What are the diagnostic criteria and treatment options for personality disorder?

Diagnostic Criteria and Treatment Options for Personality Disorders

Personality disorders are characterized by pervasive, inflexible, and stable patterns of thinking, feeling, behaving, and interacting with others that cause significant impairment in social and occupational functioning.

Diagnostic Criteria

• Personality disorders are defined by problems in functioning of aspects of self and interpersonal dysfunction, with the ICD-11 differentiating them by severity and allowing specification of maladaptive personality traits including negative affectivity, detachment, dissociality, disinhibition, anankastia, and borderline pattern 1

• The DSM-5 alternative model proposes a dimensional-categorical hybrid approach that assesses:

  • Impairments in personality functioning (self and interpersonal)
  • Evaluation of pathological personality traits across five domains: Negative Affectivity, Detachment, Antagonism, Disinhibition, and Psychoticism 1

• Personality disorders are characterized by inflexible maladaptive traits that cause significant impairment in social and occupational functioning, with an inability to cope with environmental pressure 2

• Core diagnostic features include:

  • Pervasive patterns affecting cognition, affectivity, interpersonal functioning, and impulse control
  • Inflexibility and stability across time and situations
  • Significant distress or functional impairment
  • Onset typically in adolescence or early adulthood 3

Classification of Personality Disorders

• The DSM-5 traditional model divides personality disorders into three clusters based on descriptive commonalities 3:

  • Cluster A (odd or eccentric): Paranoid, Schizoid, Schizotypal
  • Cluster B (dramatic, emotional, erratic): Antisocial, Borderline, Histrionic, Narcissistic
  • Cluster C (anxious or fearful): Avoidant, Dependent, Obsessive-Compulsive

• Borderline Personality Disorder criteria include:

  • Onset in early adulthood
  • Repeated suicide attempts and non-lethal self-injury
  • Pervasive pattern of impulsivity strongly associated with suicidality
  • Unstable mood and interpersonal relationships (alternating between idealization and denigration)
  • Varying self-concept (oscillating between grandiosity and worthlessness)
  • Dissociative symptoms and irritability
  • Self-damaging behaviors (excessive spending, impulsive sexual activity, dangerous driving) 4

Etiology

• The development of personality disorders involves a complex interaction of:

  • Genetic predisposition
  • Environmental factors, particularly adverse childhood experiences 3
  • Family psychopathology, including history of suicidal behavior, bipolar illness, physical/sexual abuse, or substance abuse 4

• No single-cause or main-effects models adequately explain the complexity of personality disorders; rather, they arise from a complex mix of risk and protective factors within an individual's biopsychosocial constellation 4

Clinical Presentation and Impact

• The core aspect of most personality disorders relates to an inability to build and maintain healthy interpersonal relationships, which negatively impacts interactions with healthcare professionals 5

• Personality disorders are associated with:

  • Inferior quality of life
  • Poor health outcomes
  • Premature mortality
  • Higher incidence of sleep disorders, chronic pain, chronic health conditions, and obesity 5, 3

• Patients with personality disorders often don't seek help for the disorder itself but for other medical issues that are complicated by underlying personality problems 5

• Personality disorders affect both the clinical presentation and outcomes of other medical conditions in a negative manner 5

Assessment

• Diagnosis should be performed by psychiatry or psychology subspecialists due to complexity 3

• Assessment requires:

  • Gathering information from multiple sources using varied developmentally sensitive techniques
  • Interviews, behavioral observation, and standard, reliable, valid rating scales
  • Confirmation from multiple informants due to potential discrepancies in self-reporting 4

• Each personality disorder shows a distinct profile of interpersonal style consistent with its characteristic pattern of symptomatic dysfunction 6

Treatment Options

• Psychotherapy is the primary treatment modality for personality disorders 3

• Evidence-based psychotherapeutic approaches include:

  • Dialectical Behavior Therapy (DBT) - particularly effective for Borderline Personality Disorder
  • Cognitive Behavioral Therapy (CBT)
  • Mentalization-Based Treatment
  • Schema Therapy
  • Transference-Focused Psychotherapy

• Pharmacotherapy is recommended in specific situations, primarily to target specific symptoms rather than the personality disorder itself 3:

  • Mood stabilizers for emotional dysregulation
  • Antipsychotics for cognitive-perceptual symptoms
  • Antidepressants for comorbid depression or anxiety
  • Anxiolytics (with caution due to addiction potential)

• Treatment should focus on developing healthier behavioral responses to stress and improving interpersonal functioning 2

Special Considerations

• Personality changes in older patients should raise suspicion for organic disease 2

• Contradicting traditional conceptualizations, research does not consistently support pervasive dysfunction across all interpersonal situations and relationships 6

• The dimensional approach of ICD-11 focuses more on severity of disturbed functioning rather than specific clinical presentation types 5

• Patients with personality disorders have higher healthcare utilization rates and require careful management of the provider-patient relationship 3