How are personality disorders diagnosed and managed?

Diagnosis and Management of Personality Disorders

Diagnostic Approach

Personality disorders should be diagnosed using structured clinical interviews rather than self-report questionnaires, as patients with these disorders have impaired insight that renders self-report minimally useful. 1, 2

Key Diagnostic Framework

• Use the ICD-11 dimensional model, which replaced discrete personality disorder categories with a single diagnosis based on problems in self-functioning and/or interpersonal dysfunction, differentiated by severity (mild, moderate, severe) with optional specification of maladaptive personality traits including negative affectivity, detachment, dissociality, disinhibition, anankastia, and borderline pattern. 2

• Gather collateral information from multiple sources using developmentally sensitive techniques, as this provides critical diagnostic information that patients cannot reliably self-report. 1, 2

• Expect and systematically evaluate informant discrepancies—these do not invalidate the diagnosis but provide additional diagnostic information about the patient's impaired insight and interpersonal functioning. 1, 2

Critical Process Observations

• Pay attention to who initiated the consultation, as patients with personality disorders (especially narcissistic personality disorder) rarely self-refer and often present under external pressure from family, employers, or legal systems. 1

• Observe whether the patient is over- or under-emphasizing disability, as this pattern reveals defensive operations and provides diagnostic information independent of patient self-report. 1

• Recognize that lack of insight is a core feature, not an exclusionary criterion—behavioral observation trumps self-report in personality disorders. 1, 2

Structured Assessment Tools

• For adults: Use the Structured Clinical Interview for DSM-5 (SCID-5 Clinician or Research version), Anxiety Disorders Interview Schedule for DSM-5 (ADIS-5), or Mini International Neuropsychiatric Interview (MINI version 7.0). 3

• For children/adolescents: Use the child or parent version of ADIS-5 or the pediatric MINI version. 3

Classification and Differential Diagnosis

Traditional DSM Cluster System (Still Clinically Useful)

• Cluster A (Odd/Eccentric): Schizoid, schizotypal, and paranoid personality disorders. 4, 5

• Cluster B (Dramatic/Emotional/Erratic): Borderline, histrionic, antisocial, and narcissistic personality disorders—these are most often problematic in clinical settings. 4, 5

• Cluster C (Anxious/Fearful): Avoidant, dependent, and obsessive-compulsive personality disorders—these are the most prevalent. 4

Distinguishing Borderline from Narcissistic Personality Disorder

• Borderline Personality Disorder features repeated suicide attempts and non-lethal self-injury as core features, more chaotic mood instability, and dissociative symptoms. 1, 2

• Narcissistic Personality Disorder maintains a more organized grandiose self-concept despite fluctuations, without the self-injury pattern. 1

Management Strategy

Primary Treatment: Psychotherapy

Psychological or psychosocial intervention is the primary treatment for personality disorders, with pharmacotherapy only advised as adjunctive treatment for specific symptoms. 2, 6

Evidence-Based Psychotherapeutic Approaches

• Dialectical Behavior Therapy (DBT) 2
• Cognitive Behavioral Therapy (CBT) 2
• Mentalization-Based Treatment 2
• Schema Therapy 2
• Transference-Focused Psychotherapy 2

Brief Interventions for Primary Care

• Motivational interviewing can be used by family physicians for patients with antisocial personality disorder. 4
• Solution-based problem solving is another brief intervention suitable for primary care settings. 4

Adjunctive Pharmacotherapy (Symptom-Targeted)

For Borderline Personality Disorder:

• Mood stabilizers for emotional dysregulation 2, 4
• Second-generation antipsychotics for cognitive-perceptual symptoms 2, 4
• Omega-3 fatty acids as an adjunctive option 4
• Antidepressants for comorbid depression or anxiety 2

For Antisocial Personality Disorder:

• Mood stabilizers as first-line pharmacotherapy 4
• Antipsychotics for impulsivity and aggression 4
• Antidepressants for mood symptoms 4

Common Pitfalls to Avoid

• Failing to recognize that lack of insight is a core feature leads to missed or incorrect diagnosis—do not expect patients to accurately describe their personality pathology. 1, 2

• Relying on self-report questionnaires will yield unreliable information due to impaired insight inherent to these disorders. 1, 2

• Misdiagnosing OCD-related beliefs with absent insight as psychotic disorder—patients with personality disorders and poor insight have beliefs related to their personality pathology without additional features of schizophrenia spectrum disorders. 3

• Expecting patients to self-refer—most personality disorder patients present under external pressure, and this presentation pattern itself provides diagnostic information. 1

Prognosis and Comorbidities

• Personality disorders are associated with premature mortality and require long-term management. 2

• Patients have higher rates of sleep disorders, chronic pain, chronic health conditions, and obesity compared to the general population. 7

• Many patients can be managed by family physicians with appropriate recognition and structured approach, though complex cases require psychiatric subspecialist involvement. 4, 7