Personality Disorders

Personality is “the range of characteristic behavioural responses that a person deploys in order to negotiate the challenges produced by the outside world and their internal feelings.”

– It is composed of 4 main components: cognition, impulse control, social communication and affect/emotions

– As these components are continuous, psychiatrists assign cut-offs indicating when they become abnormal.

A personality disorder is where one or more of these components of personality has reached an abnormal level:

i) The trait has to be pathological, pervasive and persistent (3P’s)

ii) It must lead to stereotyped responses which can be traced to childhood

iii) The trait should be quantitatively significantly different from others of a similar background (beyond cut off)

iv) It should lead to distress or impair social function for the patient

v) It should not be due to another mental disorder or medical condition 

Causes: The aetiology can be considered using a biopsychosocial model

Biological:

Genetics –> Twin studies have shown that personality disorders share a large genetic component

Psychological:

Personality –> Higher association with low self-esteem who internalise their stresses

Social:

Childhood –> Sexual and emotional abuse and insecure family relationships (greatest risk factor)

Emotionally Unstable Personality Disorder/Borderline Personality Disorder (BPD)

This is the one of the most common personality disorders with ranging emotions of high amplitude

– The aetiology can be considered by looking at the normal social development milestones a child passes:

Secure attachment – first thing you learn as a child is how to form a secure attachment (usually to parent)

– BPD patients do not experience this and so form relationships which are very doubtful, jealous.

– Instead they form very fast intense relationships, but these do not last as they are insecure.

Distress Tolerance – Children as they develop learn how to manage their emotions to distressing stimuli

– BPD patients instead do not learn to manage emotions appropriately and throw temper tantrums

– In response to stress, they instead engage in unhelpful behaviours like self-harm

Emotion Literacy – Adolescents learn to be aware of their emotions, and control them in social situations

– BPD patients do not learn to be aware of their emotions and react inappropriately in social situations

Self-identity – By the end of adolescence, we have a stable sense of who we are as individuals

– BPD patients do not have a stable sense of their own identity

Diagnostic criteria:

– Intense interpersonal relationships which alternate between love and hate

– Huge fear of abandonment

– Unstable image of self

– Difficulty controlling temper (temper tantrums)

– Unstable Affect

– Impulsive behaviour in 2 different domains (sex, gambling, drugs)

– Recurrent suicidal behaviour –> often as a poor coping response to stressful events

– Persistent feeling of emptiness and low mood

– Quasi psychotic thoughts

N.B. Emotionally unstable PD is split into borderline type and impulsive type:

– Borderline = Very emotionally unstable with repeated acts of self-harm (as shown above)

– Impulsive = Display high impulsive behaviours (gambling) without the repeated acts of self-harm

Borderline personality disorder can clinically resemble bipolar disorder, but there are key differences:

The other personality disorders share the same core features but differ in which component of personality is abnormal. By conceptualising the disorders like this, it makes it easier to remember the key symptoms.

Antisocial/Dissocial Personality Disorder

Trait: Impaired impulse control, leading to high aggressiveness and insensitivity

Origin: Stems from complete disregard for social norms, much more common in men

Patient: Patient has no regard for rights or safety of others

– They are irresponsible (cannot hold down a job)

– Highly aggressive and impulsive behaviour, and often break the law

– Very deceitful and untrustworthy blaming others for their actions, with an accompanied lack of remorse

Avoidant/Anxious Personality Disorder

Trait: Impaired emotional confidence, leading to high anxiety and tension in relationships

Origin: Stems from fear of criticism or rejection from others

Patient: Patient avoids activities with involve social contact due to fear of not being liked

– They will be very restrained in relationships and got go “all-in” in case they get rejected.

– Isolate themselves socially but still have a craving for social contact

– They have a huge inferiority complex and will put themselves down in front of others

Histrionic Personality Disorder

Trait: Impaired self-confidence, leading to extroverted behaviour to gain attention

Origin: Stems from a need to be the centre of attention

Patient: Very attention seeking, and dress flamboyantly and wear make-up to gain attention of others

– Very dramatic, impressionist speech and narcissistic

– Provocative behaviour with exaggerated emotions, but emotions are considered more intimate than they are

– Influences easily by others or circumstances

Obsessive-Compulsive/Anakastic Personality Disorder

Trait: Excessive perfectionism, giving highly stereotyped behaviours with poor flexibility

Origin: It stems pervasive pursuit of efficiency, at the expense of other leisurely activities

Patient: Excessive obsession with rules, lists, schedules, and order

– Devote themselves to work and productivity at the expense of interpersonal relationships and recreation.

– They have obsessional thoughts (but unlike OCD these are not unwanted but instead are accepted)

– little affection and warmth; their relationships and speech have a formal and professional approach

– Obsessed with controlling their environments; to satisfy this need for control

Schizotypal Personality Disorder

Trait: Impaired cognition, which leads to odd thinking and perceptual abnormalities

Origin: Stems from disorganised thinking (like semi-psychosis)

Patient: Patient has strange beliefs and magical thinking e.g. telepathies

– They have strange thinking and speech

– May have ideas of references (some insight retained so not delusions) + Unusual perceptual disturbances

– Lack of close friends and excessive social anxiety

– Inappropriate affect (react abnormally to stimuli)

Common Management:

MDT approach, using mixture of psychotherapy and encouraging communication

– Psychotherapy –> CBT/DBT teaches interpersonal effectiveness, distress tolerance and emotional regulation.

– Medication –> can use anti-depressants or anti-psychotics to treat comorbidities as an adjunct.

Whilst the personality disorders are usually only diagnosed in adults, there is a type of personality disorder which is seen in children and adolescents.

Conduct Disorder

A type of personality disorder which occurs in children, and is similar to antisocial personality disorder

– It is characterised by persistent disruptive, deceptive and aggressive behaviour

– Associated with low self-esteem, ADHD and learning/developmental disorders

Causes: Family conflict, violent parents, alcoholic parents

Patient: Child shows disobedience and no remorse for behaviour

– Engages in stealing, arson, fighting and damage to property

Management – Uses a mixture of parental training, school interventions and behavioural interventions

Prognosis – One third later develop adult antisocial personality disorder