11/14/24, 10\:50 AM Personality Disorder

Personality Disorder

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Key points ⚡
Succinct notes to superpower your revision
Personality disorder\: disturbance in personality functioning, a
prevalence ~7.8%.
Aetiology\: multifactorial, including genetic, neurobiological, social, and environmental factors (e.g. early trauma, low
socioeconomic status).
Essential features\: enduring maladaptive patterns in self, interpersonal functioning, cognition, emotion, and behaviour
lasting ≥2 years.
Severity rating\: mild (struggles in relationships), moderate (psychotic symptoms, dissociation), severe (impairment in all
areas, self-harm risk).
Trait domains\: negative a
(perfectionism).
use).
Investigations\: psychiatric history, mental state examination, exclude organic causes (e.g. hormonal imbalance, substance
Management\: psycho-social interventions (DBT, CBT), short-term pharmacotherapy for comorbid conditions (e.g.
antidepressants).
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A comprehensive topic overview

Introduction

Personality disorder (PD) is a disturbance in personality functioning regarding how an individual behaves, interprets
situations and perceives themselves.
1
The global estimated prevalence of PD is 7.8%. 2
anxiety disorders.
3
They can be diagnosed in isolation but commonly coincide with mood and
PD can be a controversial diagnosis. It can be di

4
It is also clinically challenging to assess due to the validity of classi
diagnostic process in recent years.
The ICD-10 categorised PD into subtypes and is still widely used in clinical practice. 5
However, the ICD-11 now introduces a
streamlined diagnosis of PD with an emphasis on the severity and option to describe marked traits, and is used in this
article.
1

Aetiology and risk factors

The aetiology of PD is considered multi-factorial, encompassing social, environmental, genetic and neurobiological
factors.
6
Family history of psychiatric conditions has been identi
inheritance of PD, however, this is yet to be proven
7
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Evidence also suggests a positive correlation between PD and low socioeconomic status
Early life experiences such as unstable family life and lack of support from caregivers have also been identi
predisposing factors. This includes negative experiences within the community, such as bullying, exclusion and
harassment. Disruptive behaviour exhibited as a child is a strong predictor for developing PD.
Stressful life events such as signi
shape personality development
8

Clinical features

PD involves enduring and pervasive patterns of cognition, emotional experience, expression and behaviour. These
patterns are relatively in
situations.
1
International Classi
The International Classi
undergoing signi
Table 1. The main di
ICD-10 ICD-11
Di
Single diagnosis of personality disorder with option to
describe predominant traits
Severity of personality disorder must be described
Diagnosis can be made at any age
No rating of severity Diagnosis only eligible for adults Symptoms should be enduring in nature, but no
minimum duration is speci
Symptoms should persist for two years at minimum

Diagnosis

Diagnosis of PD requires the presence of all essential features. This is then rated by severity and described by trait
domain speci
1

Essential features

All essential features should be present\:
Enduring disturbance in functioning in aspects of self or interpersonal relations
Disturbance has persisted over an extended period (two years or more)
Symptoms manifest as maladaptive patterns of cognition, emotional experience, emotional expression and behaviour
Symptoms are evident across a range of personal and social situations
Symptoms must either lead to signi
It cannot be diagnosed if other medical conditions, medications or substance use are directly causing symptoms
It cannot be diagnosed if symptoms are developmentally appropriate or can be explained by socio-cultural factors

Severity rating

To determine severity, these aspects of personality functioning should be assessed\:
Degree and pervasiveness of disturbances in the functioning of aspects of the self
Degree and pervasiveness of interpersonal dysfunction across relationships and other social contexts
Pervasiveness, severity and chronicity of emotional, cognitive and behavioural manifestations of personality
dysfunction
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Extent to which the dysfunction in the above areas is associated with distress or impairment in important areas of
functioning
The level of severity helps determine the level of risk a patient poses to themselves or others and can also guide clinicians
with treatment intensity and prognostic value.
9
Table 2. Summary of patient presentation dependent on PD severity
Severity Presentation
Mild
Struggling with many interpersonal relationships, occupational and social roles but still able to maintain
and have interest to an extent
Some elements of identity, sense of direction or self-worth impaired, contradictory or inconsistent
Typically not associated with substantial harm to self or others
Moderate
Marked problems in most interpersonal relationships, occupational and social roles
Sense of identity and view of self can be inconsistent
May experience transient dissociative states or mild psychotic symptoms
Can be associated with potential harm to self or others
Severe
Psychosocial functioning impaired in all areas of life, leading to compromise of interpersonal
relationships, occupational and social roles
Unstable view of self, regulation of self-esteem and di
Transient dissociative states and psychotic symptoms may be more prevalent
Potential harm to self or others expected with risk of endangering life

Trait domain speci

Trait domain speci
themselves but rather an expression of personality dysfunction. For this reason, more than one trait domain speci
apply to a person.
1, 9
Table 3. Trait domain speci
Trait domain speci
Negative a
Intense negative emotions with higher frequencies than the average person
Emotional lability and poor regulation of this
Feelings of hopelessness, shame and low self-esteem can lead to over-reliance on others
and being sensitive to criticism
Lack of trust in others may manifest with the tendency to hold grudges
Easily distressed and can lead to suicidal ideation
Detachment
Dissocial
Disinhibition
Socially or emotionally distant, displaying behaviours to avoid interactions, intimacy as well
as emotional expression
May not react to negative or positive events or
Self-centredness and lack of empathy
Behaviour is guided by their need to be the centre of attention and can be inappropriate or
manipulative in nature
Disregard of other’s feelings
Act impulsively in response to immediate stimuli without considering the consequences,
especially regarding safety
Easily distracted, preferring to act spontaneously with no clear objective
Prominent disinhibition can lead to irresponsible and reckless acts
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Anankastic
Borderline pattern
Strongly believe in perfectionism, controlling themselves and situations to ensure
standards and rules are met
Lack
Can experience di
Consists of at least 5 of following\:
Avoidance of real or imagined abandonment
Pattern of unstable and intense interpersonal relationships
Identity disturbance
Tendency to act rashly and engage in self-damaging behaviours
Recurrent self-harm episodes
Emotional instability
Chronic feelings of emptiness
Di
Transient dissociative symptoms or psychotic-like features

Investigations

A comprehensive history and mental state examination are key to the assessment of personality disorders, with a
particular focus on their view of themselves, the nature of their interpersonal relationships and functioning in social
environments.
10
A collateral history can aid this process and help determine the enduring nature, especially if a patient lacks insight.
Questionnaires can be used where the patient can self-report their symptoms to assess trait domains or severity, e.g. The
Personality Disorder Severity ICD-11 (PDS-ICD-11).
11
1
Excluding organic diseases or substance use is required for diagnosis. This can be through blood tests for hormonal
imbalances, a urine drug screen and brain imaging through CT or MRI head.
10

Management

It is important to foster a therapeutic relationship with the patient and explain that recovery is possible and attainable.
Risk assessment is incorporated in the severity rating for PD. The management plan should align with this to ensure the
safety of patients. Identifying stressors that can induce crises and protective factors for patients, as well as outlining
avenues for help, should be part of this.
Risk of suicide
If there is a risk of suicide, assessment and detainment under the Mental Health Act (1983) or involvement of local
Crisis Resolution Teams may be required.
11

Psycho-social interventions are the mainstay of PD management.
10,11
Dialectical behaviour therapy (DBT) is e
impulsivity
Cognitive behavioural therapy (CBT) helps patients understand how thoughts in
Other talking therapies or social support groups may also be helpful

Pharmacological management

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Short-term pharmacological management (antidepressants, antipsychotics and sedative medications) may alleviate co-
morbid conditions or speci
should not be used speci
11, 12

References

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NICE NICE CG78. CG77. B o r d e r l i n e p e r s o n a l i t y d i s o r d e r \: r e c o g n i t i o n a n d m a n a g e m e n t . Published A n t i s o c i a l p e r s o n a l i t y d i s o r d e r \: p r e v e n t i o n a n d m a n a g e m e n t . Published 2009. 2009. Available Available from\: from\: [LINK]
[LINK]

Reviewer

Dr Asim Yusuf
Consultant Psychiatrist

Anxiety Disorders
Bipolar Disorder
Bulimia Nervosa
Depression
Medically Unexplained Symptoms

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