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eMedicine Specialties > Emergency Medicine > Psychosocial

Personality Disorders

Michael S Beeson, MD, MBA, FACEP, Professor of Emergency Medicine, Northeastern Ohio Universities College of Medicine; Program Director, Emergency Medicine Residency, Summa Health System

Updated: Jul 23, 2008

Introduction

Background

Personality disorders are pervasive, persistent, inflexible, maladaptive patterns of behavior that deviate from expected cultural norms. The most common etiology is multifactorial; however, personality disorders may be secondary to biologic, developmental, or genetic abnormalities. Stressful situations may often result in decompensation, revealing a previously unrecognized personality disorder. Indeed, personality disorders are aggravated by stressors, external or self-induced.

A concept has emerged that personality may be expressed in terms of 5 basic dimensions: extraversion, agreeableness, conscientiousness, neuroticism, and openness to experience.1 This model is termed the 5-factor model, and it has developed a significant amount of acceptance among personality psychologists.

Pathophysiology

Abnormalities may be seen in the frontal, temporal, and parietal lobes. These abnormalities may be caused by perinatal injury, encephalitis, trauma, or genetics. Personality disorders are also seen with diminished monoamine oxidase (MAO) and serotonin levels. Relationships of anatomy, receptors, and neurotransmitters to personality disorders are purely speculative at this point.

Frequently, a history of psychiatric disorders is present. Developmental abnormalities secondary to abuse or incest may be present.

The 5-factor model has been used to describe the different accepted types of personality disorders. Most current research suggests that personality disorders may be differentiated by their interactions among the 5 dimensions rather than differences on any single dimension.

Frequency: Approximately 5-10% of the general population is affected.

Mortality/Morbidity: Risk of death is usually related to conditions or behaviors resulting from the disorder, such as suicide, substance abuse, or injuries from motor vehicle accidents and fighting.

Sex: Antisocial disorders occur more frequently in men than in women. Borderline, histrionic, and dependent disorders are present more commonly in women than in men.

Age: Personality disorders first become apparent in adolescence or early adulthood.

Clinical

Personality disorders are grouped into 3 clusters. The odd or eccentric group is cluster A; the dramatic, emotional, and erratic group is cluster B; and the anxious and fearful group is cluster C.

History

Cluster A

  • Paranoid: Pattern of distrust and suspiciousness with a tendency to attribute malevolent motives to others. Characterized by the following major traits:
    • Expectations of being harmed or exploited without a sufficient bias
    • Preoccupation with unjustified doubts
    • Reluctance to confide in others
    • Reading hidden, demeaning, or threatening messages in benign remarks
    • Persistently bearing grudges
    • Perceiving attacks on character or reputation not apparent to others; recurrent suspicions regarding fidelity of spouse
  • Schizoid: Pervasive pattern of detachment from social relationships and restriction of emotion in interpersonal settings. Characterized by the following major traits:
    • Neither desiring nor enjoying close relationships; choosing solitary activities
    • Little interest in sex
    • Indifference to praise or criticism
    • Emotional frigidity
  • Schizotypal: Behavior, appearance, or thinking that is consistently strange or odd. Major traits include the following:
    • Ideas of reference
    • Odd beliefs, thinking, appearance, and speech; paranoid ideation
    • Excessive social anxiety; lack of close friends

Cluster B

  • Antisocial: Chronic maladaptive behavior that disregards the rights of others. Characterized by the following major traits:
    • Aged 18 years or older
    • Conduct disorder before age of 15 years
    • Disregard for the law
    • Reckless, aggressive, deceitful, and impulsive behavior
    • Lack of remorse
    • Failure to sustain consistent work
    • Males with antisocial as well as borderline personality disorder have a predilection to alcoholism, due to difficulty with delay in self-gratification and inhibition of impulses.
  • Borderline: Instability of interpersonal relationships, self-image, and mood. Characterized by the following major traits:
    • Frantic avoidance of abandonment
    • Intense and unstable interpersonal relationships and moods
    • Identity disturbance
    • Self-damaging impulsivity and recurrent suicidal behavior
    • Chronic empty feelings and transient paranoia
  • Histrionic: Excessive emotionality and attention-seeking behavior. Major traits include the following:
    • Need to be the center of attention with self-dramatization
    • Inappropriate sexual seductiveness
    • Speech lacks detail
    • Aggrandizing but insincere relationships
    • Suggestibility
  • Narcissistic: Behavior includes grandiosity, need for admiration, and lack of empathy. Major traits include the following:
    • Exaggeration of achievements, talents, and uniqueness
    • Envy, arrogance, and lack of empathy
    • Preoccupation with fantasies of success, beauty, and love
    • Interpersonal exploitation

Cluster C

  • Avoidant: Pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation. Major traits include the following:
    • Lack of close friends and unwillingness to get involved unless certain of being liked
    • Avoidance of social activities and fear of criticism
    • Embarrassment or anxiety in front of people
  • Dependent: Personality that is predominately dependent and submissive. Major traits include the following:
    • Difficulty initiating projects, making decisions, and expressing disagreement
    • Discomfort with isolation and preoccupation with fears of being left alone
    • Going to excessive lengths to obtain support from others
    • Immediately seeking new relationships when existing relationships end
  • Obsessive-compulsive: Preoccupation with orderliness, perfectionism, and control at the expense of flexibility and efficiency. Major traits include the following:
    • Preoccupation with details, schedules, and organization; perfectionism interferes with task completion
    • Excessive devotion to work with exclusion of leisure activity
    • Reluctance to delegate
    • Overconscientious and inflexible about morality, values, or ethics; miserly, rigid, and stubborn
  • Other personality disorders not otherwise specified: Disorders of personality functioning that do not meet criteria for any specific personality disorder. Major traits include the following:
    • Features of more than one disorder present without meeting full criteria impairment in one or more areas of functioning
    • Specific disorder that is not included in classification
    • Passive-aggressive or depressive disorders

Physical

  • Evaluate airway, breathing, and circulation (usually no overt intervention is required).
  • Assess vital signs.
  • Keenly watch for evidence of overdose, suicide attempt, or injuries.
  • Reexamine often.

Differentials

Anxiety
Toxicity, Amphetamine
Axis I disorder
Toxicity, Barbiturate
Cushing Syndrome
Toxicity, Cocaine
Hyperthyroidism, Thyroid Storm, and Graves Disease
Toxicity, MDMA
Mood or anxiety disorder
Toxicity, Methamphetamine
Organic abnormality
Toxicity, Narcotics
Posttraumatic stress disorder
Substance abuse
Toxicity, Alcohols

Workup

  • CT scanning with appropriate blood work if organic etiology is suspected
  • Radiography if indicated postinjury from fighting, motor vehicle accident (MVA), or self-mutilation
  • Alcohol level or drug screen test, if appropriate
  • Gonorrhea, chlamydia, and syphilis cultures, if indicated

Treatment

Consider an organic etiology first. Remain tough-minded but caring. Assist the patient in gaining control of behavior without increasing destructive impulses. Avoid the danger of countertransference. Medication is not advisable, unless an underlying mood disorder accompanies the personality disorder. Some empirical evidence suggests that psychotherapy is beneficial.

Cluster A

  • These patients rarely seek treatment. When treatment is sought, the physician should be respectful and honest and should provide clear explanations.

Cluster B

  • Antisocial: Set behavioral limits when needed. Portray streetwise approach without being punitive.
  • Borderline: Explain care truthfully and simply. Remove anxiety. Frequently, these patients use the defense mechanism of "splitting," of describing individuals as all good or all bad. Such patients may be expert at manipulating staff and can also divide ED caregivers against each other. Be especially sure to have clear communication lines among ED caregivers. 
  • Be aware that emotional volatility may be precipitated by the news that a requested treatment or disposition is not possible or appropriate. Involve the patient in his or her evaluation by asking the patient to be specific as to what the expectation or hope was when he or she came to the emergency department. With complaints that are hard to characterize, such as weakness, headaches, dizziness, it may be helpful to ask the patient to keep a diary of his or her symptoms, including date, time, and precipitants. The goal is to have the patient take ownership of his or her presenting symptoms, rather than transferring all solutions to the health care provider.
  • Histrionic: Provide emotional support. Resist a close interpersonal relationship.
  • Narcissistic: Deal with transitions from being overidealized to being devalued by patient. Avoid being defensive about mistakes. There has been work done suggesting that narcissistic personality may share similar qualities as antisocial personality. The main difference appears to be by the degree of grandiosity, with narcissistic patients tending to exaggerate their talents.

Cluster C

  • Avoidant: Avoid criticism. Establish the physician-patient relationship.
  • Dependent: Set limits with the patient concerning the care given.
  • Obsessive-compulsive: Share control with the patient. Allow the patient to actively participate in the decision regarding care. Avoid being defensive and authoritarian.

Medication

Medication is rarely necessary. Differentiating personality disorders from pure mood disorders is important. Patients with mood disorders will benefit from medication, particularly selective serotonin reuptake inhibitors. Patients with personality disorders and manifesting comorbid mood disorder require close medical supervision in terms of initiation and following of medication therapy.

Patients with personality disorders are prone to benzodiazepine abuse.

Discharge

  • Consult with a psychiatrist.
  • Admit the patient if any of the following conditions exist:
    • Suicide attempt or ideation
    • Self-destructive behavior
    • Instability secondary to overdose or injuries
    • Detoxification needs
    • Poor concept of reality
  • If the patient is discharged to a safe environment, follow-up with a psychiatrist in 24-48 hours should be arranged. Developing a verbal or written contract with the patient that reflects follow-up concerns and eventualities, with the expectations for the patient, is frequently helpful.

References

  1. McCrae RR, John OP. An introduction to the five-factor model and its applications. J Pers. Jun 1992;60(2):175-215. [Medline].

  2. American Psychiatric Association. Personality disorders. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. 1996:629-74.

  3. Bagge C, Nickell A, Stepp S, et al. Borderline personality disorder features predict negative outcomes 2 years later. J Abnorm Psychol. May 2004;113(2):279-88. [Medline].

  4. Brim JA. Overdiagnosis of major psychiatric disorders in individuals with substance use disorders and personality disorders: the downside of the Woodruff principle [letter]. J Stud Alcohol. Jul 1998;59(4):477-8. [Medline].

  5. De Bonis M, De Boeck P, Lida-Pulik H. Self-concept and mood: a comparative study between depressed patients with and without borderline personality disorder. J Affect Disord. Mar 1998;48(2-3):191-7. [Medline].

  6. Devens M, Erickson MT. The relationship between defense styles and personality disorders. J Personal Disord. Spring 1998;12(1):86-93. [Medline].

  7. Gunderson JG, Ronningstam E. Differentiating narcissistic and antisocial personality disorders. J Personal Disord. Apr 2001;15(2):103-9. [Medline].

  8. Helgeland MI, Torgersen S. Developmental antecedents of borderline personality disorder. Compr Psychiatry. Mar-Apr 2004;45(2):138-47. [Medline].

  9. Hori A. Pharmacotherapy for personality disorders. Psychiatry Clin Neurosci. Feb 1998;52(1):13-9. [Medline].

  10. Hunter EE. An experiential-descriptive method for the diagnosis of personality disorders. J Clin Psychol. Aug 1998;54(5):673-8. [Medline].

  11. Kaplan K, Sadock B. Personality disorders. In: Pocket Handbook of Clinical Psychiatry. 1990:156-71.

  12. Leichsenring F, Leibing E. Psychodynamic psychotherapy: a systematic review of techniques, indications and empirical evidence. Psychol Psychother. Jun 2007;80(Pt 2):217-28. [Medline].

  13. Morey LC, Gunderson JG, Quigley BD. The representation of borderline, avoidant, obsessive-compulsive, and schizotypal personality disorders by the five-factor model. J Personal Disord. Jun 2002;16(3):215-34. [Medline].

  14. Rubio G, Jimenez M, Rodriguez-Jimenez R, Martinez I, Iribarren MM, Jimenez-Arriero MA, et al. Varieties of impulsivity in males with alcohol dependence: the role of Cluster-B personality disorder. Alcohol Clin Exp Res. Nov 2007;31(11):1826-32. [Medline].

  15. Scully J. Personality disorders. In: National Medical Series for Independent Study Psychiatry. 1996:259-71.

Keywords

personality disorder, behavioral disorder, borderline personality, obsessive-compulsive, psychopathy, psychopath, paranoia, paranoid, schizoid personality, schizoid, schizotypical personality, antisocial, 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, dependentpersonality disorder, obsessive-compulsive personality disorder, OCD, Minnesota Multiphasic Personality Inventory, MMPI, psychiatric disorder, mood disorder, substance abuse, suicide, alcoholism, delusional disorder, schizophrenia, depression, obsessive-compulsive disorder, anxiety disorder, somatization disorder, posttraumatic stress disorder, bulimia, anorexia nervosa, social phobia

Contributor Information and Disclosures

Author

Michael S Beeson, MD, MBA, FACEP, Professor of Emergency Medicine, Northeastern Ohio Universities College of Medicine; Program Director, Emergency Medicine Residency, Summa Health System
Michael S Beeson, MD, MBA, FACEP is a member of the following medical societies: American College of Emergency Physicians, Council of Emergency Medicine Residency Directors, National Association of EMS Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

Jerry Balentine, DO, Professor of Emergency Medicine, New York College of Osteopathic Medicine; Executive Vice President, Chief Medical Officer, Attending Physician in Department of Emergency Medicine, St. Barnabas Hospital
Jerry Balentine, DO is a member of the following medical societies: American College of Emergency Physicians, American College of Osteopathic Emergency Physicians, American College of Physician Executives, American Osteopathic Association, and New York Academy of Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Robert Harwood, MD, MPH, FACEP, FAAEM, Program Director, Department of Emergency Medicine, Advocate Christ Medical Center; Assistant Professor, Department of Emergency Medicine, University of Illinois at Chicago College of Medicine
Robert Harwood, MD, MPH, FACEP, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, Council of Emergency Medicine Residency Directors, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Jonathan Adler, MD, Attending Physician, Department of Emergency Medicine, Massachusetts General Hospital; Division of Emergency Medicine, Harvard Medical School
Jonathan Adler, MD is a member of the following medical societies: American Academy of Emergency Medicine and Society for Academic Emergency Medicine
Disclosure: eMedicine.com, Inc. Consulting fee Consulting

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