Description

• 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 (1)

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 pressure in coping with the activities of daily living (ADLs).

Epidemiology

• General population: 9% (2)
• Outpatient psychiatric clinic: 3–30%
• 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 personality disorders are more common in females, and others are more common in males.

Risk Factors

• Positive family history
• Pregnancy risk factors:
  • Nutritional deprivation
  • Use of alcohol or drugs
  • Viral and bacterial infections
• Dysfunctional family with child abuse/neglect

Genetics
Major character traits are inherited; others result from a combination of genetics and environment.

Pathophysiology

• Criteria for a PD includes an enduring pattern of:
  • Inner experience and behavior that deviate 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
• PDs are classified into 3 major clusters (2):
  • Cluster A: Eccentricism and oddness:
    • Paranoid PD: Unwarranted suspiciousness and distrust of others, defensive, guarded, and overly sensitive
    • Schizoid PD: Emotional, cold, or detached; apathetic to criticism or praise; 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
  • 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
    • PD not otherwise specified: A mixture of characteristics from other PDs without a predominant pattern compatible with preceding categories; it also can be used for specific PDs not mentioned in the American Psychological Association classification (DSM-IV-TR), such as depressive PD, passive-aggressive PD, masochistic PD, dangerous and severe PD (3), etc.

Etiology

Environmental and genetic factors (4)

Commonly Associated Conditions

Depression, other psychiatric disorders in patient and family members