Personality Disorders

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  • Personality disorders (PDs) are a group of conditions, with onset at or before adolescence, characterized by enduring patterns of maladaptive and dysfunctional behavior that deviates markedly from one’s culture and social environment, leading to functional impairment and distress to the individual, coworkers, and family.
    • These behaviors are perceived by patients to be “normal” and “right,” and they have little insight as to their ownership, responsibility, and abnormal nature of these behaviors.
    • These conditions are classified based on the predominant symptoms and their severity.
  • System(s) affected: nervous/psychiatric
  • Synonym(s): character disorder; character pathology

Geriatric Considerations
Coping with the stresses of aging is challenging.

Pediatric Considerations
A history of childhood neglect, abuse, and trauma is not uncommon.

Pregnancy Considerations
Pregnancy adds pressures in coping with the activities of daily living (ADLs).


  • General population: 15% (1)
  • Cluster A: 5.7%
  • Cluster B: 6.0%
  • Cluster C: 9.1%
  • Outpatient psychiatric clinic: 3–30%
  • In male prisoners, the prevalence of antisocial PD is ~60%.
  • Predominant age: starts in adolescence and early 20s and persists throughout patient’s life
  • Predominant sex: male = female; some PDs are more common in females, and others are more common in males.

Etiology and Pathophysiology

  • Environmental and genetic factors (2)
  • Criteria for a PD include an enduring pattern of the following:
    • Inner experience and behavior that deviates markedly from the expectations of one’s culture in ≥2 of the following areas: cognition, affectivity, interpersonal functioning, or impulse control
    • Inflexibility and pervasiveness across a broad range of personal and social situations
    • Significant distress or impairment in social or occupational functioning
    • The pattern is stable and of long duration.
    • The enduring pattern is not better explained as a manifestation of another psychiatric disorder.
    • The enduring pattern is not attributable to the effects of a drug or a medical condition.
  • PDs are classified into three major clusters:
    • Cluster A: eccentricity and oddness
      • Paranoid PD: unwarranted suspiciousness and distrust of others
      • Schizoid PD: emotional, cold, or detached; socially isolated
      • Schizotypal PD: eccentric behavior, odd belief system/perceptions, social isolation, and general suspiciousness
    • Cluster B: dramatic, emotional, or erratic behavioral patterns
      • Antisocial PD: aggressive, impulsive, irritable, irresponsible, dishonest, deceitful
      • Borderline PD: unstable interpersonal relationships, high impulsivity from early adulthood, intense fear of abandonment, mood swings, poor self-esteem, chronic boredom, and feelings of inner emptiness
      • Histrionic PD: needs to be the center of attention, with self-dramatizing behaviors and attention seeking in a variety of contexts
      • Narcissistic PD: grandiose sense of self-importance and preoccupation with fantasies of success, power, brilliance, beauty, or ideal love; lack of empathy for other people’s pain or discomfort, demanding to get their way
    • Cluster C: anxiety, excessive worry, fear, and unhealthy patterns of coping with emotions
      • Avoidant PD: social inhibition, feelings of inadequacy, hypersensitivity to negative evaluation, avoidance of occupational and interpersonal activities that involve the risk of criticism by others, views self as socially inept and personally unappealing or inferior to others
      • Dependent PD: excessive need to be taken care of, leading to submissive and clinging behavior with fears of separation, avoids expressing disagreements with others due to fear of losing support and approval, usually seeks out strong and confident people as friends or spouses and feels more secure in such relationships
      • Obsessive-compulsive PD: preoccupation with cleanliness, orderliness, perfectionism; preoccupation with excessive details, rules, lists, order, organization, and schedules to the extent that the major point of the activity is lost
    • Personality change due to another medical condition. It is a persistent personality disturbance that is caused by the physiologic effects of a medical condition such as frontal lobe lesion, epilepsy, MS, Parkinson disease, lupus, head trauma, postencephalitis or meningitis, and so forth.
    • Other specified PD and unspecified PD: A category provided for two situations: (i) the individual’s personality pattern meets the general criteria for PD and traits of several PDs are present, but the criteria for any specific PD are not met; (ii) the individual’s personality pattern meets the general criteria for PD, but the individual is considered to have a PD that is not included in DSM-5 classification such as passive–aggressive PD, depressive PD, masochistic PD, and dangerous and severe PD.

Major character traits are inherited; others result from a combination of genetics and environment.

Risk Factors

  • Positive family history
  • Pregnancy risk factors
    • Nutritional deprivation
    • Use of alcohol or drugs
    • Viral and bacterial infections
  • Dysfunctional family with child abuse/neglect

Commonly Associated Conditions

Depression; other psychiatric disorders in patient and family members

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