Personality disorders

What is a personality disorder?¹

Personality disorders can be described as the manifestation of extreme personality traits that interfere with everyday life and contribute to significant suffering, functional limitations, or both. They are associated with an inferior quality of life, poor health, and premature mortality.

The literature occasionally refers to the Diagnostic and Statistical Manual of Mental Disorders (DSM) classification system which - whilst used in clinical practice in the USA - is primarily used for research purposes elsewhere.

The ICD-11 (World Health Organization 1992) defines personality disorder (6D10) as follows¹ :

• Characterised by problems in functioning of aspects of the self (eg, identity, self-worth, accuracy of self-view, self-direction), and/or interpersonal dysfunction (eg, ability to develop and maintain close and mutually satisfying relationships, ability to understand others' perspectives and to manage conflict in relationships) that have persisted over an extended period of time (eg, two years or more).

• The disturbance is manifest in patterns of cognition, emotional experience, emotional expression, and behaviour that are maladaptive (eg, inflexible or poorly regulated) and is manifest across a range of personal and social situations (ie is not limited to specific relationships or social roles).

• The patterns of behaviour characterising the disturbance are not developmentally appropriate and cannot be explained primarily by social or cultural factors, including socio-political conflict.

• The disturbance is associated with substantial distress or significant impairment in personal, family, social, educational, occupational or other important areas of functioning.

Personality disorder causes

The causes of personality disorders remain obscure. Traditional belief is that these behaviours result from a dysfunctional early environment that prevents the evolution of adaptive patterns of perception, response and defence.

Factors in childhood which are postulated to be linked to personality disorder include² :

• Sexual abuse

• Physical abuse

• Emotional abuse

• Neglect

• Being bullied

Emotional or behavioural factors that might play a part include:

• Truanting.

• Bullying others.

• Being expelled/suspended.

• Running away from home.

• Deliberate self-harm.

• Prolonged periods of misery.

The evidence base supporting a link between personality disorder and genetic factors is growing³ .

People with personality disorders are at increased risk for many psychiatric disorders. Mood disorders are a particular risk across all personality diagnoses. Patients with depression and personality disorder have a more persistent condition than those who have depression alone⁴ . Some types of mental illnesses are more specific to particular personality disorders.

It is unsurprising from the above that many people with personality disorders offend against the law² .

Epidemiology

Personality disorders are common. A review based on 13 studies conducted in the USA and Europe, reported prevalence figures varying from 3.9% to 15.5%. A WHO World Mental Health Survey, carried out in 13 countries, found a prevalence rate of 6.1%⁵ .

One preliminary study using the ICD-11 classification found that⁶ :

• 45% of the population had no personality dysfunction.

• 48% personality difficulty.

• 5.3% mild personality disorder.

• 1.5% moderate personality disorder.

• 0.2% severe personality disorder.

Personality disorders are quite prevalent in later life, and have a serious impact on quality of life, such as high levels of suffering and decreased functioning. In the elderly, personality disorders may complicate the recognition and treatment of comorbid disorders. Treatment outcomes are poorer and rates of relapse and readmission higher in older patients⁷ .

Personality disorder symptoms (presentation)¹

ICD-11 defines severity of personality disorder as follows:

• Personality difficulty: some personality problems in certain situations but not universally.

• Mild PD: definite well-demarcated personality problems across a range of situations.

• Moderate PD: definite personality problems usually covering several personality domains and across all situations.

• Severe PD: personality problems leading to significant risk to self or others.

Prominent personality traits or patterns

Negative affectivity trait
Tendency to experience a broad range of negative emotions. Common manifestations include:

• Experiencing a broad range of negative emotions with a frequency and intensity out of proportion to the situation.

• Emotional lability and poor emotion regulation.

• Negativistic attitudes.

• Low self-esteem and self-confidence.

• Mistrustfulness.

Detachment trait
Tendency to maintain interpersonal distance (social detachment) and emotional distance (emotional detachment). Common manifestations include:

• Social detachment (avoidance of social interactions, lack of friendships, and avoidance of intimacy).

• Emotional detachment (reserve, aloofness, and limited emotional expression and experience).

Dissociality trait
Disregard for the rights and feelings of others, encompassing both self-centeredness and lack of empathy. Common manifestations include:

• Self-centeredness (eg, sense of entitlement, expectation of others' admiration, positive or negative attention-seeking behaviours, concern with own needs, desires and comfort and not those of others).

• Lack of empathy (indifference to whether actions inconvenience or hurt others, which may include being deceptive, manipulative, and exploitative of others, being mean and physically aggressive, callousness in response to others' suffering, and ruthlessness in obtaining goals).

Disinhibition trait
Tendency to act rashly based on immediate external or internal stimuli (sensations, emotions, thoughts), without consideration of potential negative consequences. Common manifestations include:

• Impulsivity.

• Distractibility.

• Irresponsibility.

• Recklessness.

• Lack of planning.

Anankastia trait
Narrow focus on rigid standard of perfection and of right and wrong, and on controlling own and others' behaviour and controlling situations to ensure conformity to these standards. Common manifestations include:

• Perfectionism (eg, concern with social rules, obligations, and norms of right and wrong, scrupulous attention to detail, rigid, systematic, day-to-day routines, hyper-scheduling and planfulness, emphasis on organisation, orderliness and neatness).

• Emotional and behavioural constraint (eg, rigid control over emotional expression, stubbornness and inflexibility, risk-avoidance, perseveration, and deliberativeness).

Borderline pattern
Pattern of personality disturbance is characterised by a pervasive pattern of instability of interpersonal relationships, self-image and affects, and marked impulsivity, as indicated by:

• Frantic efforts to avoid real or imagined abandonment.

• A pattern of unstable and intense interpersonal relationships.

• Identity disturbance, manifested in markedly and persistently unstable self-image or sense of self.

• A tendency to act rashly in states of high negative affect, leading to potentially self-damaging behaviours.

• Recurrent episodes of self-harm.

• Emotional instability due to marked reactivity of mood.

• Chronic feelings of emptiness; inappropriate intense anger or difficulty controlling anger.

• Transient dissociative symptoms or psychotic-like features in situations of high affective arousal.

Secondary personality change

Persistent personality disturbance that represents a change from previous characteristic personality pattern that is judged to be a direct pathophysiological consequence of a health condition.

The symptoms are not accounted for by delirium or any other mental and behavioural disorder, and are not a psychologically mediated response to a severe medical condition (eg, social withdrawal, avoidance, or dependence in response to a life-threatening diagnosis).

Investigations⁸

Psychological testing may support or direct the clinical diagnosis.

• The Minnesota Multiphasic Personality Inventory (MMPI) is the most commonly used⁹ .

• The Eysenck Personality Inventory and the Personality Diagnostic Questionnaire are also used.

• A structured psychometric assessment - this is particularly relevant to dissocial and emotionally unstable personality disorders¹⁰ .

Personality disorder treatment and management^{10 11}

General approach

The National Institute for Health and Care Excellence (NICE) has published guidance on the treatment, management and prevention of antisocial personality disorder and borderline personality disorder. This maps to the ICD-10 categories of dissocial and emotional unstable personality disorder respectively and so remains relevant. NICE has also published quality standards advice aimed at commissioners of mental health services¹² . This provides guidance on a number of diagnostic and management issues.

A person with a personality disorder may not need any treatment. With help, many people with personality disorder can start to lead a normal and fulfilling life.

Support

Many people with personality disorder can lead full lives with emotional and/or practical support given by friends and families, self-help groups and networks, as well as from primary care and mental health teams.

Psychotherapy

A number of psychotherapies may be effective. However therapy may be long-term, lasting for years. Potentially effective therapies include¹³ :

• Mentalisation based therapy (MBT): group and individual therapy to become more aware of what's going on in the person's mind and in the minds of others.

• Dialectical behaviour therapy (DBT): combination of cognitive and behavioural therapies, with some techniques from Zen Buddhism.

• Cognitive behavioural therapy (CBT): to change unhelpful patterns of thinking.

• Schema focused therapy: cognitive therapy to explore and change unhelpful beliefs.

• Transference focused therapy: explores and changes unconscious processes.

• Dynamic psychotherapy: looks at how past experiences affect present behaviour.

• Cognitive analytical therapy: to recognise and change unhelpful patterns in relationships and behaviour.

Treatment in a therapeutic community

Typically people with long-standing emotional problems can go (day programme or residential) for several weeks or months. Mostly in groups, people learn from relating to and learning from each other, with any disagreements or upsets being in a relatively safe place.

Medication

People with personality disorders are more likely to have another mental health difficulties, such as depression or anxiety, which may benefit from/require treatment with medication. Evidence for any benefit of medication for the treatment of personality disorders is very limited. Prescribing medication for this purpose is not advised by NICE, and medication cannot 'cure' a personality disorder. Medications may sometimes be used by psychiatrists to reduce symptoms, including:

• Antipsychotic drugs (low dose): can reduce the suspiciousness of paranoid, schizoid and schizotypal symptoms.

• Antidepressants for mood and emotional difficulties, or to reduce anxiety.

• Mood stabilisers for unstable mood and impulsivity.

• Sedatives (short-term only) may be used as part of a plan during a crisis.

A Cochrane systematic review found that mood stabilisers and second-generation antipsychotics may be helpful for specific symptoms in borderline personality disorder but that pharmacotherapy did not affect the overall severity of the condition¹⁴ .

Complications

The following may occur more often than expected:

• Suicide.

• Substance misuse (including alcohol dependency).

• Accidents and injuries.

• Depression.

• Homicide.

Frequent enquiries about suicidal ideation are warranted, regardless of whether the patient spontaneously raises the subject¹⁵ . There is no risk of implanting the idea of suicide in a patient who is not already considering it. Enquiry about drugs and other available means of suicide may help prevention.

Prevention

The NICE guidance puts some emphasis on identification of individuals at risk of developing personality disorders¹¹ . A variety of interventions is suggested to try to prevent some of the consequences of the personality disorders covered by this guidance. For example, NICE suggests that services should establish robust methods to identify children at risk of developing conduct problems and that vulnerable parents could be identified antenatally - for example, in antisocial personality, by identifying:

• Parents with other mental health problems, or with significant drug or alcohol problems.

• Mothers younger than 18 years, particularly those with a history of maltreatment in childhood.

• Parents with a history of residential care.

• Parents with significant previous or current contact with the criminal justice system.

A wide variety of different interventions is then suggested, ranging from anger management to parenting classes.

Prognosis⁵

• The prognosis is variable. However, although often chronic and life-long, many people with personality disorders improve over time, particularly if provided with effective support.

• Personality disorders are associated with an inferior quality of life, poor health, and premature mortality.

• People with personality disorders generally don't seek healthcare for their personality disorder, but instead seek care for other medical issues which are obscured by their underlying personality problems.