Personality Disorders

Personality disorders are a group of mental disturbances defined by the fourth (1994) edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) as "enduring pattern[s] of inner experience and behavior" that are sufficiently rigid and deep-seated to bring a person into repeated conflicts with his or her social and occupational environment. DSM-IV specifies that these dysfunctional patterns must be regarded as non-conforming or deviant by the person's culture, and cause significant emotional pain and/or difficulties in relationships and occupational performance. In addition, the patient usually sees the disorder as being consistent with his or her self image (ego-syntonic) and may blame others.

Description

To meet the diagnosis of personality disorder, which is sometimes called character disorder, the patient's problematic behaviors must appear in two or more of the following areas:

• perception and interpretation of the self and other people
• intensity and duration of feelings and their appropriateness to situations
• relationships with others
• ability to control impulses

Personality disorders have their onset in late adolescence or early adulthood. Doctors rarely give a diagnosis of personality disorder to children on the grounds that children's personalities are still in the process of formation and may change considerably by the time they are in their late teens. But, in retrospect, many individuals with personality disorders could be judged to have shown evidence of the problems in childhood.

It is difficult to give close estimates of the percentage of the population that has personality disorders. Patients with certain personality disorders, including antisocial and borderline disorders, are more likely to get into trouble with the law or otherwise attract attention than are patients whose disorders chiefly affect their capacity for intimacy. On the other hand, some patients, such as those with narcissistic or obsessive-compulsive personality disorders, may be outwardly successful because their symptoms are useful within their particular occupations. It has, however, been estimated that about 15% of the general population of the United States has a personality disorder, with higher rates in poor or troubled neighborhoods. The rate of personality disorders among patients in psychiatric treatment is between 30% and 50%. It is possible for patients to have a so-called dual diagnosis; for example, they may have more than one personality disorder, or a personality disorder together with a substance-abuse problem.

By contrast, DSM-IV classifies personality disorders into three clusters based on symptom similarities:

• Cluster A (paranoid, schizoid, schizotypal): Patients appear odd or eccentric to others.
• Cluster B (antisocial, borderline, histrionic, narcissistic): Patients appear overly emotional, unstable, or self-dramatizing to others.
• Cluster C (avoidant, dependent, obsessive-compulsive): Patients appear tense and anxiety-ridden to others.

The DSM-IV clustering system does not mean that all patients can be fitted neatly into one of the three clusters. It is possible for patients to have symptoms of more than one personality disorder or to have symptoms from different clusters.

Since the criteria for personality disorders include friction or conflict between the patient and his or her social environment, these syndromes are open to redefinition as societies change. Successive editions of DSM have tried to be sensitive to cultural differences, including changes over time, when defining personality disorders. One category that had been proposed for DSM-IIIR, self-defeating personality disorder, was excluded from DSM-IV on the grounds that its definition reflected prejudice against women. DSM-IV recommends that doctors take a patient's background, especially recent immigration, into account before deciding that he or she has a personality disorder. One criticism that has been made of the general category of personality disorder is that it is based on Western notions of individual uniqueness. Its applicability to people from cultures with different definitions of human personhood is thus open to question. Furthermore, even within a culture, it can be difficult to define the limits of "normalcy."

The personality disorders defined by DSM-IV are as follows:

Paranoid

Patients with paranoid personality disorder are characterized by suspiciousness and a belief that others are out to harm or cheat them. They have problems with intimacy and may join cults or groups with paranoid belief systems. Some are litigious, bringing lawsuits against those they believe have wronged them. Although not ordinarily delusional, these patients may develop psychotic symptoms under severe stress. It is estimated that0.5–2.5% of the general population meet the criteria for paranoid personality disorder.

Schizoid

Schizoid patients are perceived by others as "loners" without close family relationships or social contacts. Indeed, they are aloof and really do prefer to be alone. They may appear cold to others because they rarely display strong emotions. They may, however, be successful in occupations that do not require personal interaction. About 2% of the general population has this disorder. It is slightly more common in men than in women.

Schizotypal

Patients diagnosed as schizotypal are often considered odd or eccentric because they pay little attention to their clothing and sometimes have peculiar speech mannerisms. They are socially isolated and uncomfortable in parties or other social gatherings. In addition, people with schizotypal personality disorder often have oddities of thought, including "magical" beliefs or peculiar ideas (for example, a belief in telepathy) that are outside of their cultural norms. It is thought that 3% of the general population has schizotypal personality disorder. It is slightly more common in males. Schizotypal disorder should not be confused with schizophrenia, although there is some evidence that the disorders are genetically related.

Antisocial

Patients with antisocial personality disorder are sometimes referred to as sociopaths or psychopaths. They are characterized by lying, manipulativeness, and a selfish disregard for the rights of others; some may act impulsively. People with antisocial personality disorder are frequently chemically dependent and sexually promiscuous. It is estimated that 3% of males in the general population and 1% of females have antisocial personality disorder.

Borderline

Patients with borderline personality disorder (BPD) are highly unstable, with wide mood swings, a history of intense but stormy relationships, impulsive behavior, and confusion about career goals, personal values, or sexual orientation. These often highly conflictual ideas may correspond to an even deeper confusion about their sense of self (identity). People with BPD frequently cut or burn themselves, or threaten or attempt suicide. Many of these patients have histories of severe childhood abuse or neglect. About 2% of the general population have BPD; 75% of these patients are female.

Histrionic

Patients diagnosed with this disorder impress others as overly emotional, overly dramatic, and hungry for attention. They may be flirtatious or seductive as a way of drawing attention to themselves, yet they are emotionally shallow. Histrionic patients often live in a romantic fantasy world and are easily bored with routine. About 2–3% of the population is thought to have this disorder. Although historically, in clinical settings, the disorder has been more associated with women, there may be bias toward diagnosing women with the histrionic personality disorder.

Narcissistic

Narcissistic patients are characterized by self-importance, a craving for admiration, and exploitative attitudes toward others. They have unrealistically inflated views of their talents and accomplishments, and may become extremely angry if they are criticized or outshone by others. Narcissists may be professionally successful but rarely have long-lasting intimate relationships. Fewer than 1% of the population has this disorder; about 75% of those diagnosed with it are male.

Avoidant

Patients with avoidant personality disorder are fearful of rejection and shy away from situations or occupations that might expose their supposed inadequacy. They may reject opportunities to develop close relationships because of their fears of criticism or humiliation. Patients with this personality disorder are often diagnosed with dependent personality disorder as well. Many also fit the criteria for social phobia. Between 0.5–1.0% of the population have avoidant personality disorder.

Dependent

Dependent patients are afraid of being on their own and typically develop submissive or compliant behaviors in order to avoid displeasing people. They are afraid to question authority and often ask others for guidance or direction. Dependent personality disorder is diagnosed more often in women, but it has been suggested that this finding reflects social pressures on women to conform to gender stereotyping or bias on the part of clinicians.

Obsessive-compulsive

Patients diagnosed with this disorder are preoccupied with keeping order, attaining perfection, and maintaining mental and interpersonal control. They may spend a great deal of time adhering to plans, schedules, or rules from which they will not deviate, even at the expense of openness, flexibility, and efficiency. These patients are often unable to relax and may become "workaholics." They may have problems in employment as well as in intimate relationships because they are very "stiff" and formal, and insist on doing everything their way. About 1% of the population has obsessive-compulsive personality disorder; the male/female ratio is about 2:1.

Causes and symptoms

Personality disorders are thought to result from a bad interface, so to speak, between a child's temperament and character on one hand and his or her family environment on the other. Temperament can be defined as a person's innate or biologically shaped basic disposition. Human infants vary in their sensitivity to light or noise, their level of physical activity, their adaptability to schedules, and similar traits. Even traits such as "shyness" and "noveltyseeking" may be, at least in part, determined by the biology of the brain and the genes one inherits.

Character is defined as the set of attitudes and behavior patterns that the individual acquires or learns over time. It includes such personal qualities as work and study habits, moral convictions, neatness or cleanliness, and consideration of others. Since children must learn to adapt to their specific families, they may develop personality disorders in the course of struggling to survive psychologically in disturbed or stressful families. For example, nervous or high-strung parents might be unhappy with a baby who is very active and try to restrain him or her at every opportunity. The child might then develop an avoidant personality disorder as the outcome of coping with constant frustration and parental disapproval. As another example, child abuse is believed to play a role in shaping borderline personality disorder. One reason that some therapists use the term developmental damage instead of personality disorder is that it takes the presumed source of the person's problems into account.

Some patients with personality disorders come from families that appear to be stable and healthy. It has been suggested that these patients are biologically hypersensitive to normal family stress levels. Levels of the brain chemical (neurotransmitter) dopamine may influence a person's level of novelty-seeking, and serotonin levels may influence aggression.

Diagnosis

Diagnosis of personality disorders is complicated by the fact that affected persons rarely seek help until they are in serious trouble or until their families (or the law) pressure them to get treatment. The reason for this slowness is that the problematic traits are so deeply entrenched that they seem normal (ego-syntonic) to the patient. Diagnosis of a personality disorder depends in part on the patient's age. Although personality disorders originate during the childhood years, they are considered adult disorders. Some patients, in fact, are not diagnosed until late in life because their symptoms had been modified by the demands of their job or by marriage. After retirement or the spouse's death, however, these patients' personality disorders become fully apparent. In general, however, if the onset of the patient's problem is in mid-or late-life, the doctor will rule out substance abuse or personality change caused by medical or neurological problems before considering the diagnosis of a personality disorder. It is unusual for people to develop personality disorders "out of the blue" in mid-life.

There are no tests that can provide a definitive diagnosis of personality disorder. Most doctors will evaluate a patient on the basis of several sources of information collected over a period of time in order to determine how long the patient has been having difficulties, how many areas of life are affected, and how severe the dysfunction is. These sources of information may include:

Interviews

The doctor may schedule two or three interviews with the patient, spaced over several weeks or months, in order to rule out an adjustment disorder caused by job loss, bereavement, or a similar problem. An office interview allows the doctor to form an impression of the patient's overall personality as well as obtain information about his or her occupation and family. During the interview, the doctor will note the patient's appearance, tone of voice, body language, eye contact, and other important non-verbal signals, as well as the content of the conversation. In some cases, the doctor may contact other people (family members, employers, close friends) who know the patient well in order to assess the accuracy of the patient's perception of his or her difficulties. It is quite common for people with personality disorders to have distorted views of their situations, or to be unaware of the impact of their behavior on others.

Psychologic testing

Doctors use psychologic testing to help in the diagnosis of a personality disorder. Most of these tests require interpretation by a professional with specialized training. Doctors usually refer patients to a clinical psychologist for this type of test.

PERSONALITY INVENTORIES. Personality inventories are tests with true/false or yes/no answers that can be used to compare the patient's scores with those of people with known personality distortions. The single most commonly used test of this type is the Minnesota Multiphasic Personality Inventory, or MMPI. Another test that is often used is the Millon Clinical Multiaxial Inventory, or MCMI.

PROJECTIVE TESTS. Projective tests are unstructured. Unstructured means that instead of giving one-word answers to questions, the patient is asked to talk at some length about a picture that the psychologist has shown him or her, or to supply an ending for the beginning of a story. Projective tests allow the clinician to assess the patient's patterns of thinking, fantasies, worries or anxieties, moral concerns, values, and habits. Common projective tests include the Rorschach, in which the patient responds to a set of ten inkblots; and the Thematic Apperception Test (TAT), in which the patient is shown drawings of people in different situations and then tells a story about the picture.

Treatment

At one time psychiatrists thought that personality disorders did not respond very well to treatment. This opinion was derived from the notion that human personality is fixed for life once it has been molded in childhood, and from the belief among people with personality disorders that their own views and behaviors are correct, and that others are the ones at fault. More recently, however, doctors have recognized that humans can continue to grow and change throughout life. Most patients with personality disorders are now considered to be treatable, although the degree of improvement may vary. The type of treatment recommended depends on the personality characteristics associated with the specific disorder.

Hospitalization

Inpatient treatment is rarely required for patients with personality disorders, with two major exceptions: borderline patients who are threatening suicide or suffering from drug or alcohol withdrawal; and patients with paranoid personality disorder who are having psychotic symptoms.

Psychotherapy

Psychoanalytic psychotherapy is suggested for patients who can benefit from insight-oriented treatment. These patients typically include those with dependent, obsessive-compulsive, and avoidant personality disorders. Doctors usually recommend individual psychotherapy for narcissistic and borderline patients, but often refer these patients to therapists with specialized training in these disorders. Psychotherapeutic treatment for personality disorders may take as long as three to five years.

Insight-oriented approaches are not recommended for patients with paranoid or antisocial personality disorders. These patients are likely to resent the therapist and see him or her as trying to control or dominate them.

Supportive therapy is regarded as the most helpful form of psychotherapy for patients with schizoid personality disorder.

Cognitive-behavioral therapy

Cognitive-behavioral approaches are often recommended for patients with avoidant or dependent personality disorders. Patients in these groups typically have mistaken beliefs about their competence or likableness. These assumptions can be successfully challenged by cognitive-behavioral methods.

Group therapy

Group therapy is frequently useful for patients with schizoid or avoidant personality disorders because it helps them to break out of their social isolation. It has also been recommended for patients with histrionic and antisocial personality disorders. These patients tend to act out, and pressure from peers in group treatment can motivate them to change. Because patients with antisocial personality disorder can destabilize groups that include people with other disorders, it is usually best if these people meet exclusively with others who have APD (in "homogeneous" groups).

Family therapy

Family therapy may be suggested for patients whose personality disorders cause serious problems for members of their families. It is also sometimes recommended for borderline patients from overinvolved or possessive families.

Medications

Medications may be prescribed for patients with specific personality disorders. The type of medication depends on the disorder.

ANTIPSYCHOTIC DRUGS. Antipsychotic drugs, such as haloperidol (Haldol), may be given to patients with paranoid personality disorder if they are having brief psychotic episodes. Patients with borderline or schizotypal personality disorder are sometimes given antipsychotic drugs in low doses; however, the efficacy of these drugs in treating personality disorder is less clear than in schizophrenia.

MOOD STABILIZERS. Carbamazepine (Tegretol) is a drug that is commonly used to treat seizures, but is also helpful for borderline patients with rage outbursts and similar behavioral problems. Lithium and valproate may also be used as mood stabilizers, especially among people with borderline personality disorder.

ANTIDEPRESSANTS AND ANTI-ANXIETY MEDICATIONS. Medications in these categories are sometimes prescribed for patients with schizoid personality disorder to help them manage anxiety symptoms while they are in psychotherapy. Antidepressants are also commonly used to treat people with borderline personality disorder.

Treatment with medications is not recommended for patients with avoidant, histrionic, dependent, or narcissistic personality disorders. The use of potentially addictive medications should be avoided in people with borderline or antisocial personality disorders. However, some avoidant patients who also have social phobia may benefit from monoamine oxidase inhibitors (MAO inhibitors), a particular class of antidepressant.

Prognosis

The prognosis for recovery depends in part on the specific disorder. Although some patients improve as they grow older and have positive experiences in life, personality disorders are generally life-long disturbances with periods of worsening (exacerbations) and periods of improvement (remissions). Others, particularly schizoid patients, have better prognoses if they are given appropriate treatment. Patients with paranoid personality disorder are at some risk for developing delusional disorders or schizophrenia. The personality disorders with the poorest prognoses are the antisocial and the borderline. Borderline patients are at high risk for developing substance abuse disorders or bulimia. About 80% of hospitalized borderline patients attempt suicide at some point during treatment, and about 5% succeed in committing suicide.

Prevention

The most effective preventive strategy for personality disorders is early identification and treatment of children at risk. High-risk groups include abused children, children from troubled families, children with close relatives diagnosed with personality disorders, children of substance abusers, and children who grow up in cults or political extremist groups.