INTRODUCTION	Section 2 of 9
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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 five basic dimensions: extraversion, agreeableness, conscientiousness, neuroticism, and openness to experience. This model is termed the five-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 five-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 five 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.

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

	CLINICAL	Section 3 of 9
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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

• 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

• 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.