Personality Disorders

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  • Schizoid (introverted, withdrawn)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)

Symptoms and Signs

• See Table 25–3

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

Laboratory Tests

• These are mainly clinical diagnoses

Imaging Studies

• Consider head CT if there is an abrupt personality change

Medications

• Antipsychotic agents may be required for short periods when conditions have temporarily decompensated into transient psychoses. Options include

  • Olanzapine, 2.5–10.0 mg once daily orally

  • Risperidone, 0.5–2.0 mg once daily orally

  • Haloperidol, 0.5–2 mg/d orally, split into two doses

• Anticonvulsants have been shown to decrease the severity of behavior dyscontrol in some patients, for example

  • Carbamazepine, 400–800 mg orally daily in divided doses

  • Lamotrigine, 50–200 mg/day

  • Valproate, 500–2000 mg/day

• Antidepressants have improved anxiety, depression, and sensitivity to rejection in some patients with borderline personality disorder

• Selective serotonin reuptake inhibitors also have a role in reducing aggressive behavior in impulsive aggressive patients

  • Fluoxetine, 20–60 mg orally daily

  • Sertraline 50–200 mg orally daily

• Antipsychotics and anticonvulsants have been helpful for some patients with intermittent explosive disorder; in addition, there is some initial evidence that the combination of dextromethorphan and quinidine, which is currently approved for treating pseudobulbar affect, may have a role in managing intermittent explosive disorder

Therapeutic Procedures

• Social

  • Day hospitals, halfway houses, and self-help communities use peer pressure to modify self-destructive behavior

• Behavioral

  • Operant and aversive conditioning use reinforcement and punishment to change behavior

  • Dialectical behavioral therapy uses a cognitive-behavioral model to address self-awareness, interpersonal functioning, affective lability, and reactions to stress

  • Psychodynamic psychotherapy can also be an effective treatment

• Psychological

  • Best conducted in group settings and helpful when specific behaviors need to be improved

  • Individual therapy should initially be supportive, to restabilize and mobilize coping mechanisms

  • Long-term introspective therapy may be warranted if the patient has the ability to observe his or her own behavior

Complications

• Up to 80% of hospitalized borderline patients make a suicide attempt at some time during treatment

• Drug abuse is common among borderline patients

Prognosis

• Antisocial and borderline categories have a guarded prognosis

• Patients with a history of parental abuse and a family history of mood disorder tend to have most challenging treatments

• Mild schizoid or passive-aggressive tendencies have a better prognosis

• Patients with a schizotypal personality often improve with antipsychotics

• Patients with avoidant personality may benefit from strategies that reduce anxiety, including the use of SSRIs and benzodiazepines

When to Refer

• When patient distress or second psychotic illness is present

When to Admit

• Hospitalization is rarely indicated except in cases of suicidal risk