Personality disorders are a relatively common, chronic pattern of perceptual and behavioral abnormalities. These manifest as problems in at least two of the following domains: cognitive-perceptual, affect regulation, interpersonal functioning, or impulse control.
Onset of symptoms in childhood/adolescence with stability over time.
Typical presentation involves comorbid disorders (more than one personality disorder or additional diagnoses of depression, anxiety, somatoform, or substance use disorder).
Ongoing relationship with primary care physician is essential but may be challenging to maintain.
Potential for self-harm must be monitored. There is also potential for social withdrawal.
Psychotherapy is indicated in most cases. Selective use of pharmacotherapy can provide added benefit.
Personality disorders refer to enduring patterns of thinking and feeling about oneself and others that significantly and adversely affect how an individual functions in the various aspects of life. In the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5), the personality disorders fall into 10 distinct types: paranoid, schizoid, schizotypal, antisocial, borderline, histrionic, narcissistic, avoidant, dependent, and obsessive-compulsive. None of the criteria for personality disorders has changed in the DSM-5 compared with the previous edition, DSM-IV.
In the process of developing the DSM-5, several proposed revisions were drafted that would have significantly changed the method by which individuals with these disorders are diagnosed. However, based on feedback from a multilevel review of the proposed revisions, the American Psychiatric Association ultimately decided to retain the DSM-IV categorical approach along with the same 10 personality disorders. The motivation for the development of DSM-5 was the lack of validity of existing categories of mental disorders according to traditional criteria, yet new options for these disorders were intended to somehow meet these standards. Unfortunately the developers of DSM-5 have not improved the validity problem with any of the diagnostic categories, especially the personality disorders.
The proposed revisions that were not accepted for the main body of the manual were approved as an alternative hybrid dimensional-categorical model that will be included in a separate chapter in Section III of DSM-5. This alternative model was included to encourage further study on how this new methodology could be used to assess personality and diagnose personality disorders in clinical practice. The hybrid methodology retains six personality disorder types: borderline, obsessive-compulsive, avoidant, schizotypal, antisocial, and narcissistic. In addition, the DSM-5 has moved away from the multiaxial system to a new assessment that removes the arbitrary boundaries between personality disorders and other mental disorders.
Personality disorders involve a chronic pattern of both internal perception and observable behavior in at least two of the following four symptom domains: cognitive-perceptual, affect, interpersonal functioning, and impulse control. Personality disorders have been categorized into three general categories or clusters: cluster A (odd/eccentric); cluster B (dramatic); cluster C (anxious/fearful). However, the foundation upon which personality disorders have been defined has been the subject of rigorous debate. Thus, assessment and treatment recommendations do not share the same evidence base found for the mood, anxiety, psychotic, and other axis I (major mental) disorders. Personality disorders are associated with significant distress across these domains. In primary care settings, physicians are most likely to encounter patients with personality disorders in the context of treating the patient for a comorbid condition, such as depression.
History and exam
Key diagnostic factors
- odd thinking
- restricted range of emotions
- anger and irritability
- excessive emotionality and unstable mood states
- anxiety and tension
- impulsive behaviors
- evidence of self harm (e.g., scars, burns)
- history of abuse
- family history of schizophrenia
- negative parenting interactions
- emotional/disruptive disorder in childhood
1st investigations to order
- clinical interview
Investigations to consider
- suicide risk screening questions
- Standardized Assessment of Personality-Abbreviated Scale (SAPAS)
- Millon Clinical Multiaxial Inventory-III (MCMI-III)
- Structured Clinical Interview for DSM-5 Alternative Model for Personality Disorders Version (SCID-5-AMPD)
- Structured Clinical Interview for DSM-5 Personality Disorders
- MRI/CT scan of brain
- urine drug screen
- The Primary Care Evaluation of Mental Disorders (PRIME-MD)
- Patient Health Questionnaire-9 (PHQ-9)
- Mood Disorder Questionnaire
- Generalized Anxiety Disorder-7 (GAD-7) and GAD-2
at risk for harming self or others, or unable to attend to basic self-needs
cluster A (odd/eccentric): non-life-threatening
cluster B (dramatic): non-life-threatening
cluster C (anxious): non-life-threatening
multiple features of different personality disorders: non-life-threatening
Michael J. Schrift, DO, MA
Department of Psychiatry and Behavioral Sciences
University of Washington
MJS declares he has no competing interests.
Dr Michael J. Schrift would like to gratefully acknowledge Dr Crystal T. Clark, and the late Dr Maria Devens, previous contributors to this topic. He would also like to acknowledge Dr Eric Gausche, who contributed the psychopharmacology sections for the initial version, and Dr Richard Stringham, who reviewed and approved information on the use of imaging and laboratory tests in the diagnosis section in the initial version. MD was an author of references cited in this topic. CTC, EG, and RS declare that they have no competing interests.
Anthony W. Bateman, FRCPsych
Consultant Psychiatrist and Visiting Professor
Halliwick Psychotherapy Unit
St Ann’s Hospital
AWB declares that he has a bias towards the use of mentalization in the treatment of personality disorder.
Robin L. Kissell, MD
Borderline Personality Disorder Initiative
RLK declares that she has no competing interests.
Justin Trevino, MD
Opioid Treatment Program
Dayton Veterans Affairs Medical Center
JT declares that he has no competing interests.
Dietmar Winkler, MD
Department of Psychiatry and Psychotherapy
Medical University of Vienna
DW has received lecture fees from CSC Pharmaceuticals, GlaxoSmithKline, and Pfizer, and has served as a consultant for GlaxoSmithKline.
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