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Personality Disorders

For further information, see CMDT Part 25-10: Personality Disorders

Key Features

Essentials of Diagnosis

  • Long history dating back to childhood

  • Recurrent maladaptive behavior

  • Difficulties with interpersonal relationships or society

  • Depression with anxiety when maladaptive behavior fails

General Considerations

  • Personality results from the interaction of a genetic substrate with personal drives and outside influences

  • Classification of disorder subtypes depends on the predominant symptoms and their severity

  • The most severe disorders are those that bring the patient into greatest conflict with society and tend to be classified as antisocial or borderline

  • Types of personality disorders

    • Paranoid

    • Schizoid (introverted, withdrawn)

    • Obsessive-compulsive

    • Histrionic (dependent, immature, seductive, egocentric, emotionally labile)

    • Schizotypal (socially isolated, suspicious, eccentric behaviors)

    • Narcissistic

    • Avoidant (fear rejection, low self-esteem)

    • Dependent (passive, unable to make decisions, poor self-esteem)

    • Antisocial (selfish, callous, promiscuous, impulsive)

    • Borderline (impulsive, unstable and intense relationships, affective instability, suicidal)

    • Intermittent explosive (episodes of unwarranted anger and sometimes violence)

Clinical Findings

Symptoms and Signs

Table 25–3.Personality disorders: Classification and clinical findings (listed in alphabetical order).
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Table 25–3. Personality disorders: Classification and clinical findings (listed in alphabetical order).
Personality Disorder Clinical Findings
Antisocial Selfish, callous, promiscuous, impulsive, unable to learn from experience, often has legal problems.
Avoidant Fears rejection, hyperreacts to rejection and failure, with poor social endeavors and low self-esteem.
Borderline Impulsive; has unstable and intense interpersonal relationships; is suffused with anger, fear, and guilt; lacks self-control and self-fulfillment; has identity problems and affective instability; is suicidal (a serious problem—up to 80% of hospitalized borderline patients make an attempt at some time during treatment, and the incidence of completed suicide is as high as 5%); aggressive behavior, feelings of emptiness, and occasional psychotic decompensation.
Dependent Passive, overaccepting, unable to make decisions, lacks confidence, with poor self-esteem.
Histrionic (hysterical) Dependent, immature, seductive, egocentric, vain, emotionally labile.
Narcissistic Exhibitionist, grandiose, preoccupied with power, lacks interest in others, with excessive demands for attention.
Obsessive compulsive Perfectionist, egocentric, indecisive, with rigid thought patterns and need for control.
Paranoid Defensive, oversensitive, secretive, suspicious, hyperalert, with limited emotional response.
Schizoid Shy, introverted, withdrawn, avoids close relationships.
Schizotypal Superstitious, socially isolated, suspicious, with limited interpersonal ability, eccentric behaviors, and odd speech.

Differential Diagnosis

  • Anxiety disorder, eg, general anxiety disorder

  • Major depressive disorder

  • Psychotic disorder, eg, schizophrenia

  • Substance abuse

  • Bipolar disorder

  • Personality change due to medical illness, eg, CNS tumor, stroke

Diagnosis

Laboratory Tests

  • These are mainly clinical diagnoses

Imaging Studies

  • Consider head CT if there is an abrupt personality change

Treatment

Medications

  • Antipsychotic ...

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