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Personality Disorders

by John G. Gunderson, MD, Lois Choi-Kain, MD

Personality disorders are relatively stable patterns of thinking, perceiving, reacting, and relating that differ from expected norms and that begin early in life. These patterns cause the person significant distress and/or impair the person's ability to function socially.

  • There are several types of personality disorders, and each has characteristic problems with self-image and patterns of response to others and to stressful events.

  • Symptoms are different depending on the type of personality disorder, but in general, people have difficulty relating to others and handling stress and/or have a self-image that differs from how others perceive them.

  • Doctors consider diagnosing a personality disorder when people persistently view themselves or others in ways that have no little or no basis in fact or when they continue to act in ways that routinely have negative consequences.

  • Drugs usually do not change personality disorders but may help lessen distressing symptoms.

  • Psychosocial therapies, including certain types of psychotherapy, may help people become aware of their role in creating their problems and help them change their socially undesirable behavior.

Everyone has characteristic patterns of perceiving and relating to other people and stressful events. For example, some people respond to a troubling situation by seeking someone else's help. Others prefer to deal with problems on their own. Some people minimize problems. Others exaggerate them. However, if their characteristic patterns of behavior are ineffective or have negative consequences, mentally healthy people are likely to try alternative approaches. In contrast, people with a personality disorder do not change their response patterns even when these patterns are repeatedly ineffective and the consequences are negative. Such patterns are called maladaptive because people do not adjust (adapt) as circumstances require. Maladaptive patterns vary in how severe they are and how long they persist. For most people with a personality disorder, the disorder causes moderate problems. However, some people have severe social and psychologic problems that last a lifetime.

About 13% of people have a personality disorder. These disorders usually affect men and women equally, although some types of the disorder affect one sex more than the other. Personality disorders result from the interaction of genes and environment. That is, some people are born with a genetic tendency to have a personality disorder, and this tendency is then suppressed or enhanced by environmental factors. Generally, genes and environment contribute about equally to the development of personality disorders.

Most people with a personality disorder are distressed about their life and have problems with relationships at work or in social situations. Many people also have a mood, anxiety, somatization (see Somatic Symptom Disorder), substance abuse, or eating disorder. Having a personality disorder and one of these other disorders makes people less likely to respond to treatment for the other disorder and thus worsens their prognosis.

Personality disorders involve mainly problems with

  • Identity and a sense of self: People with a personality disorder lack a clear or stable image of themselves. That is, how they view themselves changes depending on the situation and the people they are with. For example, they may alternate between thinking of themselves as cruel or kind. Or they may be inconsistent in their values and goals. For example, they may be deeply religious while in church but irreverent and disrespectful elsewhere. Self-esteem may be unrealistically high or low.

  • Relationships: People with a personality disorder are usually unable to form close, stable relationships with others. They may be insensitive to others or emotionally detached, or they may lack empathy. Family members and others often find them confusing and/or frustrating.

People with a personality disorder are usually unaware of their role in creating their problems. Thus, they tend not to seek help on their own. Instead, they may be referred by their friends, family members, or a social agency because their behavior is causing difficulty for others. When they do seek help on their own, it is usually because of the problems created by their personality disorder (such as divorce, unemployment, or loneliness) or because of troubling symptoms (such as anxiety, depression, or substance abuse). They tend to believe these problems and symptoms are caused by other people or by circumstances beyond their control.

Did You Know...

  • People with a personality disorder often do not know that there is anything wrong with their thinking or behavior.

Classification

Personality disorders used to be divided into 10 types that were grouped into three clusters. The types in each cluster shared certain basic personality traits. In the new classification that is being developed, there are no clusters and only six types: schizotypal, borderline, antisocial, narcissistic, avoidant, and obsessive-compulsive. The types that are being omitted are schizoid, paranoid, histrionic, and dependent.

Schizotypal personality disorder

People with schizotypal personality disorder are socially withdrawn and emotionally detached. In addition, they have odd ways of thinking, perceiving, and communicating similar to those of people with schizophrenia (see Schizophrenia). Although schizotypal personality disorder is sometimes present in people who later develop schizophrenia, most people with this personality disorder do not develop schizophrenia. The genes that cause schizophrenia are thought to be involved but not fully expressed in schizotypal personality disorder.

Odd ways of thinking may include magical thinking and paranoid ideas. In magical thinking, people believe that their thoughts or actions can control something or someone. For example, people may believe that they can harm others by thinking angry thoughts. People with paranoid ideas tend to be suspicious and mistrustful and wrongfully think other people have hostile motives or intend to harm them.

Borderline personality disorder

Borderline personality disorder occurs in about 2 to 5% of the population. It occurs equally in men and women, although women are much more likely to be treated. People with this disorder have dramatic changes in their interpersonal relationships, self-image, moods, and behavior. Borderline personality disorder usually becomes evident in adolescence or early adulthood and becomes less common with age. Borderline personality disorder resolves in about 50% of people within 2 years and in about 85% within 10 years. Once it resolves, it usually does not recur. However, although symptoms usually lessen quite dramatically, interpersonal relationships and functional roles do not improve nearly as much. For example, after 10 years, only about 20% have stable relationships or full-time employment.

People with borderline personality disorder often report being neglected or abused as children. Consequently, they feel empty and angry, and they try to make up for missed care during childhood by seeking care in relationships. Thus, they may react dramatically and intensely when another person does or says anything that suggests lack of care. When they feel criticized or rejected by a caring person, their view of that person may abruptly shift from idealization to angry criticism, and they may belittle the person. They may express inappropriate and intense anger. Sometimes they turn that anger against themselves and deliberately harm themselves—for example, by cutting or burning themselves.

When these people think that no one cares for them (that is, when they feel abandoned and alone), they may have brief episodes of paranoia or dissociation (see Dissociative Disorders). Dissociation includes not feeling real (called derealization) or feeling detached from their body or thoughts, as if they were outside their own bodies (called depersonalization). These people can become desperately impulsive, leading to reckless promiscuity, substance abuse, or suicide attempts. About 10% of people with borderline personality disorder die by suicide.

Borderline personality disorder is by far the most common personality disorder treated by mental health professionals. People with this disorder also frequent medical offices; about 6% of primary care doctor visits are made by people with this disorder. At first, practitioners (and other people who care for them) are eager to provide care and support. However, after repeated crises, unfounded complaints, and failures to follow prescribed recommendations for treatment, practitioners can become frustrated and respond negatively or hostilely.

Antisocial personality disorder

This type occurs in 6 times as many men as women. People with this disorder typically have a callous disregard for the rights and feelings of others. Dishonesty and deceit usually interfere with their relationships.

People with this disorder may exploit others for materialistic gain or personal gratification. Many become frustrated easily and tolerate frustration poorly. As a result, they act impulsively and irresponsibly, sometimes committing criminal acts. In these cases, they act without considering the negative consequences of their behavior and the problems or harm they cause others, and they do not feel remorse or guilt afterward. They often rationalize their behavior or blame it on others. Punishment or other negative consequences rarely motivate them to modify their behavior or improve their judgment and foresight. Instead, negative consequences tend to confirm their harshly unsentimental view of the world.

People with this disorder are prone to alcoholism, drug addiction, and promiscuity and may not fulfill their responsibilities as a spouse or partner, as a parent, and at work. They have a shorter life expectancy than the general population. The disorder tends to lessen with age.

Narcissistic personality disorder

This type is characterized by an inflated view of self-worth (called grandiosity). People with this disorder expect to be treated with deference and may exploit others because they think their superiority justifies it. Their relationships are characterized by a need for admiration, and they often think that others are jealous of or envy them. These people are sensitive to the reactions of others but only as far as the reactions relate to themselves. They are extremely sensitive to failure, defeat, and negative reactions from others, including criticism. Such reactions from others can trigger sudden rages or depression (including suicidal thoughts or actions).

Avoidant personality disorder

This type is characterized by severe self-consciousness, anxiety, and fearfulness. People with avoidant personality disorder withdraw from people or situations when they think rejection, failure, or conflict might occur. They fear and avoid starting relationships or anything new because they may be disappointed, be shamed, or fail. Because they have a strong conscious desire for affection and acceptance, they are openly distressed by their isolation and inability to relate comfortably to other people.

Avoidant personality disorder is closely related to generalized social phobia (which is characterized by persistent anxiety in many social situations—see Social Phobia).

Obsessive-compulsive personality disorder

People with obsessive-compulsive personality disorder are preoccupied with conscientiousness, orderliness, perfectionism, and a need for control. They are inflexible and typically resist change. They take their responsibilities seriously, but because they cannot accept mistakes, they can become entangled with details and forget their purpose. As a result, they often have trouble making decisions and completing tasks. Although they like to be in control, having responsibilities is a source of anxiety, and they have trouble getting satisfaction from their achievements. As long as the traits are not too marked, people who have them often achieve much, especially in fields that require organization, attention to detail, punctuality, and perseverance.

People with this disorder tend to be uncomfortable with feelings, with interpersonal conflict, and in situations in which they lack control.

Unlike obsessive-compulsive disorder (see Obsessive-Compulsive Disorder (OCD)), obsessive-compulsive personality disorder does not involve repeated, unwanted obsessions and rituals (repetitive, purposeful, intentional acts), such as excessive hand washing or repeated checking to make sure a door is locked.

Diagnosis

People with a personality disorder usually do not see a problem with their own behavior. When they seek help, the reason is likely to be to get help with symptoms such as anxiety, depression, or substance abuse or with the problems created by their personality disorder such as divorce, unemployment, or loneliness—rather than the disorder itself. When people report such symptoms or problems, doctors usually ask them questions to determine whether a personality disorder might be involved. For example, they ask how people view themselves and others and how they respond when people react negatively to their behavior. The doctor suspects a personality disorder if people

  • Persist in viewing themselves or others in ways that have no little or no basis in fact

  • Describe a pattern of inappropriate thoughts or behavior that they resist changing despite the negative consequences of such behavior

To help confirm the diagnosis, doctors usually try to talk with the person's friends and family members. Without such help, the doctor and the person might remain unaware of the person's role in creating the problems.

Doctors base the diagnosis of a specific personality disorder on lists of personality traits (criteria) provided for each disorder in the Diagnostic and Statistical Manual of Mental Disorders (DSM).

Treatment

Treatment is with psychosocial therapy, which includes individual psychotherapy, group therapy, and family therapy. Drugs do not change personality traits, but they can help relieve symptoms of distress.

Personality disorders can be particularly difficult to treat, so it is important to choose a therapist with experience, enthusiasm, and who is capable of understanding the person's self-image, areas of sensitivity, and usual ways of coping. However, as important as kindness and sensible advice are, they by themselves do not change personality disorders.

General principles

Although specific treatments differ according to the type of personality disorder, treatment, in general, aims to

  • Reduce distress

  • Help people understand that their problems are internal (not caused by other people or situations)

  • Decrease maladaptive and socially undesirable behavior

  • Modify the personality traits that are causing difficulties

The first goal of treatment is reducing immediate stress, such as anxiety and depression. Reducing stress makes treatment of the personality disorder easier. First, therapists help people identify what is causing stress. Then, they consider ways to relieve the stress. Psychosocial therapy can usually help the person get out of highly stressful situations or relationships. Drugs for anxiety or depression can help relieve those symptoms. When drugs are used, they are used in small doses and for a limited time.

Because people with a personality disorder usually do not see a problem with their own behavior, doctors try to help them understand that their problems are internal and that their behavior is inappropriate and has harmful consequences. By establishing a cooperative, mutually respectful doctor-patient relationship, doctors can help people become more aware of themselves and recognize their socially undesirable, inappropriate behavior. Through this relationship, people can also realize that changes in their behavior and view of themselves and others will take time and effort. Achieving this understanding can take a long time.

Maladaptive and undesirable behaviors (such as recklessness, social isolation, lack of assertiveness, and temper outbursts) should be dealt with quickly to minimize ongoing damage to jobs and relationships. Sometimes doctors need to set limits on behavior in their office. For example, people may be told that they cannot raise their voice in anger. If behavior is extreme—for example, if people are reckless, isolate themselves socially, have outbursts of anger, or are very fearful—they may need treatment at a day hospital or in a residential institution.

Changes in behavior are most important for people with borderline, antisocial, or avoidant personality disorder. Group therapy and behavioral modification can typically improve behavior within months. Self-help groups or family therapy can also help change inappropriate behavior. The involvement of family members is helpful and often essential because they can act in ways that either reinforce or diminish the inappropriate behavior or thoughts.

Individual psychotherapy is the cornerstone of treatment that aims to modify problematic personality traits. It is most effective for people with narcissistic, avoidant, and obsessive-compulsive types of personality disorders. Psychotherapy can help people understand how their personality disorder relates to their current problems. It can also help people learn new and better ways of interacting and coping. Usually, change is gradual. Although behavioral changes can occur within a year, changes in personality traits (such as dependency, distrust, arrogance, and manipulativeness) take longer.

Treatment of specific disorders

Specific types of personality disorders are treated differently.

Schizotypal personality disorder may be treated with antipsychotic drugs (used to treat schizophrenia—see Antipsychotic drugs) and individual therapy. Therapy (using reality testing) helps people view the external world as something distinct from their thoughts and feelings and helps them learn more appropriate ways to behave in various situations. The benefits of these therapies are modest.

Borderline personality disorder may be treated with individual, group, family, and/or drug therapy. Such therapies can help reduce suicidal tendencies, the need for hospitalization, and use of the emergency department. They can also help relieve depression. One type of therapy is dialectical behavior therapy. This therapy provides weekly individual and group sessions and a therapist who is available 24 hours a day by telephone. In such calls, the therapist helps the caller resist urges to behave self-destructively. This therapy aims to help people find more appropriate ways of responding to stress. Another effective therapy is general psychiatric management. It provides weekly individual therapy sessions and sometimes drug therapy. Drugs that can help stabilize mood, particularly topiramate and lamotrigine (both anticonvulsants), may help, particularly in managing anger and changes in mood.

Antisocial personality disorder is the most difficult to treat. Currently, it has no effective treatment. People with this disorder tend to use being in therapy as a way to avoid the negative consequences of negligent or illegal behavior or to avoid social responsibilities. Thus, therapy focuses on encouraging accountability.

Narcissistic personality disorder is sometimes be helped by psychodynamic forms of individual psychotherapy. This therapy emphasizes the identification of unconscious patterns in current thoughts, feelings, and behavior (see Psychotherapy). However, to be effective, such therapy requires therapists who emphasize empathy and do not confront people when they express feelings of entitlement or exaggerate their sense of self-worth and self-importance.

Avoidant personality disorder often responds to individual (usually cognitive-behavioral—see Psychotherapy) and group therapy. However, people with this disorder strongly resist exposing themselves to what they usually avoid. For them, avoiding things spares them conflicts and the experience of failure or rejection.

Obsessive-compulsive personality disorder responds to psychodynamic forms of individual psychotherapy that focuses on helping people tolerate uncertainty and accept their world. The resulting changes are usually gradual.

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  • TOPAMAX
  • LAMICTAL