Personality Disorders

Personality disorders (PD) are mental health conditions characterised by enduring maladaptive patterns of behaviour, cognition, and inner experience. These behaviours significantly deviate from cultural expectations, develop early in life, are inflexible, and often lead to significant distress or disability. The prevalence of personality disorders among psychiatric patients is estimated to be between 40 and 60%, affecting their quality of life profoundly.

Classification and Symptoms

Personality disorders are classified in the International Classification of Diseases (ICD) and the Diagnostic and Statistical Manual of Mental Disorders (DSM). The ICD-11 and DSM-5 are the latest editions, with some differences in the classification of specific disorders.

DSM-5

The DSM-5 lists ten specific personality disorders under three clusters based on descriptive similarities:

Cluster A (Odd or Eccentric Disorders)

• Paranoid Personality Disorder: Characterised by irrational suspicion and mistrust of others.
• Schizoid Personality Disorder: Marked by detachment from social relationships and restricted emotional expression.
• Schizotypal Personality Disorder: Involves extreme discomfort in social interactions and distorted cognition.

Cluster B (Emotional or Erratic Disorders)

• Antisocial Personality Disorder: A pervasive pattern of disregard for the rights of others.
• Borderline Personality Disorder: Instability in relationships, self-image, and emotions.
• Histrionic Personality Disorder: Excessive attention-seeking behaviour and emotionality.
• Narcissistic Personality Disorder: Grandiosity and a need for admiration.

Cluster C (Anxious or Fearful Disorders)

• Avoidant Personality Disorder: Social inhibition and feelings of inadequacy.
• Dependent Personality Disorder: A psychological need to be cared for by others.
• Obsessive–Compulsive Personality Disorder: Preoccupation with orderliness and control.

The DSM-5 also includes categories for personality disturbances due to medical conditions and unspecified personality disorders.

ICD-11

The ICD-11 simplifies the classification into one category of personality disorder, which can be coded as mild, moderate, or severe. It includes five trait domains:

1. Negative affectivity
2. Detachment
3. Dissociality
4. Disinhibition
5. Anankastia

A borderline pattern, similar to borderline personality disorder in DSM-5, is included as a combination of these traits.

Diagnosis

Both the DSM-5 and ICD-11 provide detailed criteria for diagnosing personality disorders. The DSM-5 criteria emphasise enduring patterns that deviate from cultural expectations, cause significant distress or impairment, and are not better explained by other mental disorders or substance use. The ICD-11 also requires evidence of long-standing and pervasive disturbances in self-functioning and interpersonal relationships.

Treatment

Treatment primarily involves psychotherapy, with cognitive behavioural therapy and dialectical behaviour therapy being particularly effective for certain disorders like borderline personality disorder. Other approaches include:

• Individual and family therapy
• Group therapy
• Psychoeducation
• Medications for symptom management
• Milieu therapy and mindfulness practice

Challenges in Management

Managing personality disorders can be challenging due to the enduring and pervasive nature of these conditions. Patients may not recognise their problems, and therapists may struggle with maintaining therapeutic relationships and professional boundaries. Moreover, there is substantial stigma associated with personality disorders, which can affect both diagnosis and treatment.

Epidemiology

The prevalence of personality disorders in the general population is estimated at around 10.6%, with variations based on demographic and socioeconomic factors. Some disorders, such as antisocial personality disorder, are more common in certain populations, such as prison inmates.

History

The concept of personality disorders has evolved significantly over time, from early notions of 'moral insanity' to the current classifications in the DSM and ICD. The historical development reflects changing attitudes towards mental health and the influence of various theoretical approaches, including psychoanalysis and personality psychology.

In preparing for professional exams, understanding the classification, diagnosis, and treatment of personality disorders, as well as the associated challenges and epidemiology, will provide a comprehensive overview needed for effective clinical practice.

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Self-assessment MCQs (single best answer)

Which of the following is NOT part of Cluster A personality disorders in DSM-5?

What is the main characteristic of Narcissistic Personality Disorder according to DSM-5?

Which type of therapy is particularly effective for Borderline Personality Disorder?

The ICD-11 includes which of the following trait domains for personality disorders?

Which personality disorder is characterised by a pervasive pattern of disregard for the rights of others?

What is the estimated prevalence of personality disorders in the general population?

In the DSM-5, which of the following is a characteristic of Schizoid Personality Disorder?

What is the primary focus when diagnosing personality disorders in both DSM-5 and ICD-11?

Which of the following is a common challenge in managing personality disorders?

Historically, the concept of personality disorders evolved from the notion of what?