Personality Disorders
Definition
- Personality disorders are enduring patterns of behaviour, cognition, and inner experience that deviate markedly from cultural norms, cause distress or impairment, and persist over time.
- Symptoms typically emerge in adolescence or early adulthood and affect relationships, self-image, and emotional regulation.
Causes & Risk Factors
Pathophysiology
- Genetic Factors → Dysregulation of Serotonin, Dopamine, and GABA.
- Neurobiological Abnormalities → Altered Prefrontal Cortex, Limbic System Hyperactivity.
- Environmental Factors → Early Trauma, Neglect, Insecure Attachment, Chronic Stress.
Risk Factors for Personality Disorders
|
Risk Factor |
Description |
|
Genetic Predisposition |
Higher Incidence in First-Degree Relatives. |
|
Early Childhood Trauma |
Emotional, Physical, or Sexual Abuse, Neglect. |
|
Parental Mental Illness or Substance Abuse |
Disrupted Attachment, Poor Emotional Regulation. |
|
Inconsistent or Unstable Caregiving |
Frequent Caregiver Changes, Childhood Abandonment. |
|
Substance Misuse |
Can Contribute to Emotional Dysregulation & Impulsivity. |
🔹 Personality disorders arise from a combination of genetic vulnerability and adverse early life experiences.
Types of Personality Disorders (ICD-10/DSM-5 Classification)
Cluster A (Odd & Eccentric)
- Paranoid PD → Suspicious, distrustful.
- Schizoid PD → Detached, avoids socializing.
- Schizotypal PD → Eccentric, magical thinking, anxious in social settings.
Cluster B (Dramatic & Emotional)
- Antisocial PD → Disregards rules, aggressive, manipulative.
- Borderline PD → Unstable emotions, fear of abandonment, impulsive.
- Histrionic PD → Seeks attention, overly emotional.
- Narcissistic PD → Grandiose, lacks empathy, craves admiration.
Cluster C (Anxious & Fearful)
- Avoidant PD → Fears rejection, avoids social situations.
- Dependent PD → Clingy, submissive, fears being alone.
- Obsessive-Compulsive PD → Perfectionist, rigid, obsessed with order.
This makes it easier to remember key traits for each disorder! 👍
🔹 Cluster B (especially Borderline PD) is most commonly encountered in clinical practice.
Clinical Features
Core Symptoms Across Personality Disorders
|
Category |
Common Symptoms |
|
Affective Dysregulation |
Mood Instability, Intense Anger, Chronic Emptiness. |
|
Impulsivity & Risk-Taking |
Self-Harm, Reckless Spending, Substance Abuse. |
|
Interpersonal Dysfunction |
Unstable Relationships, Fear of Abandonment. |
|
Distorted Self-Image |
Identity Confusion, Low Self-Worth, Grandiosity (NPD). |
|
Cognitive Distortions |
Paranoia, Magical Thinking, Rigid Thought Patterns. |
Specific Features by Disorder
|
Disorder |
Key Features |
|
Borderline PD |
Emotional instability, impulsivity, self-harm, intense fear of abandonment. |
|
Antisocial PD |
Disregard for rules, aggression, lack of empathy, criminal behaviour. |
|
Histrionic PD |
Attention-seeking, excessive emotions, dramatic speech. |
|
Narcissistic PD |
Grandiosity, need for admiration, lack of empathy. |
|
Avoidant PD |
Social withdrawal, fear of criticism, hypersensitivity to rejection. |
🔹 Borderline and Antisocial PDs are most associated with crisis presentations and self-harm.
Referral Criteria (NICE Guidelines)
Urgent Referral (If Severe Symptoms or Risk to Self/Others)
- Suicidal Ideation or Self-Harm (Common in Borderline PD).
- Severe Aggression or Violence (Common in Antisocial PD).
- Psychotic Symptoms or Dissociation.
Routine Referral (If Symptoms Persist or Affect Functioning)
- Recurrent Self-Harm Without Suicidal Intent.
- Chronic Interpersonal Difficulties Affecting Work & Relationships.
- Comorbid Mental Health Disorders (Depression, PTSD, Substance Use).
🔹 Severe cases require specialist input, while mild cases may be managed with therapy and social support.
Diagnosis (ICD-10/DSM-5 Criteria)
|
Criterion |
Description |
|
Enduring Pattern of Behaviour |
Pervasive Across Personal & Social Situations. |
|
Significant Functional Impairment |
Affects Work, Relationships, Self-Identity. |
|
Early Onset |
Symptoms Start in Adolescence or Early Adulthood. |
|
Not Due to Another Mental or Medical Condition |
Exclude Schizophrenia, Bipolar, or Neurological Disorders. |
Differential Diagnosis
|
Condition |
Key Differences |
|
Bipolar Disorder |
Episodic Mood Swings (Not Persistent Emotional Dysregulation). |
|
Schizophrenia |
Persistent Psychotic Symptoms (Not Episodic Paranoia or Dissociation). |
|
Complex PTSD |
History of Trauma, Flashbacks, Emotional Dysregulation. |
|
Autism Spectrum Disorder (ASD) |
Social Communication Deficits, Not Driven by Emotional Instability. |
🔹 Personality disorders are diagnosed clinically using structured assessments (e.g., SCID-II, IPDE).
Management (NICE Guidelines)
Psychological Therapies (First-Line Treatment)
|
Therapy |
Best For |
Description |
|
Dialectical Behaviour Therapy (DBT) |
Borderline PD |
Improves Emotional Regulation, Reduces Self-Harm. |
|
Mentalisation-Based Therapy (MBT) |
Borderline PD |
Enhances Self-Understanding & Interpersonal Skills. |
|
Cognitive Behavioural Therapy (CBT) |
Avoidant, Dependent, Obsessive-Compulsive PDs |
Targets Maladaptive Thought Patterns. |
|
Schema Therapy |
All Personality Disorders |
Addresses Deep-Seated Beliefs & Emotional Trauma. |
🔹 DBT is the gold standard for Borderline PD, reducing self-harm and emotional instability.
Pharmacological Treatment (Limited Role, Symptom-Targeted)
|
Symptom |
Medication |
Considerations |
|
Emotional Instability (Borderline PD) |
SSRIs (Fluoxetine, Sertraline). |
Used If Comorbid Depression or Anxiety. |
|
Impulsivity & Aggression |
Atypical Antipsychotics (Risperidone, Olanzapine). |
Short-Term Use Only. |
|
Psychotic-Like Symptoms (Paranoid PD) |
Low-Dose Antipsychotics. |
Used If Significant Paranoia or Dissociation. |
🔹 Medication should not be used routinely but may help specific symptoms.
UKMLA Key Points
- Best first-line treatment for personality disorders: Psychotherapy (DBT, MBT, Schema Therapy).
- Best treatment for self-harm in Borderline PD: Dialectical Behaviour Therapy (DBT).
- When to refer urgently: Suicidal intent, severe aggression, psychotic symptoms.
- When to use medication: Only for symptom control (e.g., SSRIs for depression, antipsychotics for impulsivity).
- Best long-term management strategy: Combination of therapy, social support, and crisis planning.