorder. Benzodiazepines are contraindicated since they might cause behavioural disinhibition.
Efficacy of psychotherapy is very little in antisocial patients. Fear of intimacy causes difficulties in establishing a therapeutic alliance, which should be oriented to find alternative defence mechanisms to acting-out and to self-defeating behaviours. Therapeutic communities based on the principles outlined by Maxwell Jones(21) with a general social adjustment as a main task, might give positive results.
Borderline personality disorder
Borderline personality disorder (BPD) is the denomination of a syndromal picture characterized by intense affective instability and impulsivity together with an unstable sense of self-identity. It is often manifested by impulsive self-aggression and suicide attempts, substance abuse, chronic feelings of emptiness, and persistent pattern of severely unstable interpersonal relationships.
The term borderline was first used by Stern(22) in 1938 to denominate a group of syndromes placed in the border between neuroses and psychoses and included also the current label of schizotypal personality disorder and a group of disorders currently classified as psychotic disorders. Only some decades later the term borderline began to be understood as a disorder of character(23) and introduced in DSM-III as a personality disorder, after being separated from schizotypal personality disorder.
Borderline personality disorder derives but is not fully equivalent to the concept of borderline personality organization developed by Kernberg.(24) BPO is a stable permanent state based on three criteria: diffuse identity, primitive defence mechanisms (splitting, denial, and projective identification), and intact reality testing. This personality organization can be found not only in BPD but also in other severe personality disorders and Axis I conditions.
Borderline personality disorder itself can be found in association with so many Axis I and Axis II disorders that its validity as an independent diagnostic category is still weak compared with other personality disorders. Some authors have suggested that borderline personality disorder reflects rather a state of severely impaired personality function than a discrete diagnostic entity.(25) Others have suggested that BPD is an atypical variant of affective disorder and should be included in the affective disorder spectrum.(26) In the ICD-10, this disorder is named as ‘emotionally unstable personality disorder’, with two subtypes: impulsive and borderline. Borderline subtype is specifically linked to the presence of self-identity weakness and diffusion.
(a) Epidemiology
The number of people suffering from borderline personality disorder ranges from 1.5 to 5 per cent of general population with wide differences between studies because of lack of reliable measures. The prevalence is greater in clinical samples of patients at the outpatient clinics, ranging form 10 to 15 per cent. The disorder is more common in women than in men and is commonly initiated between 18 and 35 years old.(27)
(b) Aetiology
Several factors have been associated with a higher prevalence of borderline personality disorder, including genetic, biological, and developmental findings.(28) Family studies indicate that parents of patients with BPD have a greater incidence of mood disorders but not of schizophrenia. Additionally, there is also high family incidence of antisocial personality disorder and alcoholism.
Among the biochemical findings, those indicating a brain serotonin deficiency are the more consistent. Reduced levels of 5-hydroxyindoleacetic acid in cerebrospinal fluid and blunted prolactin response to serotonin agonists have been demonstrated in association with impulsive aggression, which is a core feature of BPD.(29) Hypothalamic-pituitary—adrenal axis dysfunctions, suggesting increased feedback inhibition, as well as increased sensitivity of some areas of the amigdala, have been reported in samples of BPD patients. Current available data suggest that BPD might be associated with abnormal emotional reactivity in the limbic areas and insufficient regulatory function at the cingulated and prefrontal areas of the brain.(30)
The role of childhood trauma in the development of borderline personality disorder could be crucial. Higher incidence of childhood traumatic experiences, both for sexual/physical abuse or for neglect, has been demonstrated in these patients.(31) Other proposed developmental factors include deficiencies in self and identity development linked to attachment failures with parental figures in the early developmental phases.(32,33)
The onset of BPD needs the interaction of predisposing factors, both biological and developmental, and environmental precipitants. BPD patients seem to be extremely sensitive to frustrations in the intimate relationships, which are commonly detected at the onset of the disorder.
(c) Clinical features and diagnosis
Impulsivity and affective instability, self-aggression, identity disturbance, and unstable/intense interpersonal relationships are the most characteristic manifestations of borderline personality disorder.
Identity weakness and diffusion explain several aspects of borderline personality disorder (Table 4.12.3.6). It is clinically manifested by contradictory character traits and sense of discontinuity of the self and feelings of emptiness.(34) Probably related with this is also the intolerance to be alone and the desperate efforts to avoid abandonment by significant others. The chronic feeling of emptiness is recurrently intensified and unbearable leading to drug abuse and self-defeating behaviours.
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