Personality Disorders (PDs)

(Enduring patterns of inner experience/behavior that deviate from cultural norms, leading to distress/impairment)

DSM-5-TR Classification (3 Clusters)

Cluster A (Odd/Eccentric)

  1. Paranoid PD
    • Pervasive distrust/suspicion of others
    • Interprets benign remarks as threats
  2. Schizoid PD
    • Detachment from social relationships
    • Restricted emotional expression
  3. Schizotypal PD
    • Cognitive/perceptual distortions
    • Eccentric behavior + social anxiety

Shared Features: Genetic link to schizophrenia spectrum disorders

Cluster B (Dramatic/Erratic)

  1. Antisocial PD
    • Disregard for others’ rights (conduct disorder before age 15)
    • Lack remorse (≠ psychopathy, which includes affective deficits)
  2. Borderline PD
    • Frantic efforts to avoid abandonment
    • Unstable relationships, self-image, affect
    • Impulsivity + recurrent self-harm
  3. Histrionic PD
    • Excessive emotionality/attention-seeking
    • Theatrical, rapidly shifting emotions
  4. Narcissistic PD
    • Grandiosity, need for admiration
    • Lack empathy (vulnerable vs. grandiose subtypes)

Key Risk: High suicidality in BPD; ASPD more common in males

Cluster C (Anxious/Fearful)

  1. Avoidant PD
    • Social inhibition + hypersensitivity to criticism
    • Desires relationships but fears rejection
  2. Dependent PD
    • Excessive need to be cared for
    • Submissive/clinging behavior
  3. Obsessive-Compulsive PD
    • Preoccupation with orderliness/perfectionism
    • Rigid control (≠ OCD: no true obsessions/compulsions)

Treatment Note: Often co-occurs with anxiety disorders

Emerging Concepts

  • Alternative DSM-5 Model (Section III):
    Focuses on impairments in personality functioning (self/others) + pathological traits (e.g., detachment, antagonism)
  • Dimensional Approach:
    Rates severity (mild to extreme) rather than categorical diagnosis

Etiology

✔ Biological:

  • Genetic loading (heritability ~40-60%)
  • Neurochemical differences (e.g., low serotonin in BPD/ASPD)
  • Limbic system hyperactivity (BPD emotional dysregulation)

✔ Environmental:

  • Childhood trauma (especially BPD: 70% report abuse/neglect)
  • Invalidating environments (BPD)
  • Early institutionalization (Cluster A/C)

Assessment Tools

  • Structured Clinical Interviews:
    • SCID-5-PD (gold standard)
    • PID-5 (for DSM-5 alternative model)
  • Self-Report:
    • Personality Assessment Inventory (PAI)
    • Millon Clinical Multiaxial Inventory (MCMI)

Differential Dx:

  • Mood disorders (borderline vs. bipolar)
  • Autism spectrum (schizoid vs. ASD)
  • PTSD (complex trauma mimics PD traits)

Treatment Approaches

1. Psychotherapy (Mainstay)

  • Dialectical Behavior Therapy (DBT): BPD (emotion regulation skills)
  • Mentalization-Based Therapy (MBT): BPD (understanding mental states)
  • Transference-Focused Psychotherapy (TFP): NPD/BPD (object relations)
  • Schema Therapy: All PDs (addresses maladaptive life patterns)

2. Pharmacotherapy (Symptom-Targeted)

  • BPD: SSRIs (affective instability), mood stabilizers (impulsivity)
  • Schizotypal: Low-dose antipsychotics (psychotic-like symptoms)
  • Avoidant: SSRIs (social anxiety)

3. Hospitalization:

  • Brief crises (BPD self-harm)
  • Never treat PDs alone in inpatient settings (risk of regression)

Prognostic Considerations

  • Most improve with age (except ASPD)
  • BPD: 50% achieve remission by 10-year follow-up
  • Best outcomes: Early intervention + structured therapies

Clinical Pearls

  • Axis I Comorbidity: 80% of BPD patients have co-occurring mood disorder
  • Countertransference: Common (e.g., frustration with dependent PD, awe with narcissistic PD)
  • Cultural Factors: Some traits may be adaptive in specific contexts

Resource: National Education Alliance for BPD