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Personality Disorders
Moshe S. Torem, MD, DLFAPA
image BASICS
  • Personality disorders (PDs) are a group of conditions, with onset at or before adolescence, characterized by enduring patterns of maladaptive and dysfunctional behavior that deviates markedly from one's culture and social environment, leading to functional impairment and distress to the individual, coworkers, and family.
    • These behaviors are perceived by patients to be “normal” and “right,” and they have little insight as to their ownership, responsibility, and abnormal nature of these behaviors.
    • These conditions are classified based on the predominant symptoms and their severity.
  • System(s) affected: nervous/psychiatric
  • Synonym(s): character disorder; character pathology
Geriatric Considerations
Coping with the stresses of aging is challenging.
Pediatric Considerations
A history of childhood neglect, abuse, and trauma is not uncommon.
Pregnancy Considerations
Pregnancy adds pressures in coping with the activities of daily living (ADLs).
  • General population: 15% (1)
  • Cluster A: 5.7%
  • Cluster B: 6.0%
  • Cluster C: 9.1%
  • Outpatient psychiatric clinic: 3-30% (2)
  • In male prisoners, the prevalence of antisocial personality disorder is ˜60%.
  • Predominant age: starts in adolescence and early 20s and persists throughout patient's life
  • Predominant sex: male = female; some PDs are more common in females, and others are more common in males.
  • Environmental and genetic factors (3)
  • Criteria for a PD includes an enduring pattern of the following:
    • Inner experience and behavior that deviates markedly from the expectations of one's culture in ≥2 of the following areas: cognition, affectivity, interpersonal functioning, or impulse control.
    • Inflexibility and pervasiveness across a broad range of personal and social situations
    • Significant distress or impairment in social or occupational functioning
    • The pattern is stable and of long duration.
    • The enduring pattern is not better explained as a manifestation of another psychiatric disorder.
    • The enduring pattern is not attributable to the effects of a drug or a medical condition.
  • PDs are classified into three major clusters:
    • Cluster A: eccentricism and oddness
      • Paranoid PD: unwarranted suspiciousness and distrust of others
      • Schizoid PD: emotional, cold, or detached; socially isolated
      • Schizotypal PD: eccentric behavior, odd belief system/perceptions, social isolation, and general suspiciousness
    • Cluster B: dramatic, emotional, or erratic behavioral patterns
      • Antisocial PD: aggressive, impulsive, irritable, irresponsible, dishonest, deceitful
      • Borderline PD: unstable interpersonal relationships, high impulsivity from early adulthood, intense fear of abandonment, mood swings, poor self-esteem, chronic boredom, and feelings of inner emptiness
      • Histrionic PD: needs to be the center of attention, with self-dramatizing behaviors and attention seeking in a variety of contexts
      • Narcissistic PD: grandiose sense of self-importance and preoccupation with fantasies of success, power, brilliance, beauty, or ideal love; lack of empathy for other people's pain or discomfort, demanding to get their way
    • Cluster C: anxiety, excessive worry, fear, and unhealthy patterns of coping with emotions
      • Avoidant PD: social inhibition, feelings of inadequacy, hypersensitivity to negative evaluation, avoidance of occupational and interpersonal activities that involve the risk of criticism by others, views self as socially inept and personally unappealing or inferior to others
      • Dependent PD: excessive need to be taken care of, leading to submissive and clinging behavior with fears of separation, avoids expressing disagreements with others due to fear of losing support and approval, usually seeks out strong and confident people as friends or spouses and feels more secure in such relationships
      • Obsessive-compulsive PD: preoccupation with cleanliness, orderliness, perfectionism; preoccupation with excessive details, rules, lists, order, organization, and schedules to the extent that the major point of the activity is lost.
    • Personality change due to another medical condition. It is a persistent personality disturbance that is caused by the physiologic effects of a medical condition such as frontal lobe lesion, epilepsy, MS, Parkinson disease, lupus, head trauma, post encephalitis or meningitis, and so forth.
    • Other specified PD and unspecified PD: A category provided for two situations: (i) the individual's personality pattern meets the general criteria for PD and traits of several PDs are present, but the criteria for any specific PD are not met; (ii) the individual's personality pattern meets the general criteria for PD, but the individual is considered to have a PD that is not included in DSM-5 classification such as passive-aggressive PD, depressive PD, masochistic PD, and dangerous and severe PD.
Major character traits are inherited; others result from a combination of genetics and environment.
  • Positive family history
  • Pregnancy risk factors
    • Nutritional deprivation
    • Use of alcohol or drugs.
    • Viral and bacterial infections
  • Dysfunctional family with child abuse/neglect
Depression; other psychiatric disorders in patient and family members
Psychological testing (e.g., MMPI-II)
Initial Tests (lab, imaging)
  • CBC
  • Comprehensive metabolic panel
  • Thyroid-stimulating hormone
  • HIV
  • Toxicology screen for substance abuse
Follow-Up Tests & Special Considerations
  • EEG to rule out a chronic seizure disorder
  • CT and MRI of the brain may be necessary in newly developed symptoms to rule out organic brain disease (e.g., frontal lobe tumor).
  • Medical disorders with behavioral changes
  • Other psychiatric disorders with similar symptoms
    • In obsessive-compulsive disorder (OCD), symptoms are ego-dystonic (i.e., perceived as foreign and unwanted). In addition, OCD has a pattern of relapse and partial remission.
    • In obsessive-compulsive personality disorder (OCPD), symptoms are perceived as desirable behaviors (ego-syntonic) that the patient feels proud of and wants others to emulate. In addition, OCPD has a lifelong pattern (i.e., without significant relapse or remission).
Psychotherapy with family involvement is the foundation of treatment. No specific drugs are indicated to treat PDs; some medications can reduce the intensity, frequency, and dysfunctional nature of certain behaviors (4)[B].

  • Long-term psychotherapy and cognitive-behavioral therapy (5)[B]
  • Group therapy is helpful in the use of therapeutic confrontation and increasing one's awareness of and insight regarding the damaging effects of dysfunctional behavior patterns (6)[B].
Medications are effective in the treatment of comorbid conditions such as anxiety and depression.
First Line
  • Symptom management (7)[B]
    • Mini psychosis (associated with paranoid, schizoid, borderline, and schizotypal PDs): atypical antipsychotics: risperidone (Risperdal), quetiapine (Seroquel), olanzapine (Zyprexa), ziprasidone (Geodon), aripiprazole (Abilify), asenapine (Saphris), lurasidone (Latuda); start with a low dose, gradually adjusting to the patient's needs.
    • Anxiety: anxiolytics (benzodiazepines, buspirone [Buspar], and serotonin reuptake inhibitors)
    • Depressed mood: antidepressants
    • Many patients with borderline PD respond well to small doses of atypical neuroleptics and mood stabilizers (8)[B].
  • Precautions: Some atypical neuroleptic drugs may be associated with hyperglycemia and insulin-resistant metabolic syndrome.
Second Line
Mood stabilizers: lithium carbonate, lamotrigine (Lamictal), carbamazepine (Tegretol, Equetro), and valproate (Depacon, Depakene, Depakote) (9)[B]
  • When psychiatric comorbidity of Axis I disorders is present (e.g., mood disorders, anxiety disorders, substance abuse, etc.)
  • Suicidal ideation or attempts
  • Dialectical behavior therapy
  • Psychoanalytic therapy
  • Interactive psychotherapy
  • Group therapy
Admission Criteria/Initial Stabilization
Disorders with complications of suicide attempts
Continue outpatient treatment, potentially long term
Patient Monitoring
  • Regular physical exercise (e.g., 30 to 45 min/day, helps with stress and improving the ADLs)
  • If substance abuse is suspected, check drug screens.
  • Infrequent sessions with relatives or friends are helpful in monitoring behavioral progress.
Emphasize variety of healthy foods; avoid obesity.
  • Bibliotherapy and writing therapy, specific assignments, and watching certain movies to better understand the nature and origin of one's specific condition are helpful.
    • Kreger R. The Essential Family Guide to Borderline Personality Disorder. Center City, MN: Hazelden; 2008.
    • Mason PT, Kreger R. Stop Walking on Eggshells. Oakland, CA: New Harbinger Publishers; 2010.
  • The movie As Good as It Gets illustrates someone with obsessive-compulsive behaviors and their impact on ADLs and relationships with family and friends.
  • The movie series The Godfather includes several characters with antisocial PD and shows how this affects their interpersonal relationships and their own physical and mental health.
  • The movie What About Bob? illustrates the challenges involved in treating certain patients with a borderline PD, especially in the management of boundaries in the doctor-patient relationship.
  • The movie A Streetcar Named Desire illustrates an example of a woman with a histrionic PD.
  • The movie Wall Street illustrates an example of a person with a narcissistic PD.
  • The movie The Caine Mutiny illustrates an example of a person with a paranoid PD.
  • The movie Four Weddings and a Funeral illustrates an example of a person with an avoidant PD.
PDs are enduring patterns of behavior throughout one's lifetime and are not readily responsive to treatment.
1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Association; 2013:645-684.
2. Angstman KB, Rasmussen NH. Personality disorders: review and clinical application in daily practice. Am Fam Physician. 2011;84(11):1253-1260.
3. Reichborn-Kjennerud T. Genetics of personality disorders. Clin Lab Med. 2010;30(4):893-910.
4. Hadjipavlou G, Ogrodniczuk JS. Promising psychotherapies for personality disorders. Can J Psychiatry. 2010;55(4):202-210.
5. Clarkin JF. An integrated approach to psychotherapy techniques for patients with personality disorder. J Pers Disord. 2012;26(1):43-62.
6. Livesley WJ. Integrated treatment: a conceptual framework for an evidence-based approach to the treatment of personality disorder. J Pers Disord. 2012;26(1):17-42.
7. Ripoll LH, Triebwasser J, Siever LJ. Evidence-based pharmacotherapy for personality disorders. Int J Neuropsychopharmacol. 2011;14(9):1257-1288.
8. Ripoll LH. Clinical psychopharmacology of borderline personality disorder: an update on the available evidence in light of the Diagnostic and Statistical Manual of Mental Disorders-5. Curr Opin Psychiatry. 2012;25(1):52-58.
9. Lieb K, Völlm B, Rücker G, et al. Pharmacotherapy for borderline personality disorder: cochrane systematic review of randomised trials. Br J Psychiatry. 2010;196(1):4-12.
Additional Reading
  • Paris J. Modernity and narcissistic personality disorder. Personal Disord. 2014;5(2):220-226.
  • Ronningstam E. Narcissistic personality disorder: a current review. Curr Psychiatry Rep. 2010;12(1): 68-75.
  • Stoffers J, Völlm BA, Rücker G, et al. Pharmacological interventions for borderline personality disorder. Cochrane Database Syst Rev. 2010;(6):CD005653.
See Also
Obsessive-Compulsive Disorder (OCD)
  • F60.9 Personality disorder, unspecified
  • F60.0 Paranoid personality disorder
  • F60.1 Schizoid personality disorder
Clinical Pearls
  • PDs are enduring patterns of behavior throughout one's lifetime and are not readily responsive to treatment.
  • No specific drugs are effective to treat PDs; however, specific medications can reduce the intensity, frequency, and dysfunctional nature of certain behaviors, thoughts, and feelings.
  • Most patients with a PD require a well-trained and experienced mental health professional.
  • A stable, trustful alliance with the patient is the foundation for any therapeutic progress.
  • Showing genuine interest in the patient as a whole person including the patient's life history and current life circumstances may be helpful in establishing a therapeutic and working alliance that are necessary for continuing treatment of PD patients.