Personality Disorders Clinical Presentation

In general, patients with personality disorders have wide-ranging problems in social relationships and mood regulation. These problems have usually been present throughout adult life. These patients' patterns of perception, thought, and response are fixed and inflexible, although their behavior is often unpredictable. These patterns markedly deviate from their specific culture's expectations. To meet the DSM-IV-TR threshold for clinical diagnosis, the pattern must result in clinically significant distress or impairment in social, occupational, or other important areas of functioning. Note that the disorder occurs in all settings (eg, social as well as vocationally), and it not limited to one sphere of activity.^{[1, 3]}

• Cluster A (odd, eccentric)

  • Paranoid personality disorder: Individuals with this disorder display pervasive distrust and suspiciousness. Common beliefs include the following:
    • Others are exploiting or deceiving the person.
    • Friends and associates are untrustworthy.
    • Information confided to others will be used maliciously.
    • There is hidden meaning in remarks or events others perceive as benign.
    • The spouse or partner is unfaithful.
  • Schizoid personality disorder: This type of personality disorder is uncommon in clinical settings. A person with this disorder is markedly detached from others and has little desire for close relationships. This person's life is marked by little pleasure in activities. People with this disorder appear indifferent to the praise or criticism of others and often seem cold or aloof.
  • Schizotypal personality disorder: People with this disorder exhibit marked eccentricities of thought, perception, and behavior. Typical examples are as follows:
    • Ideas of reference (ie, believing that public messages are directed personally at them)
    • Odd beliefs or magical thinking
    • Vague, circumstantial, or stereotyped speech
    • Excessive social anxiety that does not diminish with familiarity
    • Idiosyncratic perceptual experiences or bodily illusions
• Cluster B (dramatic, emotional)

  • Antisocial personality disorder: Individuals with antisocial personality disorder display a pervasive pattern of disregard for and violation of the rights of others and the rules of society. Onset must occur by age 15 years and includes the following features:
    • Repeated violations of the law
    • Pervasive lying and deception
    • Physical aggressiveness
    • Reckless disregard for safety of self or others
    • Consistent irresponsibility in work and family environments
    • Lack of remorse
  • Borderline personality disorder: The central feature of borderline personality disorder is a pervasive pattern of unstable and intense interpersonal relationships, self-perception, and moods. Impulse control is markedly impaired. Transiently, such patients may appear psychotic because of the intensity of their distortions. Borderline personality disorder is one of the most commonly overused diagnoses in DSM-IV-TR. Diagnostic criteria require at least 5 of the following features:
    • Frantic efforts to avoid expected abandonment
    • Unstable and intense interpersonal relationships
    • Markedly and persistently unstable self-image
    • Impulsivity in at least 2 areas that are potentially self-damaging (eg, sex, substance abuse, reckless driving)
    • Recurrent suicidal behaviors or threats or self-mutilation
    • Affective instability
    • Chronic feelings of emptiness
    • Inappropriate and intense anger
    • Transient paranoia or dissociation
  • Histrionic personality disorder: Patients with histrionic personality disorder display excessive emotionality and attention-seeking behavior. They are quite dramatic and often sexually provocative or seductive. Their emotions are labile. In clinical settings, their tendency to vague and impressionistic speech is often highlighted.
  • Narcissistic personality disorder: Narcissistic patients are grandiose and require admiration from others. Particular features of the disorder include the following:
    • Exaggeration of their own talents or accomplishments
    • Sense of entitlement
    • Exploitation of others
    • Lack of empathy
    • Envy of others
    • An arrogant, haughty attitude
• Cluster C (anxious, fearful)

  • Avoidant personality disorder: Avoidant patients are generally very shy. They display a pattern of social inhibition, feelings of inadequacy, and hypersensitivity to rejection. Unlike patients with schizoid personality disorder, they actually desire relationships with others but are paralyzed by their fear and sensitivity into social isolation.
  • Dependent personality disorder: While many people exhibit dependent behaviors and traits, people with dependent personality disorder have an excessive need to be taken care of that results in submissive and clinging behavior, regardless of consequences. Diagnosis requires at least 5 of the following features:
    • Difficulty making decisions without guidance and reassurance
    • Need for others to assume responsibility for most major areas of the person's life
    • Difficulty expressing disagreement with others
    • Difficulty initiating activities because of lack of confidence
    • Excessive measures to obtain nurturance and support
    • Discomfort or helplessness when alone
    • Urgent seeking for another relationship when one has ended
    • Unrealistic preoccupation with fears of being left to fend for themselves
  • Obsessive-compulsive personality disorder: People with obsessive-compulsive personality disorder are markedly preoccupied with orderliness, perfectionism, and control. They lack flexibility or openness. Their preoccupations interfere with their efficiency despite their focus on tasks. They are often scrupulous and inflexible about matters of morality, ethics, and values to a point beyond cultural norms. They are often stingy as well as stubborn.

No specific physical findings are associated with any personality disorders. Physical examination may reveal findings related to the consequences and sequelae of various personality disorders.

• Patients (particularly those with cluster B disorders) may show signs of prior suicide attempts or stigmata of substance abuse.
• Substance abuse is a common comorbidity and may be reflected in the physical stigmata of alcoholism or drug abuse.
• Suicide attempts may leave scars from self-inflicted wounds.

Mental status findings: Few of the relevant findings here are the result of direct questioning, but instead reflect careful observation of the patient while the clinician is eliciting the history.

• Patients with histrionic personality disorder may display la belle indifference, a seemingly indifferent detachment, while describing dramatic physical symptoms.
• A hostile attitude is typical of patients with antisocial personality disorder. In some instances, they may become homicidal.
• Patients with cluster B personality disorders, particularly borderline personality disorder, frequently display affective lability. This lability makes suicide risk high.
• Patients with paranoid personality disorder voice persecutory ideation without the formal thought disorder observed in schizophrenia. The examiner should investigate thoughts of harm to the perceived persecutor(s).
• Hallucinations are rare, but patients with borderline personality may experience dissociative phenomena as if they are hallucinatory.
• Patients with schizotypal personality disorder speak with odd or idiosyncratic use of language.
• Thought process is generally normal in persons with personality disorders.
• Cognitive functions, including memory, orientation, and intelligence, are usually unimpaired.
• Insight is often limited, as patients attribute their suffering to uncontrollable influences outside themselves. Judgment can be inferred by the presenting circumstances.

• Paranoid personality disorder: A genetic contribution to paranoid traits and a possible genetic link between this personality disorder and schizophrenia exist. Psychosocial theories implicate projection of negative internal feelings and parental modeling.
• Schizoid personality disorder: Support for the heritability of this disorder exists.
• Schizotypal personality disorder: This disorder is genetically linked with schizophrenia. Evidence for dysregulation of dopaminergic pathways in these patients exists.
• Antisocial personality disorder: A genetic contribution to antisocial behaviors is strongly supported. Low levels of behavioral inhibition may be mediated by serotonergic dysregulation in the septohippocampal system. There may also be developmental or acquired abnormalities in the prefrontal brain systems and reduced autonomic activity in antisocial personality disorder. This may underlie the low arousal, poor fear conditioning, and decision-making deficits described in antisocial personality disorder.^[4]
• Borderline personality disorder: Psychosocial formulations point to the high prevalence of early abuse (sexual, physical, and emotional) in these patients, and the borderline syndrome is often formulated as a variant of posttraumatic stress disorder. Mood disorders in first-degree relatives are strongly linked. Biological factors, such as abnormal monoaminergic functioning (especially in serotonergic function) and prefrontal neuropsychological dysfunction, have been implicated but have not been well established by research.^{[5, 6]}
• Histrionic personality disorder: Little research has been conducted to determine the biologic sources of this disorder. Psychoanalytic theories incriminate seductive and authoritarian attitudes by fathers of these patients.
• Narcissistic personality disorder: No data on biological features of this disorder are available. In the classic model, narcissism functions as a defense against awareness of low self-esteem. More modern psychodynamic models postulate that this disorder can arise from an imbalance between positive mirroring of the developing child and the presence of an idealizable adult figure.
• Avoidant personality disorder: This personality disorder appears to be an expression of extreme traits of introversion and neuroticism. No data on biological causes are available, although a diagnostic overlap with social phobia probably exists.
• Dependent personality disorder: No studies of genetics or of biological traits of these patients have been conducted. Central to their psychodynamic constellation is an insecure form of attachment to others, which may be the result of clinging parental behavior.
• Obsessive-compulsive personality disorder: Modest evidence points toward the heritability of this disorder. Psychodynamically, these patients are viewed as needing control as a defense against shame or powerlessness.