Personality Disorders Clinical Presentation

Updated: Feb 15, 2016
  • Author: David Bienenfeld, MD; Chief Editor: Iqbal Ahmed, MBBS, FRCPsych(UK)  more...
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In general, patients with personality disorders have wide-ranging problems in social relationships and mood regulation that usually been present throughout adult life. In these patients, patterns of perception, thought, and response are fixed and inflexible, although the behavior of these patients is often unpredictable. Moreover, these patterns markedly deviate from the expectations of the patient’s culture.

To meet the DSM-5 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 will occur in all settings (eg, social as well as vocational) and will not be limited to 1 sphere of activity. [1, 11]

Cluster A (odd, eccentric)

Paranoid personality disorder

Individuals with this disorder display pervasive distrust and suspiciousness, with a tendency to attribute malevolent motives to others, to be preoccupied with unjustified doubts, and to persistently bear grudges. 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
  • Attacks are being made on the person’s character or reputation that are not apparent to others
  • The person’s 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, choosing solitary activities. The person's life is marked by little pleasure in activities and little interest in sexual relations. 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 - 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. Although the formal diagnosis of antisocial personality disorder is made only after one is aged at least 18 years, the following features must start to be exhibited by age 15 years or earlier:

  • 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. 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, and reckless driving
  • Recurrent suicidal behaviors or threats or self-mutilation
  • Affective instability
  • Chronic feelings of emptiness
  • Inappropriate and intense anger
  • Transient paranoia or dissociation

Borderline personality disorder is, however, one of the most commonly overused diagnoses in DSM-5.

Histrionic personality disorder

Major traits of this condition 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 personality disorder

Narcissistic patients are grandiose and require admiration from others. [12] Particular features of the disorder include the following:

  • Exaggeration of their own talents or accomplishments
  • Preoccupation with fantasies of success, beauty, and love
  • 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.

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 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 display the following traits:

  • Preoccupation with orderliness, perfectionism, and control; however, such preoccupations interfere with efficiency, despite the individual’s focus on a task
  • Lack of flexibility or openness
  • Reluctance to delegate tasks
  • An excessive devotion to work, with the exclusion of leisure activity
  • Often, scrupulousness and inflexibility with regard to matters of morality, ethics, and values to a point beyond cultural norms
  • In many cases, stinginess and stubbornness

Other personality disorders not otherwise specified

These are disorders of personality functioning that do not meet the criteria for any specific personality disorder. Major traits include the following:

  • Features of more than 1 disorder present without meeting full criteria impairment in 1 or more areas of functioning
  • Specific disorder that is not included in classification
  • Passive-aggressive or depressive disorders

Physical Examination

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

Patients (particularly those with cluster B disorders) may show signs of prior suicide attempts, such as scars from self-inflicted wounds, or stigmata from alcoholism or drug abuse.

In emergent care settings, the examination should include the following:

  • Evaluation of airway, breathing, and circulation - Usually, no overt intervention is required
  • Assessment of vital signs
  • Keen observance for evidence of overdose, suicide attempt, or injuries
  • Frequent reexamination

Mental status findings

Few relevant mental status findings are obtained through direct questioning of the patient; they are instead gathered through careful observation of the patient while the clinician is eliciting the history.

Thought process is generally normal in persons with personality disorders, and 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.

Mental status findings include the following:

  • Histrionic personality disorder - Patients with histrionic personality disorder may display la belle indifference, a seemingly indifferent detachment, while describing dramatic physical symptoms
  • Antisocial personality disorder - A hostile attitude is typical of patients with this disorder; in some instances, they may become homicidal
  • Borderline personality disorder - Patients with cluster B personality disorders, particularly borderline personality disorder, frequently display affective lability, making suicide risk high; hallucinations are rare, but patients with borderline personality may experience dissociative phenomena as if they are hallucinatory
  • Paranoid personality disorder - Patients with this disorder voice persecutory ideation without the formal thought disorder observed in schizophrenia; the examiner should investigate thoughts of harm to the perceived persecutor(s)
  • Schizotypal personality disorder - Patients with schizotypal personality disorder speak with odd or idiosyncratic use of language