eMedicine Specialties > Psychiatry > Adult

Personality Disorders

David Bienenfeld, MD, Vice-Chair, Program Director, Professor, Department of Psychiatry, Wright State University School of Medicine

Updated: Jul 17, 2008

Introduction

Background

A personality disorder, as defined in the Diagnostic and Statistical Manual of the American Psychiatric Association, Fourth Edition, Text Revision (DSM-IV-TR), is an enduring pattern of inner experience and behavior that differs markedly from the expectations of the individual's culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment. Personality disorders are a long-standing and maladaptive pattern of perceiving and responding to other people and to stressful circumstances. Ten personality disorders, grouped into 3 clusters (ie, A, B, C), are defined in the DSM-IV-TR.¹

Pathophysiology

The origin of personality disorders is a matter of considerable controversy. Traditional thinking holds that these maladaptive patterns are the result of dysfunctional early environments that prevent the evolution of adaptive patterns of perception, response, and defense. A body of data points toward genetic and psychobiologic contributions to the symptomology of these disorders; however, the inconsistency of the data prevents authorities from drawing definite conclusions.

Frequency

United States

Personality disorders affect 10-15% of the adult US population. Individuals may have more than one personality disorder. The following are prevalences for specific personality disorders in the general population:²

• Paranoid personality disorder - 0.5-2.5%
• Schizotypal personality disorder - 3%
• Antisocial personality disorder - 3% of men, 1% of women
• Borderline personality disorder - 2%
• Histrionic personality disorder - 2-3%
• Narcissistic personality disorder - Less than 1%
• Avoidant personality disorder - 0.5-1%
• Obsessive-compulsive personality disorder - 1%

International

Because the DSM-IV-TR criteria are so bound to North American cultural definitions, epidemiologic data about personality disorders in other countries are notoriously unreliable.

Mortality/Morbidity

Patients with personality disorders are at higher risk than the general population for many (Axis I) psychiatric disorders. Mood disorders are a particular risk across all personality diagnoses. Some comorbidities are more specific to particular personality disorders and clusters.

• Cluster A: Paranoid personality disorder may appear as a prodrome to delusional disorder or frank schizophrenia. These individuals are at risk for agoraphobia, major depression, obsessive-compulsive disorder, and substance abuse. Individuals with schizoid personality disorder may develop major depression. Patients with schizotypal personality disorder may develop brief psychotic disorder, schizophreniform disorder, or delusional disorder. At the time of diagnosis, 30-50% have concurrent major depression, and most have a history of at least one major depressive episode. For more information, see Medscape's Schizophrenia Resource Center.
• Cluster B: Antisocial personality disorder is associated with a risk for anxiety disorders, substance abuse, somatization disorder, and pathological gambling. Borderline personality disorder is associated with a risk for substance abuse, eating disorders (particularly bulimia), and posttraumatic stress disorder. Suicide is a particular risk in borderline patients. Histrionic personality disorder is associated particularly with somatoform disorders. People with narcissistic personality disorder are at risk for anorexia nervosa and substance abuse as well as experiencing depression. For more information, see Medscape's Anxiety Disorders Resource Center.
• Cluster C: Avoidant personality disorder is associated with anxiety disorders (especially social phobia). Dependent personality disorder carries a risk for anxiety disorders and adjustment disorder. People with obsessive-compulsive personality disorder may be at risk for myocardial infarction because of their common type A lifestyles. They may also be at risk for anxiety disorders. Notably, they are probably not at increased risk for obsessive-compulsive disorder.

Race

No differences in prevalence across the races have been noted.

Sex

• Cluster A: Schizoid personality disorder is slightly more common in males than in females.
• Cluster B: Antisocial personality disorder is 3 times more prevalent in men than in women. Borderline personality disorder is 3 times more common in women than in men. Of patients with narcissistic personality disorder, 50-75% are male.
• Cluster C: Obsessive-compulsive personality disorder is diagnosed twice as often in men than in women.

Age

Personality disorders generally should not be diagnosed in children and adolescents because personality development is not complete and symptomatic traits may not persist into adulthood. Therefore, the rule of thumb is that personality diagnosis cannot be made until the person is at least 18 years of age. Because the criteria for diagnosis of personality disorders are closely related to behaviors of young and middle adulthood, DSM-IV-TR diagnoses of personality disorders are notoriously unreliable in the elderly population.

Clinical

History

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.

Physical

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
  • 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.
  • Patients with paranoid personality disorder voice persecutory ideation without the formal thought disorder observed in schizophrenia.
  • 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.
  • 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.

Causes

• 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
• 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.

Differential Diagnoses

Other Problems to Be Considered

The diagnosis of personality disorders in patients who have comorbid Axis I disorders, including mood, substance abuse, and medical disorders (eg, head injury, seizure disorders), can make the diagnosis of personality disorders more difficult because of overlapping features. Premorbid and developmental history, especially from collateral sources, is helpful in differential diagnosis.

Workup

Laboratory Studies

• Toxicology screen: Substance abuse is common in many personality disorders, and intoxication can lead patients to present with some features of personality disorders.
• Screening for HIV and other sexually transmitted diseases: Patients with personality disorders often exhibit poor impulse control and many act without regard to risk.

Other Tests

• Psychological testing may support or direct the clinical diagnosis.^3,2
  • The Minnesota Multiphasic Personality Inventory (MMPI) is the best-known psychological test. The Eysenck Personality Inventory and the Personality Diagnostic Questionnaire are also used. None of these has been reliably validated against DSM-IV-TR diagnoses.
  • The Structured Clinical Interview for DSM-IV-TR for Axis II Disorders (SCID-II) can also be used to aid in diagnosis.

Treatment

Medical Care

Psychotherapy is at the core of care for personality disorders. Because personality disorders produce symptoms as a result of poor or limited coping skills, psychotherapy aims to improve perceptions of and responses to social and environmental stressors.

• Psychodynamic psychotherapy examines the ways that patients perceive events, based on the assumption that perceptions are shaped by early life experiences. Psychotherapy aims to identify perceptual distortions and their historical sources and to facilitate the development of more adaptive modes of perception and response. Treatment is usually extended over a course of several years at a frequency from several times a week to once a month; it makes use of transference.⁶
• Cognitive therapy (also called cognitive behavior therapy [CBT]) is based on the idea that cognitive errors based on long-standing beliefs influence the meaning attached to interpersonal events. It deals with how people think about their world and their perception of it. This very active form of therapy identifies the distortions and engages the patient in efforts to reformulate perceptions and behaviors. This therapy is typically limited to episodes of 6-20 weeks, once weekly. In the case of personality disorders, episodes of therapy are repeated often over the course of years.⁷
• Interpersonal therapy (IPT) conceives of patients' difficulties resulting from a limited range of interpersonal problems including such issues as role definition and grief. Current problems are interpreted narrowly through the screen of these formulations, and solutions are framed in interpersonal terms. Therapy is usually weekly for a period of 6-20 sessions. Though empirically validated for anxiety and depression, IPT is not widely practiced, and therapists conversant in the technique are difficult to locate.⁸
• Group psychotherapy allows interpersonal psychopathology to display itself among peer patients, whose feedback is used by the therapist to identify and correct maladaptive ideas, communication, and behavior. Sessions are usually once weekly over a course that may range from several months to years.
• Dialectical behavior therapy (DBT): This is a skills-based therapy (developed by Marsha Linehan, PhD) that can be used in both individual and group formats. It has been applied to borderline personality disorder. The emphasis of this manual-based therapy is on the development of coping skills to improve affective stability and impulse control and on reducing self-harmful behavior. This treatment is also being used with other cluster B personality disorders to reduce impulsive behavior.²

Consultations

The primary care physician should usually consider psychiatric consultation for patients with personality disorders because the ongoing psychiatric care that patients require is not readily provided in the primary care setting.

Medication

The focus is on treatment of symptom clusters such as cognitive-perceptual symptoms, affective dysregulation, and impulsive-behavioral dyscontrol. These symptoms may complicate almost all personality disorders to varying degrees, but all of them have been noted in borderline personality disorder.^{9,10,11,12,13}

The assumption is that neurotransmitter abnormalities underlie these symptom clusters that transcend the concepts of Axis I and Axis II disorders. The strongest evidence for pharmacologic treatment of personality disorders has been for borderline personality disorder, but even this is based on a fairly small database of studies.

Antidepressants

Because of overdose risk, tricyclic antidepressants and monoamine oxidase inhibitors (MAOIs) are usually not prescribed for patients with personality disorders. The selective serotonin reuptake inhibitors (SSRIs) and newer antidepressants are safe and reasonably effective. However, because the depression of most patients with personality disorders stems from their limited range of coping capacities, antidepressants are usually less effective than in patients with uncomplicated major depression.

Antidepressants are most often prescribed for a limited time in patients with serious depressive episodes lasting longer than a few weeks.

Sertraline (Zoloft)

Selectively inhibits presynaptic serotonin reuptake.

Dosing

Adult

50-150 mg/d PO

Pediatric

Not established

Interactions

Serotonergic agents, such as other SSRIs, meperidine, and MAOIs, can produce serotonergic reactions with sertraline

Contraindications

Documented hypersensitivity; concurrent administration of MAOIs or within the last 2 wk

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in preexisting seizure disorders and those that have experienced recent MI, have unstable heart disease, or hepatic or renal impairment

Paroxetine (Paxil)

Potent selective inhibitor of neuronal serotonin reuptake. Also has weak effect on norepinephrine and dopamine neuronal reuptake.

Dosing

Adult

20-60 mg/d PO

Pediatric

Not established

Interactions

Phenobarbital, phenytoin, and carbamazepine may decrease effects; cimetidine may increase toxicity; because of its effects on the cytochrome P-450 enzyme systems and protein binding, can increase blood levels of antipsychotics, anticonvulsants, other antidepressants, beta-blockers, type 1C antiarrhythmics, and Coumadin; serotonin syndrome may occur when used with other serotonergic agents such as buspirone, meperidine, tramadol, dextromethorphan, triptans, mirtazapine, nefazodone, and other SSRIs, but especially with MAOIs

Contraindications

Documented hypersensitivity; concurrent administration with MAOIs, or within 14 d of discontinuing

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in history of seizures, mania, renal disease, and cardiac disease; adverse effects include drowsiness, headache, weight gain, and sexual dysfunction

Fluoxetine (Prozac)

Selectively inhibits presynaptic serotonin reuptake with minimal or no effect in the reuptake of norepinephrine or dopamine.

Dosing

Adult

20-80 mg/d PO

Pediatric

Not established

Interactions

Phenobarbital, phenytoin, and carbamazepine may decrease effects; cimetidine may increase toxicity; because of its effects on the cytochrome P-450 enzyme systems and protein binding can increase blood levels of antipsychotics, anticonvulsants, other antidepressants, beta-blockers, type 1C antiarrhythmics, and Coumadin; serotonin syndrome may occur when used with other serotonergic agents such as buspirone, meperidine, tramadol, dextromethorphan, triptans, mirtazapine, nefazodone, and other SSRIs, but especially with MAOIs

Contraindications

Documented hypersensitivity; concurrent administration of MAOIs or within the last 2 wk

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in hepatic impairment and history of seizures; MAOIs should be discontinued at least 14 d before initiating fluoxetine therapy;
adverse effects include insomnia, headache, weight gain, and sexual dysfunction

Escitalopram (Lexapro)

Enhances serotonin activity because of selective reuptake inhibition at the neuronal membrane.
Selective serotonin reuptake inhibitor (SSRI) and S-enantiomer of citalopram. Used for the treatment of depression. Mechanism of action is thought to be potentiation of serotonergic activity in central nervous system resulting from inhibition of CNS neuronal reuptake of serotonin. Onset of depression relief may be obtained after 1-2 wk, which is sooner than other antidepressants.

Dosing

Adult

10 mg PO qd initially; if needed, may increase to 20 mg/d after 1 wk

Pediatric

Not established

Interactions

Primarily metabolized by CYP450 3A4 and 2C19; coadministration with alcohol or other centrally acting drugs increases CNS depression; cimetidine increases AUC and maximum serum concentration; coadministration with sumatriptan and SSRIs has caused weakness and hyperreflexia

Contraindications

Documented hypersensitivity; concurrent MAOI therapy

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution with history of seizures, mania, suicide; common adverse effects include insomnia, ejaculation disorder (primarily ejaculatory delay), nausea, sweating, fatigue, and somnolence

Nefazodone (Serzone)

Antagonist at the 5-HT2 receptor and inhibits the reuptake of 5-HT. Also has negligible affinity for cholinergic and histaminergic receptors.

Dosing

Adult

300-600 mg/d PO

Pediatric

Not established

Interactions

Increases effects of digoxin, carbamazepine, triazolam, alprazolam, and protease inhibitors through its effect of inhibiting CYP-450 3A4 enzyme. Serotonin syndrome may occur when used with other serotonergic agents such as buspirone, meperidine, tramadol, dextromethorphan, triptans, mirtazapine, and SSRIs, but especially with MAOIs

Contraindications

Documented hypersensitivity; MAOIs within 14 d of initiating treatment

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in cardiac disease, cerebrovascular disease, or seizures; discontinue therapy and reevaluate if priapism occurs; adverse effects include drowsiness, headache, and weight gain

Mirtazapine (Remeron)

Increases availability of serotonin and norepinephrine.

Dosing

Adult

15-60 mg/d PO

Pediatric

Not established

Interactions

May potentiate effects of alcohol and benzodiazepines; serotonin syndrome may occur when used with other serotonergic agents such as buspirone, meperidine, tramadol, dextromethorphan, triptans, nefazodone, and SSRIs, but especially with MAOIs

Contraindications

Documented hypersensitivity; MAOIs within 14 d of initiating treatment

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Common adverse effects include drowsiness, headache, and weight gain

Anticonvulsants

Useful in stabilizing the affective extremes in patients with bipolar disorder but are less effective for that purpose in patients with personality disorders. They have some demonstrated efficacy in suppressing impulsive and particularly aggressive behavior in patients with personality disorder.

Valproic acid (Depakote)

Most widely used agent in its class. Modestly effective and generally well tolerated.

Dosing

Adult

Initial: 750 mg/d in divided doses; may increase by 500 mg/d q2-3d to achieve trough serum levels of 50-125 mcg/mL

Pediatric

Not established

Interactions

Coadministration with cimetidine, salicylates, felbamate, and erythromycin may increase toxicity; rifampin may significantly reduce levels; in pediatric patients, protein binding and metabolism of valproate decrease when taken concomitantly with salicylates; coadministration with carbamazepine may result in variable changes of carbamazepine concentrations with possible loss of seizure control; valproate may increase diazepam and ethosuximide toxicity (monitor closely); may increase phenobarbital and phenytoin levels while either one may decrease valproate levels; may displace warfarin from protein-binding sites (monitor coagulation tests); may increase zidovudine levels in patients who are HIV seropositive

Contraindications

Documented hypersensitivity; hepatic disease/dysfunction

Precautions

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Thrombocytopenia and abnormal coagulation parameters have occurred; risk of thrombocytopenia increases significantly at total trough valproate plasma concentrations >110 mcg/mL in females and 135 mcg/mL in males; at periodic intervals and prior to surgery determine platelet counts and bleeding time before initiating therapy; reduce dose or discontinue therapy if hemorrhage, bruising, or a hemostasis/coagulation disorder occur; hyperammonemia may occur, resulting in hepatotoxicity; monitor patients closely for appearance of malaise, weakness, facial edema, anorexia, jaundice, and vomiting; may cause drowsiness; adverse effects include headache, drowsiness, nausea, tremor, dizziness, and alopecia

Antipsychotics

Some personality disorders produce transient psychotic periods (especially borderline personality disorder), while others (eg, schizotypal personality disorder) feature chronic idiosyncratic ideation of nearly psychotic proportions.

Response to antipsychotics is less dramatic than in true psychotic Axis I disorders, but symptoms such as anxiety, hostility, and sensitivity to rejection may be reduced. Antipsychotics are typically used for a short time while the symptoms are active.

The atypical antipsychotics have almost completely replaced the traditional neuroleptics because of their safety margin, but neurologic risks (including tardive dyskinesia and neuroleptic malignant syndrome) are never absent. Risperidone and olanzapine are described here; however, quetiapine and ziprasidone may also be used. No evidence indicates that any of these has superior efficacy, and each one may have advantages and disadvantages from the standpoint of adverse effects.

Risperidone (Risperdal)

Binds to dopamine D2 receptor with a 20-times lower affinity than for the 5-HT2 receptor. Improves negative symptoms of psychoses and reduces incidence of extrapyramidal adverse effects.

Dosing

Adult

0.5-4 mg/d PO

Pediatric

Not established

Interactions

Coadministration enhances the effects of alcohol and other CNS suppressants; may inhibit effects of levodopa; may increase clozapine levels

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

May cause extrapyramidal reactions, hypotension, tachycardia, and arrhythmias; adverse effects include pseudoparkinsonism (particularly at doses > 6 mg/d), sedation, dizziness, and rhinitis

Olanzapine (Zyprexa)

May inhibit serotonin, muscarinic, and dopamine effects.

Dosing

Adult

3.75-30 mg/d PO

Pediatric

Not established

Interactions

Fluvoxamine may increase effects; antihypertensives may increase risk of hypotension and orthostatic hypotension; levodopa, pergolide, bromocriptine, charcoal, carbamazepine, omeprazole, rifampin, and cigarette smoking may decrease effects

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in narrow-angle glaucoma, cardiovascular disease, cerebrovascular disease, prostatic hypertrophy, seizure disorders, hypovolemia, and dehydration; adverse effects include sedation, constipation, weight gain, and postural hypotension; tardive dyskinesia has been reported

Quetiapine (Seroquel)

May act by antagonizing dopamine and serotonin effects. Efficacy similar to risperidone and olanzapine. Fewer dose-dependent adverse effects and less concern of weight gain.

Dosing

Adult

25 mg PO bid; titrate to 150-750 mg/d PO; not to exceed 800 mg/d

Pediatric

Not established

Interactions

May antagonize levodopa and dopamine agonists; phenytoin, thioridazine, and other liver enzyme inducers may reduce quetiapine levels; CYP450 3A inhibitors (eg, ketoconazole, fluconazole, erythromycin) increase quetiapine serum concentration

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

May induce orthostatic hypotension associated with dizziness, tachycardia, and syncope; the neuroleptic malignant syndrome and tardive dyskinesia has been associated with this treatment; hyperglycemia may occur and in some cases be extreme, resulting in ketoacidosis, hyperosmolar coma, or death; caution in hepatic impairment (decrease dose)

Follow-up

Further Inpatient Care

• Criteria for hospitalization of patients with personality disorders are generally the same as for patients with Axis I psychiatric disorders: imminent danger to self or others, inability to care for basic needs, or psychosocial stressors overwhelming the patient's capacity to cope.
• Because the underlying disorder remains basically unchanged by inpatient interventions, length of stay should be minimized to avoid dependency that subverts recovery from the circumstances prompting the hospitalization.
• Short stays may be used to stabilize environmental factors, adjust medication regimen, and/or implement short-term psychotherapeutic intervention.

Further Outpatient Care

• All patients hospitalized for manifestations of personality disorders should be referred for follow-up psychotherapy or counseling.
• See Medical Care.

Inpatient & Outpatient Medications

• See Medication.

Transfer

• Patients observed in the emergency department or admitted to a medical-surgical unit of a hospital without a psychiatric service may require transfer to a hospital that provides such service. Psychiatric consultation can provide guidance about whether the patient would benefit from such transfer.
• Some patients hospitalized in the psychiatric units of general hospitals, where stays are generally shorter than 2 weeks, may require transfer to psychiatric hospitals that can provide long-term care. Such cases are unusual and are limited to those patients with personality disorders whose coping capacities are so grossly impaired that they cannot maintain adequate function in the community or in a less restrictive environment.

Deterrence/Prevention

• Within the limits of contemporary medical knowledge, personality disorders cannot be prevented, although steps can be taken to prevent or deter some of the consequences and complications of personality disorders.
  • Frequent inquiries about suicidal ideation are warranted, regardless of whether the patient spontaneously raises the subject. The physician need not fear instilling the idea of suicide in a patient who is not already entertaining it. Subsequent inquiry about firearms, lethal medications, and other available means of suicide point to avenues of preventive behavior.¹⁴
  • Benzodiazepines, narcotic analgesics, and other drugs with potential for dependency should be used rarely and with great caution. Nearly all personality disorders are marked by impaired impulse control and consequent risk of addictive behavior.
  • Patients with personality disorder who have children should be asked frequently and in detail about their parenting practices. Their low frustration tolerance, externalization of blame for psychological distress, and impaired impulse control put the children of these patients at risk for neglect or abuse.

Complications

• Suicide¹⁴
• Substance abuse
• Accidental injury
• Depression
• Homicide - A potential complication, particularly in paranoid and antisocial personality disorders

Prognosis

• Personality disorders are lifelong conditions.
• Attributes of cluster A and B personality disorders tend to become less severe and intense in middle age and late life.
• Patients with cluster B personality disorders are particularly susceptible to problems of substance abuse, impulse control, and suicidal behavior, which may shorten their lives.
• Cluster C characteristics tend to become exaggerated in later life.

Patient Education

• See Medical Care.
• Patients should be advised that their patterns of perception and response are the results of some combination of inheritance and personal history, and that recovery is therefore likely to be a prolonged process, requiring effort and attention. The relevance of ongoing psychotherapy to long-standing vulnerabilities requires frequent reemphasis by the physician.
• Alcoholism and drug abuse are not merely complications of personality disorders, they are also aggravating factors. Patients need constant reminding that yielding to the temptation to drink or use drugs is likely to make their emotional distress worse and is certain to increase the risk of complications, including suicide.
• With the patient's permission, education to the family can alert them to the possibilities of disruptive and destructive behavior, and can provide guidelines for limit-setting and safety.

Miscellaneous

Medicolegal Pitfalls

• The poor impulse control of these patients, particularly those with cluster B disorders, places some degree of legal responsibility on the physician. If a patient threatens someone else with injury, the physician may have a duty to warn the intended victim, either directly or through legal authorities, under the Tarasoff ruling.
• Caregivers should be vigilant about suicidal potential and should document their assessments in the medical record at each visit.
• If patients without true psychotic conditions are treated with antipsychotic agents, the physician may be liable for serious neurologic effects such as tardive dyskinesia and neuroleptic malignant syndrome. The physician should carefully document the indication for the use of such agents, and these agents should be discontinued as soon as possible.
• It can be difficult to accurately diagnose an Axis II disorder in the context of acute and severe Axis I symptoms unless the clinician is very familiar with the patient's long-term history. For example, signs and symptoms of individuals with major depression, mania, panic attacks, obsessive-compulsive disorder, or substance abuse may resolve with successful treatment. Examples may include dependent or avoidant features in major depression or obsessive-compulsive disorder, antisocial behaviors in substance abuse, or histrionic or narcissistic features in mania.

References

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2. Widiger TA, Sanderson CJ. Personality disorders. In: Tasman A, Kay J, Lieberman JA, eds. Psychiatry. Philadelphia, Pa: Harcourt Brace & Co; 1997:1291-1317.

3. Shedler J, Westen D. Refining personality disorder diagnosis: integrating science and practice. Am J Psychiatry. Aug 2004;161(8):1350-65. [Medline].

4. Raine A, Lencz T, Bihrle S, et al. Reduced prefrontal gray matter volume and reduced autonomic activity in antisocial personality disorder. Arch Gen Psychiatry. Feb 2000;57(2):119-27; discussion 128-9. [Medline].

5. Lyons-Ruth K, Holmes BM, Sasvari-Szekely M, Ronai Z, Nemoda Z, Pauls D. Serotonin transporter polymorphism and borderline or antisocial traits among low-income young adults. Psychiatr Genet. Dec 2007;17(6):339-43. [Medline].

6. Britton R. Narcissistic disorders in clinical practice. J Anal Psychol. Sep 2004;49(4):477-90. [Medline].

7. Beck AT, Freeman A. Cognitive Therapy of Personality Disorders. London, England: Guilford Press; 1990.

8. Livesley WJ. A practical approach to the treatment of patients with borderline personality disorder. Psychiatr Clin North Am. Mar 2000;23(1):211-32. [Medline].

9. Kavoussi RJ, Coccaro EF. Divalproex sodium for impulsive aggressive behavior in patients with personality disorder. J Clin Psychiatry. Dec 1998;59(12):676-80. [Medline].

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11. [Best Evidence] Binks CA, Fenton M, McCarthy L, Lee T, Adams CE, Duggan C. Pharmacological interventions for people with borderline personality disorder. Cochrane Database Syst Rev. Jan 25 2006;CD005653. [Medline]. [Full Text].

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13. Herpertz SC, Zanarini M, Schulz CS, Siever L, Lieb K, Möller HJ. World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for biological treatment of personality disorders. World J Biol Psychiatry. 2007;8(4):212-44. [Medline].

14. Suominen KH, Isometsa ET, Henriksson MM, et al. Suicide attempts and personality disorder. Acta Psychiatr Scand. Aug 2000;102(2):118-25. [Medline].

Keywords

character disorder, sociopathy, sociopath, psychopathy, hysteria, paranoid personality disorder, schizoid personality disorder, schizotypal personality disorder, antisocial personality disorder, borderline personality disorder, histrionic personality disorder, narcissistic personality disorder, avoidant personality disorder, dependent personality disorder

obsessive-compulsive personality disorder, OCD, Minnesota Multiphasic Personality Inventory,MMPI, psychiatric disorder, mood disorder, substance abuse, suicide, alcoholism, delusionaldisorder, schizophrenia, depression, obsessive-compulsive disorder, anxiety disorder, somatization disorder, posttraumatic stress disorder, bulimia, anorexia nervosa, social phobia

Contributor Information and Disclosures

Author

David Bienenfeld, MD, Vice-Chair, Program Director, Professor, Department of Psychiatry, Wright State University School of Medicine
David Bienenfeld, MD is a member of the following medical societies: American Medical Association, American Psychiatric Association, and Association for Academic Psychiatry
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Sarah C Aronson, MD, Associate Professor, Departments of Psychiatry and Medicine, Case Western Reserve School of Medicine/University Hospitals of Cleveland
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CME Editor

Harold H Harsch, MD, Program Director of Geropsychiatry, Department of Geriatrics/Gerontology, Associate Professor, Department of Psychiatry and Department of Medicine, Froedtert Hospital, Medical College of Wisconsin
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