DSM–IVTR (synopsis)	ICD–10 (synopsis)
General diagnostic criteria for a personality disorder An enduring pattern of inner experience and behaviour that deviates markedly from the expectations of the individual’s culture. This pattern is manifested in two (or more) of the following areas: • cognition (i.e. ways of perceiving and interpreting self, other people and events) • affectivity (i.e. the range, intensity, lability and appropriateness of emotional response) • interpersonal functioning, and • impulse control. The enduring pattern is inflexible and pervasive across a broad range of personal and social situations. The enduring pattern leads to clinically significant distress or impairment in social, occupational, or other important areas of functioning. The pattern is stable and of long duration, and its onset can be traced back at least to adolescence or early adulthood. The enduring pattern is not better accounted for as a manifestation or consequence of another mental disorder. The enduring pattern is not due to the direct physiological effects of a substance (e.g. a drug of abuse or a medication) or a general medical condition (e.g. head trauma)

DSM–IVTR (synopsis)

ICD–10 (synopsis)

General diagnostic criteria for a personality disorder

An enduring pattern of inner experience and behaviour that deviates markedly from the expectations of the individual’s culture. This pattern is manifested in two (or more) of the following areas:

• cognition (i.e. ways of perceiving and interpreting self, other people and events)

• affectivity (i.e. the range, intensity, lability and appropriateness of emotional response)

• interpersonal functioning, and

• impulse control.

The enduring pattern is inflexible and pervasive across a broad range of personal and social situations. The enduring pattern leads to clinically significant distress or impairment in social, occupational, or other important areas of functioning. The pattern is stable and of long duration, and its onset can be traced back at least to adolescence or early adulthood. The enduring pattern is not better accounted for as a manifestation or consequence of another mental disorder. The enduring pattern is not due to the direct physiological effects of a substance (e.g. a drug of abuse or a medication) or a general medical condition (e.g. head trauma)

Disorders of adult personality and behaviour (F60–F69)

This block includes a variety of conditions and behaviour patterns of clinical significance, which tend to be persistent and appear to be the expression of the individual’s characteristic lifestyle and mode of relating to himself or herself and others. Some of these conditions and patterns of behaviour emerge early in the course of individual development, as a result of both constitutional factors and social experience, while others are acquired later in life.

Specific personality disorders (F60.1 to F60.9), mixed and other personality disorders (F61.0 to F61.1), and enduring personality changes (F62.1 to F62.9), are deeply ingrained and enduring behaviour patterns, manifesting as inflexible responses to a broad range of personal and social situations. They represent extreme or significant deviations from the way in which the average individual in a given culture perceives, thinks, feels and, particularly, relates to others. Such behaviour patterns tend to be stable and to encompass multiple domains of behaviour and psychological functioning. They are frequently, but not always, associated with various degrees of subjective distress and problems of social performance

The concept of personality disorder requires judgments to be made about what is ‘maladaptive’ about persistent patterns of behaviour and self-perceptions. Determining what is maladaptive must take into account differences in cultural norms, social context and even moral values. However, loss of flexibility and adaptiveness in self-awareness and behaviour, which persistently and extensively impinge negatively upon relationships, can still be identified.

Recognising such difficulties clinically offers greater insights and opportunities for assistance for the people involved. A diagnosis of personality disorder can be used pejoratively and can become destructive. It may also provoke challenges that the problems are ‘normal variants’ and do not justify treatment or special consideration as the consequences of illness. This ignores the destructiveness of personality dysfunction to both the patient and others, as well as the lack of choice experienced by such patients with their problems.

The current classifications first assign people with personality dysfunctions into clusters and then into specific disorders. Such categories have the value of identifying broad common features, which illustrate the problems of rigidity and maladaptiveness mentioned above. They also illustrate the limitations of categories which do not reflect the many variations in human beings, both at any one time and over a period of time. However, the clusters can also be considered to reflect dimensions of personality dysfunction which have been grouped into broad categories for conceptual convenience (see Box 12.1).

BOX 12.1 Personality disorders by cluster

Cluster A

These individuals tend to be persistently cold, awkward and isolative in their interactions with other people in their culture or social group. Robert Cloninger suggests they exhibit ‘low reward dependence’ among other prominent variable traits. This cluster includes:

• paranoid personality disorder, which is characterised by pervasive distrust and suspiciousness of others such that their motives are interpreted as malevolent

• schizoid personality disorder, which is characterised by a pervasive pattern of detachment from social relationships and a restricted range of expression of emotions in interpersonal settings, and

• schizotypal personality disorder, which is characterised by a pervasive pattern of social and interpersonal deficits marked by acute discomfort with, and reduced capacity for, close relationships, as well as by cognitive or perceptual distortions and eccentricities of beliefs and behaviour.

Cluster B

These individuals tend to be emotionally highly dramatic, labile and distressed (particularly in relationships with other people) in comparison with other people in their culture or social group. Robert Cloninger suggests they exhibit high ‘novelty seeking’, among other prominent variable traits. This cluster includes:

• antisocial personality disorder, which is characterised by a pervasive pattern of disregard for and violation of the rights of others

• borderline personality disorder, which is characterised by a pervasive pattern of instability of interpersonal relationships, self-image and affects, and marked impulsivity

• histrionic personality disorder, which is characterised by a pervasive pattern of excessive emotionality and attention seeking, beginning by early adulthood, and

• narcissistic personality disorder, which is characterised by a pervasive pattern of grandiosity (in fantasy, self-evaluation and behaviour), need for admiration and lack of empathy for others.

Cluster C

These individuals tend to be persistently anxious and inhibited in relationships and behaviour, compared with other people in their culture or social group. Robert Cloninger suggests they exhibit high ‘harm avoidance’, among other prominent variable traits. This cluster includes:

• avoidant personality disorder, which is characterised by a pervasive pattern of social inhibition, feelings of inadequacy and hypersensitivity to negative evaluation

• dependent personality disorder, which is characterised by a pervasive and excessive need to be taken care of that leads to clinging and submissive behaviour, and fears of separation, and

• obsessive-compulsive personality disorder, which is characterised by a pervasive pattern of preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness and efficiency.

Frequently, patients present with the features of more than one personality disorder cluster. This observation emphasises the importance of avoiding rigid personality disorder categories and labels.

CASE EXAMPLES: personality disorders

Cluster A: schizoid personality disorder

A 32-year-old single lawyer working in legislative drafting had no friends and was regarded as a loner by his colleagues. However, he was extremely competent at his job and was very well regarded in this respect. He was courteous with people he met, but did not converse beyond pleasantries. He presented for psychiatric assistance with persistent depressive symptoms of moderately severe intensity. Consultations were brief and very distant. When once offered brief psychotherapy for treatment of his depressive symptoms, he commented (without eye contact): ‘What could you possibly say that would be of any use to me?’ Management was confined to antidepressant medications.

Cluster B: borderline personality disorder

A 23-year-old woman presented in crisis after recently ending a highly traumatic relationship with an older man who physically and emotionally abused her. This was not the first abusive relationship in which she had been involved and she recognised that her choice of partners had been poor. She recalled first suffering depressive symptoms aged 11 and had struggled with occasional episodes of severe depression ever since. In addition, she suffered distressing mood swings which might last only several hours, varying from deep despair to feeling almost elated. There did not seem to be any pattern to these mood fluctuations, and she was desperate for relief from this ‘roller-coaster’ existence. From early adolescence she had found cutting herself to be relieving of her emotional distress, but also had attempted suicide by hanging on one occasion. The self-mutilation had improved with the introduction of an antipsychotic medication in low dose and her persistence with individual psychotherapy over the past year. At times, she could see a real future for herself and attended university intermittently. However, her despair and hopelessness would recur and disrupt her studies. Despite her major emotional upheavals, she was determined to go on and contacted her therapists frequently to obtain their help with a multitude of life problems.

Cluster C: obsessive-compulsive (also known as anankastic) personality disorder

A 27-year-old divorcee presented for help after her marriage of 4 years ended because her husband could no longer tolerate her need for fastidious regulation of everything which happened in their lives. She demanded that their home was spotless and highly organised at all times, but did not exhibit any cleaning or other rituals. All activities were recorded and planned in intricate detail, with her insistence that nothing could be undertaken spontaneously and without careful consideration. Items at home, including clothing and foodstuffs, had a designated place and there was a place for everything.

However, she did not see that there was a significant problem with her behaviour and said, ‘I am very organised and I like things to be “just so”. My husband said I was “too obsessional and controlling” and I suppose I found him chaotic and disorganised. His decision to leave me was very distressing and I wrote him lots of letters trying to understand his reasons for going. Surely, he could see I just needed to be very organised?’ Treatment designed for obsessive-compulsive disorder was administered but was ineffective, despite her assiduous participation.

Comorbidity

Personality disorders are often associated with major psychological disorders and a variety of general medical disorders, more than expected by chance (Box 12.2). Sometimes, these comorbid conditions are present during the developmental period (including in prodromal form) and probably contribute to the distortions of development which promote the formation of personality dysfunction. Genetic factors may also have relevance here, as inheritance may be shared with other disorders.

BOX 12.2 Specific disorders commonly comorbid with personality disorders or responsible for personality change

Disorders include:

• substance abuse (e.g. alcohol), illicit psychoactive substances (e.g. cannabis, stimulants of various kinds and hallucinogens), prescribed medications (e.g. benzodiazepines, opiates and ketamine) and other varied substances with psychoactive effects (e.g. petrol and solvents)

• bipolar disorder, including types I and II (particularly cluster B)

• depressive disorders, including major depressive disorders, dysthymic disorder

• schizophrenia and related disorders (particularly cluster A), and

• anxiety disorders of all kinds (particularly cluster C).

Differential diagnoses

The differential diagnoses of personality disorders are critically important, as often the suggestion of personality dysfunction means that other possible diagnoses are not considered. This is particularly important when the onset of personality dysfunction is relatively recent or is evident before the age of 18 years. A diagnosis of personality disorder cannot be made before the age of 18 and should be considered putative until after the age of 25 years. Possible differential diagnoses are listed in Box 12.3.

BOX 12.3 Common differential diagnoses for personality disorders

Differential diagnoses include:

• bipolar disorder (particularly for cluster B personality disorders)

• depressive disorders (all clusters)

• schizophrenia (particularly cluster A)

• anxiety disorders (cluster C)

• acquired brain injury secondary to trauma

• early dementia, including from multiple sclerosis, HIV/AIDS, Huntington’s disease, neurosyphilis, frontotemporal dementias, vascular dementias such as secondary to vasculitis, and a variety of other infectious diseases

• cerebrovascular disorders, including cerebrovascular accidents (affecting frontal lobes), and

• cerebral malignancy (affecting the frontal lobes).

All of the above disorders can present as personality disorders when in prodromal form as well as in overt diagnosed form, and may be responsible for persistent personality change.

Aetiology

Neurobiological theories

Genetics

There is increasingly strong evidence that some personality disorders (e.g. borderline personality disorder) contain a significant genetic contribution, which appears to provide vulnerability to traumatic and meaningful life experiences during the developmental period. The relative contributions of inheritance and environment remain the subject of intense curiosity.

Developmental factors

Childhood and adolescent experiences interact with the genetic profile and promote change in the developing brain. Neurones create ‘neural networks’ forming the foundation for learning, both implicit (not available to conscious awareness) and explicit (available to conscious awareness). Deprivation of normal experiences and/or an overwhelming load of unpleasant experiences create neural networks which promote unhelpful patterns of physiological responses to a range of future life experiences.

Some patterns relate to excessive arousal (linked to excessive activity in the amygdala, hippocampus and sympathetic nervous system), while others relate to altered awareness, which clinically is reflected as dissociative phenomena (linked to altered activity in the cingulate cortices and parasympathetic nervous system). In adult life these altered patterns of self-experience and behaviour result in a variety of problems coping with stress, relationships and occupation. The combination of intense arousal and dissociation can result in distressing behaviour, such as self-injury and mutilation. Sometimes, experience of self-inflicted pain at these times is emotionally relieving and can become quite established as a maladaptive pattern of coping.

Psychosocial theories

Management

The management of patients with personality disorders can be difficult yet enormously rewarding. It is important to avoid pejorative labelling, and to work as effectively as possible with the individual to establish a good working therapeutic alliance.

Therapeutic alliance

A strong therapeutic alliance is critically important because of the difficulties patients with personality disorders have with important relationships, but this is also the site of frequent problems in treatment. These individuals frequently present with complaints of illness, but are often difficult to engage and maintain in treatment. They are sometimes very pleasant and clearly distressed, but can also often be hostile, demanding or clinging in behaviour. This provokes a mix of empathy, anger and sometimes distrust in health professionals, which then amplifies their difficulties with self-identity and relationships.

Tolerating their intense mixed feelings is fundamental to further treatment, of any kind. Negotiating a mix of behaviours which can be tolerated is also essential and will require both consistent boundaries (e.g. violence can never be tolerated) and reasonable tolerance of unpleasant emotions (e.g. some verbal abuse). Some form of simple contract is useful, establishing the expectations for frequency of contact, arrangements for crisis intervention, a policy regarding telephone contact between sessions and the expectations of further treatment.

Understanding that the negative emotion and behaviour is an established ‘habit’ and not a ‘personal’ issue with the therapist can help the therapist to cope more effectively. Further, it helps to recognise that this is also a maladaptive but efficient strategy for conveying distress and eliciting assistance.

Crisis planning

Part of the management of patients with personality disorder, expressly cluster B, must encompass the fact that they are likely to react to difficult life situations in maladaptive ways, and self-harm might be one of these ways. Thus, the clinician and patient need to establish agreed ways of coping with and reacting to crises. Box 12.4 outlines the main issues relating to crisis plans. Presentations to emergency departments with self-mutilation, suicide attempts or intent, severe depression, severe anxiety and psychotic symptoms are very common.

BOX 12.4 Crisis intervention

• Establish a therapeutic alliance by presenting a reasonably (but not intensely) caring attitude and focusing upon the immediate needs for intervention.

• Obtain a history of the presenting complaint. Review of the complexities of past problems is usually best addressed after the crisis has resolved.

• Perform a thorough mental status examination and all necessary physical examinations.

• Safety is a major concern, but admission to hospital should be offered with care and planned (at least initially) to be brief and crisis focused. Avoid admission if safe and a reasonable alternative management strategy can be offered. Often individuals with personality disorders respond to admission with further psychological regression, returning to patterns of feeling, thinking and behaviour which are associated with much earlier times in their lives. The result can be loss of more mature coping strategies and unhelpful behaviour such as intense dependency, self-injury and/or aggressive behaviour. This is a risk with any psychological intervention in such patients, but intervention can be helpful in the management of a life crisis.

• Alternative strategies to admission to a psychiatric facility include offering rapid review by a therapist outside of hospital, accessing the support of significant others and, most importantly, a strong focus in treatment upon reinforcement of the patient’s own psychological coping strategies.Day hospital or ‘partial hospitalisation’ strategies have been usefully employed for borderline personality disorder.

• Medications can be helpful to reduce anxiety, reduce intensity of depressed mood and thinking, reduce impulsivity, reduce psychotic symptoms and facilitate further intervention (see Ch 13). These can include antipsychotic agents such as chlorpromazine, olanzapine and risperidone (particularly for clusters A and B, but sometimes also for cluster C). Benzodiazepines can be useful to reduce anxiety, particularly for cluster C, but the risk of dependence and abuse must be considered carefully in these patients.