V.

Personality Disorders

37. PERSONALITY AND PERSONALITY DISORDERS

Alexis A. Giese, M.D

1. What is the difference between a personality trait and a personality disorder? Everyone has a distinct personality style, including typical ways of perceiving the self and the world, preferred coping mechanisms in response to stress, and values derived from cultural, familial, and individual experiences. Although personality development continues throughout life, most characteristic traits are formed by early adulthood. Personality disorders, on the other hand, are distinguished by persistently inadequate adaptive capacities affecting several realms of functioning, such as social relationships or occupational performance. People with personality disorders have chronic problems dealing with responsibilities, roles, and stressors; they also have difficulty understanding the causes of their problems or changing their behavior patterns. 2. Give an example of each. A person with dependent personality traits may be somewhat overreliant on others, but generally functions fairly well. During a crisis (such as an acute medical illness), he or she may exhibit exaggerated neediness in the healthcare setting or increase demands on family and friends to make decisions and provide care. However, when the illness is over, previous patterns of relating and functioning return. By contrast, someone with dependent personality disorder has trouble making even routine decisions without extensive support and advice, is underfunctioning socially and occupationally because of the inability to initiate things independently, and is submissive, clinging, and fearful of loss of nurturance, even in everyday situations.
3. What is the natural history of personality disorders? Early manifestations of personality disorders generally are evident in adolescence or even childhood. By young adulthood, maladaptive traits cause major problems in social or occupational functioning or significant distress to the individual. Developmental tasks common to late adolescence or early adulthood, such as completing an education, emancipation from the family of origin, obtaining employment, and pursuit of romantic relationships, often are mishandled or delayed. Impairment from a personality disorder (especially antisocial and borderline personality disorders) is usually most pronounced during the third and fourth decades and decreases thereafter. However, some personality disorders, such as obsessive-compulsive and schizotypal, are less likely to remit with age and may become more problematic in later life.

4. Give examples of age-related manifestations. Borderline personality disorder may present first in the middle or late teens with onset of selfmutilatory behaviors, eating disorder symptoms, depression, or suicide attempts. The twenties and thirties can be tumultuous, with frequent crises and hospitalizations. By 40 years of age, however, the features of borderline personality disorder typically have attenuated, with decreased impulsive
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behaviors, but with residual feelings of emptiness and identity disturbance. Crises that occur in midlife (e.g., loss of employment) may precipitate a recurrence of some borderline symptoms such as self-mutilatory behavior, but such symptoms tend to be more limited than earlier because of some degree of social stability and coping skills. Older adults may manifest previously quiescent personality disorders, especially dependent and obsessive-compulsive, when faced with late-life stressors such as illness or loss of partner.

5. Describe the clinical features that help distinguish an axis I disorder from an axis I1 disorder. Axis I disorders (clinical syndromes) are primarily focal disturbances affecting one mental dimension, such as thought (as in psychotic disorders) or mood (as in mania). Axis I disorders may be episodic, chronic, or progressive, but in general they represent a distinct departure from premorbid functioning. Many axis I disorders are highly amenable to specific pharmacotherapeutic and psychotherapeutic interventions. Axis I1 (personality) disorders represent an impairment in baseline functioning, in which the person generally functions below the level expected for his or her intelligence, education, and resources. The impairment is most evident in self-perceptions and interpersonal relationships. By definition the personality impairment has an early onset and affects several realms of functioning. Clinical tip-offs to an axis I1 problem include atypical presentations that do not fit readily into the usual axis 1 categories. For example, a patient who complains of mood swings and depression that are of insufficient severity and duration to meet criteria for bipolar disorder or cyclothymia may have histrionic or borderline personality disorder. Another clue is the presence of multiple, conflicting psychiatric diagnoses. For example, a patient seen in several clinics and diagnosed variably with schizophrenia, chronic depression, and social phobia may have schizotypal personality disorder. A high degree of chaos and emotional response is sometimes a tip-off to personality disorder, especially the cluster B group (see Question 6). In addition, failure to respond to appropriately aggressive treatment of an axis I disorder may suggest an underlying axis I1 problem. The distinction between axis I and axis I1 symptoms often is made only after extensive longitudinal data are obtained. A thorough diagnostic evaluation for axis 1 disorders must precede or accompany consideration of a personality disorder diagnosis.

6. Name the three clusters of personality disorders in DSM-IV. Cluster A is the odd or eccentric group, which includes paranoid, schizoid, and schizotypal personality disorders. Cluster B is the dramatic, overly emotional, or erratic group, including antisocial, borderline, histrionic, and narcissistic personality disorders. Cluster C is the anxious or fearful
group, including avoidant, dependent, and obsessive-compulsive personality disorders.

7. Describe the general characteristicsof cluster A. This group is characterized by a general distrust of others, misinterpretation of others actions, odd or idiosyncratic beliefs, and a tendency toward social isolation. The assessment that beliefs and behaviors are abnormal must take into account the patients cultural and religious background. Some religious and ethnic traditions may appear bizarre on the surface (e.g., voodoo, dietary restrictions) but are pervasive in certain cultures. The distinction that the finding is pathologic is strengthened by evidence that the belief or behavior puts the patient at odds with his or her society and interferes with social or occupational functioning. The initial presentation of cluster A personality disorders often is hostility or conflict with others; the underlying mistrust and unusual ideas become apparent over time. Only rarely do people with cluster A disorders self refer for mental health treatment. Referral for psychiatric evaluation may be prompted by primary medical providers when depression or frank psychotic symptoms develop or when the odd beliefs interfere with treatment of a general medical condition. Occasionally, such persons come to psychiatric attention through the legal system when idiosyncratic behaviors conflict with social convention or laws. For example, a person with schizotypal personality disorder may live an isolated lifestyle with dozens of cats, ignoring hygiene and health codes; he or she may refuse to leave the home when it is condemned by authorities and ultimately be brought to mental health care by the police.

Personality and Personality Disorders

DSM-IV Personality Disorder Clusters
CLUSTER DESCRlPTlON PERSONALITY DlSORDERS

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Oddteccentric

Dramatiderratic

Anxious/fearful

Paranoid Schizoid Schizotypal Antisocial Borderline Histrionic Narcissistic Avoidant Dependent Obsessive-compulsive

Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Copyright 1994 American Psychiatric Association.

8. Describe individuals in cluster B.

Such people often are characterized as labile, unpredictable, unlikable, and impulsive. The initial presentation typically is crisis-related and chaotic, often involving severe symptoms (that may decrease after the crisis has passed), substance abuse, and conflicts with family members, employers, or the healthcare system. Persons with cluster B disorders have difficulty establishing and maintaining interpersonal relationships (e.g., with medical providers) and often have a history of discharge against medical advice, doctor shopping, or failure to follow recommended treatment.

9. What are the characteristicsof patients in cluster C? Patients often are anxious, timid, perfectionistic, and conflict-avoidant; presentation frequently is triggered by depression or somatic complaints. Although sometimes reluctant to engage in general medical or psychiatric treatment, they may become highly attached because they have few other important relationships and have difficulty disengaging at the appropriate time.

10. How frequently do personality disorders occur in the general and psychiatric populations?
Standardized, structured diagnostic interviews estimate the lifetime prevalence of personality disorders in the general population at 10-13%. Schizotypal personality disorder is the most common cluster A disorder in the general population, borderline personality disorder the most common in cluster B, and dependent personality disorder the most common in cluster C. The prevalence of personality disorders in clinical psychiatric populations is, of course, much higher than in the general population. Psychiatric inpatients have prevalence rates of personality disorders ranging from 30-60%. In most studies, borderline personality disorder is the most frequently found axis I1 disorder in hospitalized psychiatric patients (20-30%). In outpatient psychiatric clinics prevalence rates of personality disorder fall between those for the general population and inpatients, ranging from 2 0 4 0 % in some estimates. Avoidant, dependent, and borderline personality disorders have been reported most frequently in psychiatric outpatient clinics. Many individuals meet criteria for more than one personality disorder. Multiple diagnoses of axis I1 disorders are allowed in DSM-IV, and the clinician should list all disorders in order of clinical importance. 11. Describe common comorbid psychiatric disorders in persons with personality disorders. Mood disturbances, such as depression, anger, and anxiety, are frequent findings in people with personality disorders. Major depressive episodes and suicide attempts are more common in persons with a personality disorder than in those without. Anxiety disorders such as social phobia are frequent comorbid diagnoses in the cluster C group, particularly avoidant personality disorder. Posttraumatic symptoms (e.g., intrusive memories and flashbacks of traumatic events) are common in borderline personality disorder, although only a minority of cases meet full criteria for posttraumatic stress disorder.

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Substance abuse is a frequent comorbid diagnosis with personality disorders, especially in cluster B. Substance intoxication or withdrawal may contribute to some of the presenting symptoms, and may explain why some of the symptoms are severe at presentation yet remit fairly quickly. Transient psychotic symptoms may lead to treatment, especially in the cluster A group and borderline personality disorder. People with personality disorders often present to primary medical providers with physical complaints, rather than seek mental health services. A personality disorder may complicate or prolong medical treatment and result in higher service utilization and costs if unidentified.

12. What types of psychiatric treatment approaches are useful for treating personality disorders? By definition, personality disorders are chronic and relatively fixed and thus are not easily cured. In short-term treatments, adaptational approaches that help the patient to cope with the current crisis and solve problems more effectively are most helpful. Commonly used treatment modalities include crisis intervention, supportive psychotherapy, environmental manipulation (such as change in living situation), and treatment for substance abuse. Behavioral therapies (such as assertiveness training or systematic desensitization) may be helpful for avoidant and obsessive-compulsive personality disorders. Careful consideration of comorbid axis I disorders may lead to a diagnosis with specific treatment implications, including medications. Certain patients with personality disorders may benefit from long-term psychotherapy that attempts to restructure faulty coping mechanisms. Because of the intensity and complexity of the therapeutic relationship, such treatment is best undertaken by professionals with specific expertise (such as a psychiatrist, psychologist, or psychiatric social worker with psychodynamic training). This type of treatment is not without its risks and should be recommended only to patients who are not in crisis, who have some degree of stability in their lives, and who have resolved substance abuse problems.

13. What personality changes commonly are seen when underlying organic brain disease is present? Personality changes are a feature of many organic brain diseases, sometimes presenting as the earliest signs of illness or even its major manifestation. Dementias due to Alzheimers disease and other neurodegenerative disorders often begin with subtle personality changes that are typically recognized in retrospect after other findings, such as memory deficits, are evident. Structural damage to the brain may result from tumors, trauma, or infarcts and cause significant, permanent personality changes-especially if the frontal and/or temporal lobes are involved. The abrupt and/or late onset of personality changes should not be attributed to a personality disorder until a thorough diagnostic investigation (e.g., premorbid functioning, neurologic history, review of systems, physical exam) has been conducted. Disorder Common personality changes Dementias Early: apathy, narrowing of interests, loss of humor, poor social (e.g., Alzheimers) judgment, impulsivity, immaturity Late: irritability, oppositionality, aggressive outbursts, suspiciousness Frontal lobe damage Apathy, indifference Depression Disinhibition, excitement Temporal lobe epilepsy Heightened emotional tone Rigidity, hypermoralisin Circumstantiality, loquaciousness Dissociative symptoms Temper outbursts Acquired immunodefiEarly: social withdrawal, apathy, agitation ciency syndrome (AIDS) Late: progressive dementia, paranoia, manic symptoms Head trauma Impulsivity, aggression, affective lability

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14. Are personality disorders caused by environmental or constitutionalfactors? The DSM-IV avoids the question by taking an empirical, atheoretical approach; the disorders are defined by descriptive criteria emphasizing observable behaviors. In the past, personality was traditionally viewed as a product of upbringing, whereas the major mental illnesses were thought to be related to biologic vulnerabilities. These issues are now understood to be much more complex, and a substantial body of evidence suggests that both biologic and environmental variables play important interacting roles in personality development and disorders. A familial relationship may exist between schizophrenia and cluster A personality disorders, especially schizotypal personality disorder. Family studies also have suggested a hereditary component to antisocial personality disorder. Borderline personality disorder clusters in families, although this is not clearly genetically determined. Some axis I illnesses such as depression are present at elevated rates in families of personality disordered probands, suggesting that in some cases personality disorder symptoms may be inherited subsyndromal forms of axis I problems. Data supporting the role of environmental factors are strongest in the cluster B group, including high rates of childhood sexual and physical abuse as well as elevated rates of childhood stressors such as divorce, parental loss, inadequate parenting, frequent moves, and institutional placements. Although the association between borderline personality disorder and childhood abuse is the most strongly established (7680% prevalence in most studies), other personality disorders have been estimated to have childhood abuse prevalence rates of approximately 50% compared with estimates of 2040% in mixed psychiatric populations and 10-15% in the general population.
15. Are psychotropic drugs useful in treating personality disorders? Most clinicians agree that psychotropic drugs have at least limited usefulness. If an axis I disorder that usually responds to pharmacologic intervention is present, such as a major depression, treatment should be not be withheld because a personality disorder is suspected. Some of the apparent personality disorder symptoms may remit with adequate treatment of depression and anxiety. Even in the absence of a formal axis I diagnosis, medications are sometimes moderately effective for certain target symptoms in personality disorders. For example, the perceptual distortions and brief psychotic symptoms in paranoid or schizotypal personality disorders may respond to low doses of antipsychotics. Severe behavioral dyscontrol (as sometimes seen in antisocial and borderline personality disorders) may respond to carbamazepine or beta blockers at high doses.
16. Can psychotropic drugs be the mainstay of treatment? A treatment plan that focuses largely or exclusively on medications probably will not meet the needs of a patient with a personality disorder. Many such patients desperately want amelioration of distress, and seek pharmacologic intervention as a panacea. Multidrug regimens carry the risk of combined toxicity and provide a ready means of suicide and drug dependence, particularly if substance abuse is a comorbid diagnosis. The definitive resolution of many problems faced by personality disordered patients requires the development of new coping mechanisms and better social slulls; even with aggressive pharmacotherapy, such goals are usually best reached through psychotherapeuticprocesses.
BIBLIOGRAPHY
1. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Washington, DC, American Psychiatric Association, 1994. 2. Andreasen NC, Black DW (eds): Introductory Textbook of Psychiatry. Washington, DC, American Psychiatric Press, 1991. 3. Gorton G , Akhtar S : The literature on personality disorders, 1985-88: Trends, issues, and controversies. Hosp Community Psychiatry 41 :39-51, 1990. 4. Hori A: Pharmacotherapy for personality disorders. [Review] Psychiatry Clin Neurosci 52: 13-19, 1998. 5. Oldham JM: Personality disorders: Current perspectives. JAMA 272: 1770-1776, 1994. 6 . Oldharn JM, Skodol AE: Personality disorders and mood disorders. In Tasman A, Riba MB (eds): Review of Psychiatry, vol 1 I . Washington, American Psychiatric Press, 1992, pp 418435. 7. Perry JC, Banon E, lanni F: Effectiveness of psychotherapy for personality disorders. [Review] Am J Psychiatry 156:1312-1 321, 1999. 8. Shea MT, Pilkonis PA, Beckham E, et al: Personality disorders and treatment outcome in the NIMH treatment of depression collaborative research program. Am J Psychiatry 147:71 1-718, 1990.

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9. Siever LJ, Davis KL: A psychobiological perspective on the personality disorders. Am J Psychiatry 148: 1657-1658, 1991. 10. Turkat ID: The Personality Disorders: A Psychological Approach to Clinical Management. Elmsford, NY, Pergamon Press, 1990. 1 1. Tyrer P: Personality Disorders. Management and Course. London, Butterworth, 1988.

38. BORDERLINE PERSONALITY DISORDER

Robin A. McCann, P k D . , and Elissa M. Ball, M.D

1. What is borderline personality disorder? The key to recognizing borderline personality disorder (BPD) is instability-instability in affect, interpersonal relationships, and self-identity. The emotional instability of patients with BPD is characterized by vulnerability, intensity, and poor regulation. Emotions are quickly and easily aroused and more intense than those of others; patients often experience difficulty soothing themselves and returning to a stable emotional baseline. They are particularly vulnerable to perceived or actual abandonment and often react with rage, panic, and despair. As people with BPD have difficulty in soothing themselves, they may attempt to block the experience of pain by experiencing, if not inducing, changes in consciousness, including feelings of derealization, depersonalization, and brief psychotic reactions with delusions and hallucinations. Substance use, gambling, overspending, eating binges, and/or self-mutilation, including suicidal threats, gestures, and attempts, are often used to escape intensely painful affect. People with BPD frequently engage in self-injurious acts, ranging from minor scratches or self-inflicted cigarette bums to overdoses or other acts requiring ICU admissions; such nonfatal, intentionally self-harmful acts are referred to as parasuicidal behaviors. 2. What are the diagnostic criteria for BPD? The criteria for BPD were developed by consensus rather than empirical study and were first published in 1980 in DSM 111. Specific DSM IV diagnostic criteria' for BPD are as follows: A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following: 1. Frantic efforts to avoid real or imagined abandonment. Note: Do not include suicidal or selfmutilating behavior covered in Criterion 5. 2. A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation. 3. Identity disturbance: markedly and persistently unstable self image or sense of self. 4. Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating). Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5. 5 . Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior. 6. Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability or anxiety usually lasting a few hours and only rarely more than a few days). 7. Chronic feelings of emptiness. 8. Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights). 9. Transient, stress-related paranoid ideation or severe dissociative symptoms.
Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Copyright 1994 American Psychiatric Association.