Personality Disorders

The prevalence of personality disorders is higher than actual diagnoses suggest. An estimated 9% to 14% of Americans have one or more personality disorder. These disorders affect both males and females, but the sex distribution for subtypes may differ. You may encounter patients with personality disorders when they present for a comorbid condition (e.g., depression) and a concurrent diagnosis of personality disorder is identified.

Personality disorders are characterized by persistent disruption in perception and behavior that results in distressing symptoms within the domains of cognitive, perceptual, affect, interpersonal functioning, and impulse control. Symptoms can appear in childhood but more often in adolescence and may stabilize over time.

The Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5), specifies 10 distinct personality disorders. The features or traits of one disorder often are shared across disorders. The 10 distinct types of personality disorders are grouped into the following three clusters:

Cluster A disorders are characterized by behaviors that are considered as unusual or eccentric to others. Types and associated features of cluster A disorders are:

paranoid personality disorder: mistrust of others, suspicious, hypervigilant
schizoid personality disorder: loner, lacking interest in social engagement
schizotypal personality disorder: odd or unusual perceptions and behavior

Cluster B disorders are characterized by dramatic and erratic behavior patterns. Types and associated features of cluster B disorders are:

antisocial personality disorder: disregard for rights of others, lacks remorse
borderline personality disorder: impulsive, unstable self-image and relationships, emotionally labile
histrionic personality disorder: attention-seeking, exaggerated emotions, superficial
narcissistic personality disorder: self-important, seeks admiration, lacks empathy

Cluster C disorders share a foundation of anxiety or fear and exhibit behavior guided by those emotions. Types and associated features of cluster C disorders are:

avoidant personality disorder: preoccupied with rejection, socially inhibited, feels inadequate
dependent personality disorder: psychological dependence on others, feels helpless when alone, clingy
obsessive-compulsive personality disorder: preoccupied with order and control

Screening

The Structured Clinical Interview (SCID) is a semi-structured diagnostic interview that includes questions about medical and family history as well as symptom presence, duration, and severity. The SCID is recommended in the DSM-5 as a screening tool for personality disorders. It is usually administered during the patient interview and can take anywhere from a few minutes to hours, depending on the patient’s condition.
The Level of Personality Functioning Scale (LPFS) is a self‐report questionnaire that assesses level of impairment.
Personality Inventory for DSM-5 (PID-5) is a self-report assessment of personality traits offered in short and long forms.
The Standardised Assessment of Personality: Abbreviated Scale (SAPAS) is a short interview tool designed for use in a clinic or survey setting to identify traits that may contribute to a personality disorder. In a validity study, a score of 3 or more on the eight-question interview correctly identified 90% of psychiatric patients with DSM-IV personality disorder:

Standardised Assessment of Personality - Abbreviated Scale (SAPAS)
Only circle yes or no if the patient thinks that the description applies most of the time and in most situations. A total score of 3 or more indicates personality disorder is likely. In general, do you have difficulty making and keeping friends? (yes=1, no=0) Would you normally describe yourself as a loner? (yes=1, no=0) In general, do you trust other people? (yes=0, no=1) Do you normally lose your temper easily? (yes=1, no=0) Are you normally an impulsive sort of person? (yes=1, no=0) Are you normally a worrier? (yes=1, no=0) In general, do you depend on others a lot? (yes=1, no=0) In general, are you a perfectionist? (yes=1, no=0)

Standardised Assessment of Personality - Abbreviated Scale (SAPAS)

Only circle yes or no if the patient thinks that the description applies most of the time and in most situations. A total score of 3 or more indicates personality disorder is likely.

In general, do you have difficulty making and keeping friends? (yes=1, no=0)
Would you normally describe yourself as a loner? (yes=1, no=0)
In general, do you trust other people? (yes=0, no=1)
Do you normally lose your temper easily? (yes=1, no=0)
Are you normally an impulsive sort of person? (yes=1, no=0)
Are you normally a worrier? (yes=1, no=0)
In general, do you depend on others a lot? (yes=1, no=0)
In general, are you a perfectionist? (yes=1, no=0)

Diagnosis

Personality disorders are characterized by persistent patterns of disruptive thinking, feeling, and behaviors that affect an individual’s work, productivity, activities of daily living, and quality of life. This pattern of behavior deviates from cultural norms and leads to distress or impairment in at least two of the following areas:

thinking about oneself and others
emotional responses
relating to others
controlling one’s behavior

These traits or behaviors often appear during adolescence and persist into adulthood, are not secondary to other medical or psychiatric conditions, and are not the result of substance misuse. In addition to separate criteria for the 10 distinct personality disorders, the DSM-5 lists the following general criteria for diagnosis of a personality disorder:

DSM-5 Diagnostic Criteria for General Personality Disorder
An enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture. This pattern is manifested in two (or more) of the following areas: Cognition (i.e., ways of perceiving and interpreting self, other people, and events) Affectivity (i.e., the range, intensity, lability, and appropriateness of emotional response) Interpersonal functioning Impulse control The enduring pattern is inflexible and pervasive across a broad range of personal and social situations. The enduring pattern leads to clinically significant distress or impairment in social, occupational, or other important areas of functioning. The pattern is stable and of long duration, and its onset can be traced back at least to adolescence or early adulthood. The enduring pattern is not better explained as a manifestation or consequence of another mental disorder. The enduring pattern is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., head trauma).

DSM-5 Diagnostic Criteria for General Personality Disorder

An enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture. This pattern is manifested in two (or more) of the following areas:
- Cognition (i.e., ways of perceiving and interpreting self, other people, and events)
- Affectivity (i.e., the range, intensity, lability, and appropriateness of emotional response)
- Interpersonal functioning
- Impulse control
The enduring pattern is inflexible and pervasive across a broad range of personal and social situations.
The enduring pattern leads to clinically significant distress or impairment in social, occupational, or other important areas of functioning.
The pattern is stable and of long duration, and its onset can be traced back at least to adolescence or early adulthood.
The enduring pattern is not better explained as a manifestation or consequence of another mental disorder.
The enduring pattern is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., head trauma).

Treatment

Epidemiologic studies have found significant links between personality disorders and arthritis, cardiovascular disease, and diabetes, although the etiology of these associations is uncertain. Individuals with personality disorders are more likely to have impaired functioning, a negative health perception, and high rates of health care utilization and medication use. Studies also suggest that patients with personality disorders have shortened life expectancy and higher rates of all-cause mortality. Therefore, thorough investigation of the whole patient with personality disorder is important.

Traditionally, treatment approaches for personality disorder have included both psychosocial therapy and pharmacotherapy, although the utility of the latter has been challenged by recent trials showing little benefit over placebo.

Psychosocial therapy is the recommended primary treatment for personality disorders. A mix of behavioral and psychoanalytic approaches helps the patient gain insight into the condition and learn more about symptoms and how to identify them.

Psychosocial therapy may include:

psychoanalytic/psychodynamic approach
cognitive behavioral therapy (CBT)
dialectical behavioral therapy (CBT focused on validation of the patient with compassion and acceptance therapy)
group or individual therapy
psychoeducation (teaching about the illness, treatment, and coping mechanisms for individual and family)

Pharmacotherapy is most often used to control or treat particular symptoms of personality disorders rather than the overall disorder itself. Comorbid psychiatric disorder (e.g., depression or anxiety) are not uncommon in patients with personality disorders. As a result, medications such as antidepressants, antianxiety drugs, and mood stabilizers are used frequently in the management of personality disorders.

Antidepressant medications may be useful in the treatment of cluster C personality disorders.
Antipsychotic medications are used with some success in patients with cluster A personality disorders.
Anticonvulsant and mood-stabilizing medications are used in the treatment of cluster B personality disorders (associated with mood reactivity) to help mitigate uncontrolled behavior and hypersensitivity to rejection.

Research

Landmark clinical trials and other important studies

Research

Efficacy of Psychotherapies for Borderline Personality Disorder: A Systematic Review and Meta-analysis

Cristea IA et al. JAMA Psychiatry 2017.

A systematic review of psychotherapeutic approaches for the treatment of borderline personality disorder

Personality Disorders and Physical Comorbidities in Adults from the United States: Data from the National Epidemiologic Survey on Alcohol and Related Conditions

Quirk SE, et al. Social Psychiatry and Psychiatric Epidemiology Soc Psychiatry Psychiatr Epidemiol 2015.

This study examined the associations between personality disorders and physical comorbidities.

The Addition of STEPPS in the Treatment of Patients with Bipolar Disorder and Comorbid Borderline Personality Features: A Protocol for a Randomized Controlled Trial

Riemann G et al. BMC Psychiatry 2014.

A randomized controlled trial of treatment for patients with bipolar disorder and borderline personality disorder

Personality Disorders and Physical Health: A Longitudinal Examination of Physical Functioning, Healthcare Utilization, and Health-Related Behaviors in Middle-Aged Adults

Powers AD and Oltmanns TF. J Pers Disord 2012.

In this longitudinal study, the presence of disordered personality was predictive of worse functioning, regardless of actual health status, and increased health care utilization.