Personality Disorders

Prof Mohd Razali Salleh

General Concept

Definition- PDs are enduring subjective experiences and behaviour that deviate from cultural standards, are rigidly pervasive, have onset in adolescence or early adulthood, are stable through time, and lead to unhappiness and impairment When personality traits are rigid and maladaptive and produce functional impairment or subjective distress, a PD may be diagnosed Prevalence ~ 10-20% in general population

About half of all psychiatric patients have PDs, which is frequently comorbid with Axis I conditions PD is a predisposing factor for other psychiatric disorders; e.g. substance use, suicide, affective disorders, impulsecontrol disorders, eating disorders and anxiety disorders

PDs symptoms are allopathic (e.g. able to adapt to, and alter the external environment; and ego-syntonic (i.e. accepted by the ego) Persons with PDs do not feel anxiety about their maladaptive behaviour. They are more likely refused psychiatric help.

Classification (DSM-IV-TR)
Cluster A- odd, aloof features Schizotypal, schizoid, paranoid Cluster B- dramatic, impulsive, erratic features Narcissistic, borderline, antisocial, histrionic. Cluster C- anxious and fearful features Avoidance, dependent, obsessive-compulsive.

ETIOLOGY

GENETIC FACTORS Cluster A PDs are more common in the biological relatives of patients with schizophrenia, especially Schizotypal PD. Less correlation paranoid and schizoid PD Cluster B apparently have genetic base. Antisocial PD associated with alcohol use disorders. Depression is common in family with borderline PD. A strong correlation is found between histrionic PD and somatization disorder.

Cluster C PDs may also have genetic basis. Patients with avoidance PD have high anxiety level (GAD). Patients with obsessive-compulsive PD show some sign of depression; e.g. shortened REM latency.

BIOLOGICAL FACTORS Impulsive trait often show high level of testosterone, 17-estradiol and estrone. DST results are abnormal in some patients with borderline PD Low platelet MAO have been noted in some patients with schizotypal PD Smooth Pursuit Eye Movements have been linked with schizotypal PD

Low level of 5-hydroxyindoleacetic acid (5HIAA) are found in patients who attempt suicide and with impulsivity and aggressive Slow wave activity on EEG are found in patients with antisocial and borderline PD

PSYCHOANALYTIC THEORY Sigmund Freud suggest personality traits are related to a fixation at one psychosocial stage of development. Oral character- passive and dependent because they depends on others for food Anal character- stubborn and highly conscientious because they are struggling over toilet training

DSM-IV-TR General Diagnostic Criteria for Personality Disorder

A. An enduring pattern of inner experience and behaviour that deviates markedly from the expectations of the individuals culture. The pattern is manifested in two or more of the following areas: i) cognition i.e. ways of perceiving, and interpreting self, other people and events. ii) affectively i.e. the range, intensity, lability and appropriateness of emotional response iii) interpersonal functioning Iv) impulse control

B. The enduring pattern is inflexible and pervasive across a broad range of personal and social situations C. The enduring pattern lead to clinically significant distress of impairment in social, occupational or other important area of functioning. D. The pattern is stable and of long duration, and its onset can be traced back to adolescence or early childhood.

E. The enduring pattern is not better accounted for as a manifestation or consequences of another mental disorder F. The enduring pattern is not due to the direct physiological effects of a substance; e.g. drug abuse, a medication or general medical conditions/ head trauma

Clinical Features

Paranoid PD Long standing suspicious and mistrust of person. Refused responsibility for their own feeling and assign responsibility to others Schizoid PD Cool and aloof. Appear quiet, distant, seclusive and unstable. Displayed a remote reserve and show no involvement with everyday events and the concerns of others Schizotypal PD Have a peculiar speech which has meaning to them only. Exhibit a disturbed thinking and claiming of having power of clairvoyance

Antisocial PD Appeared to be normal and even charming. Had h/o running away from home, truancy and involved in illegal activities during childhood and adolescence. Borderline PD Always appear in the state of crisis. Had extreme mood swing and the behavour is highly unpredictable. Histrionic PD High degree of attention-seeking behaviour. Displayed temper tantrum, tears and accusation when they are not in the centre of attention

Narcissistic PD Characterized by heightened sense of self-importance and grandiose feeling of uniqueness. They consider themselves special and expect special treatment. Selfish, insisted on their own way to achieve fame and fortune. Have fragile relationship and unable to show empathy

Avoidance PD/ Anxious PD (ICD) Timidity, lack of self-confidence and having inferiority complex. Desire the warmth and security of human relationship. Show hypersensitivity to rejection and may lead to socially withdrawn. Dependent PD Pervasive pattern of dependent and submissive behaviour. Cannot make decision without advices from others . Lack of self confident and may experience intense discomfort when alone after a brief period. Obsessive-compulsive PD/ Anancastic PD (ICD) Preoccupied with rules, regulations, orderliness, neatness, details and the achievement of perfection. Lack of flexibility and are intolerants. Shows emotional constriction, stubbornness, indecisiveness and lack of sense of humour.

Personality disorder not otherwise specified Passive-aggressive PD/ Negativistic PD Characterized by covert obstructionism, procrastination, stubbornness and inefficiency. Always find faults with those on whom they depend. Depressive PD/ Melancholic PD Pessimistic, anhedonic, self-doubting and chronically unhappy

Treatment
PSYCHOTHERAPY Dialectical behaviour therapy (DBT) for borderline PD, especially those with para suicidal behaviour Psychoanalytically oriented psychotherapy Insight-oriented psychotherapy Behaviour therapy Group therapy

PHARMACOTHERAPY Antipsychotics In conjunction with psychotherapy in paranoid PD, schizotypal PD, Brief psychotic episode in Borderline PD Antidepressant and anxiolytics To control agitation, anxiety/ depression for short term

Mood stabilizers Evidence of mood swing Poor impulse control/ impulsivity Psychostimulants Evidence of attention-deficit/ hyperactivity in Antisocial PD Serotonergic agents Control depression, panic attack, impulsiveness and rumination