2.1.10 Personality Disorders

Personality Disorders

Personality disorders are a group of mental health conditions characterized by long-standing patterns of behaviour, thoughts, and emotions that deviate significantly from cultural norms and cause significant impairment in social, occupational, or other important areas of functioning. These conditions are prevalent among adults and can have a profound impact on their lives, as well as the lives of those around them. In this educational piece, we will discuss the prevalence/incidence, aetiology, presentation, treatment, and outcome of personality disorders in adulthood.

Debate: A recurring critique of the current clinical understanding of personality disorders (PDs) is the issue of circular reasoning. This occurs when the same characteristics exhibited by a patient, which indicate a PD diagnosis, are subsequently used to justify that diagnosis. For instance, an individual may demonstrate “an inability to feel guilt” and “a low tolerance for frustration, including aggression,” leading to an ICD-10 diagnosis of antisocial PD. It becomes illogical to use this diagnosis to “explain” a future violent act without remorse in that person. Some mental health professionals argue that psychiatry should not be involved in treating individuals with PDs. Their reasoning includes: personality, by its nature, is unchangeable; there is no evidence of psychiatry benefiting those with PDs; these individuals negatively impact the treatment of other patients; people with PDs are not sick and should be held accountable for their actions; and psychiatry is being asked to address what is fundamentally a societal issue. Conversely, there are those who maintain that PDs fall squarely within the field of psychiatry. They argue that: individuals with PDs experience symptoms related to their condition; they have elevated suicide rates, other forms of early death, and comorbid mental disorders; there are effective treatment options available; their critics are rejecting patients due to personal dislike; and the issue is not that these individuals cannot be helped, but rather that conventional psychiatric services do not offer the appropriate approach and resources required.

Prevalence/Incidence:

Personality disorders are common in the general population, with estimates of prevalence ranging from 5 to 15 per cent (Grant et al., 2015). The incidence of personality disorders is difficult to determine, as these conditions are often unrecognized or misdiagnosed. However, research suggests that personality disorders are more prevalent in certain populations, such as those with a history of trauma or abuse, substance use disorders, or other mental health conditions (Skodol et al., 2011).

Aetiology:

The exact causes of personality disorders are not fully understood, but research suggests that a combination of genetic, environmental, and social factors contribute to the development of these conditions. Studies have identified specific genetic variations associated with personality disorders, as well as early childhood experiences, such as neglect or abuse, that increase the risk of developing these conditions (Bornovalova et al., 2013). Additionally, social and cultural factors, such as stigma, discrimination, and social isolation, can exacerbate symptoms and hinder treatment.

Presentation:

The presentation of personality disorders can vary widely depending on the specific condition and individual factors. Generally, these conditions are characterized by persistent patterns of behaviour, thoughts, and emotions that cause significant distress or impairment in social, occupational, or other important areas of functioning. Symptoms may include:

• Difficulty regulating emotions
• Impulsive behaviour
• Disordered thinking
• Interpersonal problems
• Distorted self-image
• Paranoid or suspicious thoughts
• Excessive sensitivity to criticism or rejection

Treatment:

Treatment for personality disorders often involves a combination of medication, psychotherapy, and other interventions tailored to the individual’s specific needs. Psychotherapy, particularly dialectical behaviour therapy (DBT) and cognitive-behavioural therapy (CBT) has been shown to be effective in reducing symptoms and improving functioning in individuals with personality disorders (Stoffers et al., 2012). Medications, such as mood stabilizers and antidepressants, may also be prescribed to alleviate symptoms.

Outcome:

The outcome of personality disorders varies depending on the severity of the condition, the individual’s response to treatment, and other factors. Some individuals may experience significant improvement in symptoms and function with treatment, while others may struggle with persistent symptoms and impaired functioning. The prognosis for personality disorders is generally better when these conditions are identified and treated early.

Personality Disorder	Prevalence	Characteristics
Borderline	1-2%	Unstable mood, impulsive behaviour, self-harm
Narcissistic	1%	Grandiosity, lack of empathy, need for admiration
Antisocial	1%	Impulsivity, disregard for others’ rights and feelings
Obsessive-compulsive	1%	Preoccupation with orderliness and control
Avoidant	2.4%	Fear of criticism, social isolation
Dependent	0.5-0.6%	Excessive dependence on others, fear of separation
Schizotypal	3-4%	Odd beliefs, social anxiety, eccentric behavior

References:

1. Bornovalova, M. A., Gratz, K. L., Daughters, S. B., Nick, B., Delany-Brumsey, A., Lynch, T. R., & Kosson, D. (2013). A multimodal assessment of the relationship between emotion dysregulation and borderline personality disorder among inner-city substance users in residential treatment. Journal of Psychiatric Research, 47(5), 607-616.
2. Grant, B. F., Chou, S. P., Goldstein, R. B., Huang, B., Stinson, F. S., Saha, T. D., … & Ruan, W. J. (2015). Prevalence, correlates, disability, and comorbidity of DSM-IV borderline personality disorder: Results from the Wave 2 National Epidemiologic Survey on Alcohol and Related Conditions. Journal of Clinical Psychiatry, 76(4), 533-545.
3. Skodol, A. E., Gunderson, J. G., Shea, M. T., McGlashan, T. H., Morey, L. C., Sanislow, C. A., … & Zanarini, M. C. (2011). The Collaborative Longitudinal Personality Disorders Study (CLPS): overview and implications. Journal of Personality Disorders, 25(1), 1-16.
4. Stoffers, J. M., Völlm, B. A., Rücker, G., Timmer, A., Huband, N., & Lieb, K. (2012). Psychological therapies for people with borderline personality disorder. Cochrane Database of Systematic Reviews, (8). CD005652. doi: 10.1002/14651858.CD005652.pub2