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DSM5577 - SECTION 16: ADDRESSING THE COMPLEXITIES - PERSONALITY DISORDERS

Section XVI: Addressing the Complexities – Personality Disorders

Personality Disorders are pervasive, inflexible and enduring patterns of behavior and inner sense of self that deviate greatly from an individual’s cultural expectations.  All personality disorders can be traced back at least to early adolescence or young adulthood.  Any person diagnosed with a personality disorder will show a great deal of impairment and/or distress in social, occupational and every significant area of functioning.  All these patterns are very stable and last a long time, and cannot be related to any medical condition. The personality patterns must be pervasive and inflexible in two or more of the following patterns:

The DSM 5 lists 10 specific personality disorders.  They are grouped into three categories called clusters.  Each cluster is grouped around specific behavior or interactive typologies.

Cluster A includes persons who present as odd or eccentric in their lifestyle and/or interactions with others.  These three personality disorders are paranoid, schizoid and schizotypal.

Cluster B personality disorders are used to describe persons who are dramatic, erratic or emotional in their interactions and behavior.  The four cluster B disorders are antisocial, borderline, histrionic and narcissistic.

Cluster C includes the three personality disorders that describe persons who show consistent anxious or fearful traits.

The 10 personality disorders with ICD-10 codes (listed by clusters) are as follows:

 

Cluster A

Cluster B

 

Cluster C

 

Personality Change Due to Another Medical Condition        F07.0

The diagnosis of any of the 10 personality disorders is in addition to a person’s mental health or substance use diagnosis.  Personality disorders can begin to emerge based on developmental, traumatic and detrimental life experiences in childhood or adolescence. An isolated traumatic experience or any combination of traumatic events may lay the foundation for a personality disorder but does not guarantee an automatic personality disorder.

The cluster A personality disorders are marked by eccentric and/or odd behaviors. Paranoid personality disorders are marked by suspiciousness and distrust.  Four or more of the following traits must be present:

Persons with paranoid personality disorders are very difficult to get along with as they are suspicious of everyone’s motives.  They can be aloof or argumentative, all in the service of keeping other persons at a distance. 

Schizoid personality disorder presents with a restricted emotional range and consistent detachment from others.  Four or more of the following must be present:

Schizotypal personality disorder is listed with schizophrenia spectrum disorders due to marked interpersonal deficits in social interactions that result in cognitive and perceptual distortions and strange behaviors. These persons are extremely uncomfortable in relating to other people. The pattern is fully developed by early adulthood and is manifested by five or more of the following:

Persons diagnosed with an Antisocial personality disorder show a prevalent pattern of total disregard for the rights of others. They violate the rights of others consistently and the pattern starts around age 15. The following behaviors are consistent with antisocial personality disorder:

Deceit and manipulation are central components of antisocial personality disorder so a thorough assessment and review of the individual’s history from collaborative resources, in addition to treatment history, is necessary for an accurate diagnosis.  Psychopathy and sociopathy are additional terms used to describe this personality disorder.  No empathy, a total disregard for the rights of others, and putting their needs/wants first with cynicism and a self-inflated sense of self are the primary characteristics of avoidant personality disorder.

Borderline personality disorder is a diagnosis that can bring chills to the spine of the clinician.  An absolute fear of abandonment or the creation of situation where the significant other will abandon the person living with borderline personality disorder is a core characteristic. There is a consistent pattern of emotional volatility, unstable relationships, poor self-image and excessive impulsivity.  To receive this diagnosis, an individual must show five of the nine patterns consistently, starting in early adulthood.  These patterns are:

Histrionic personality disorder will show extreme emotionality and attention seeking behavior.  It will begin in early adulthood and exhibit five of the following:

Persons with a histrionic personality disorder must be the center of attention.  They are often flamboyant and sexually provocative, they are energetic and dramatic and often seductive.  This disorder may limit a person’s ability to form lasting, intimate relationships.  Suicidal gestures and threats may be another way of being the center of attention.

Narcissistic personality disorder is marked by a constant need for attention and lack of concern or interest in others.  A tremendous sense of self-importance and consistent amplification of successes, talents and abilities have persons with narcissistic personality disorder presenting as boastful, ostentatious and showy at the expense of everyone else. Five or more of the following must be present for this diagnosis.

Persons with this disorder require constant attention, and excessive admiration.  No one equals their ‘specialness’ or ‘uniqueness’ and they regularly compare themselves to famous people.  They have no understanding, comprehension or

Persons diagnosed with a cluster C personality disorders consistently appear anxious or fearful when interacting with others. 

Avoidant personality disorder diagnosis is given when a person shows a hypersensitivity to negative evaluation, intense social hesitancy and consistently inadequate feelings.  Four of the following must be noted.

Dependent personality disorder shows a pervasive need to be cared for by others with submissive and clinging behaviors in all interpersonal relationships.  Five or more of the following are needed for this diagnosis.

Obsessive-compulsive personality disorder manifests in a severe and persistent need for order and perfection in all interactions and activities.  Four or more of the following must be present for this diagnosis.

Personality change due to another medical condition is used when a personality

Disturbance is evident but not pervasive enough to meet the criteria for any of the 10 personality disorders previously defined.

There are seven specifiers to use to document any personality change due to a medical condition.  They are:

To summarize personality disorders, remember that these behavior patterns are pervasive, consistent and evident in all areas of the individual’s life, work and interpersonal relationships (to the level that they can interact comfortably and confidently with others.  All personality disorder characteristics begin to manifest in late adolescence and are set by early adulthood.  Cultural patterns and practices must not be confused with personality disorders.  Any possible medical condition must be ruled out before diagnosing any of the ten accepted personality disorders. 

 

Personality Disorder Not Otherwise Specified

This category is used when Personality Disorder criteria are partially met under several Disorder categories, but do not meet full criteria for any one Personality Disorder.

Criteria must create clinically significant distress for the individual in at least one important area of functioning (work, social, etc.).

 

Differential Diagnoses

Because personality disorders can present with such a variety of extreme and severe symptoms, it is often difficult to distinguish between certain personality disorders and certain serious thought disorders. This section will provide some key information about how to distinguish between personality disorders and thought disorders, as well as guidelines for distinguishing between different kinds of personality disorders.

 

Paranoid Personality Disorder (PD) versus Schizophrenia 

Paranoid personality disorders are distinguished from Schizophrenia in that Schizophrenia is characterized by a period of persistent psychotic symptoms (delusions / hallucinations). Paranoid personality disorders present with longer term suspiciousness without the presence of clear delusional or hallucinogenic breakthroughs. 

 

Schizoid versus Schizotypal Personality Disorder (PD)

Schizoid PD is differentiated from Schizotypal PD by the lack of perceptual and cognitive distortions. Schizoid PD is differentiated from Paranoid PD by lack of suspicion and paranoia. Although they share social isolation as a symptom, Schizoid PD is different from Avoidant PD in that social isolation in Avoidant PD is due to fear of embarrassment or rejection. Schizoid PD includes social isolation due to detachment and lack of desire for social intimacy.

 

Borderline PD versus Dependent PD

Borderline PD differs from Dependent PD primarily in the reaction to abandonment. An individual with Borderline PD reacts to rejection and abandonment with rage, demands, and emotional emptiness. An individual with Dependent PD, on the other hand, reacts with greater submissiveness, and seeks to immediately replace the relationship with another in order to gain further support and care-giving. The fear of loss and abandonment outweighs the anger at rejection.

In addition, a person with Borderline PD has a typical pattern of intense, unstable relationships. Patients with Dependent PD, on the other hand, will frequently be engaged in somewhat more stable - albeit still dysfunctional - relationships over extended periods of time.

 

Borderline PD versus Histrionic PD

Histrionic PD and Borderline PD are different in that Borderline PD includes more immediately visible self-destructive behaviors, angry disruptions in intimate relationships, feelings of extreme emptiness and identity disturbance.

 

Histrionic PD versus Dependent PD

Histrionic PD is distinguished from Dependent PD in that while they both include dependence upon others for praise; Histrionic PD also includes exaggerated and dramatic emotionality. Patients with Dependent PD are more likely to suffer in silence, fearing the abandonment that will follow dramatic emotional expressions of need.

 

Obsessive-Compulsive PD versus Obsessive-Compulsive Disorder

Obsessive-Compulsive Disorder differs from Obsessive-Compulsive Personality Disorder in that an individual with Obsessive-Compulsive Disorder has true obsessions and compulsions, especially when hoarding is extreme. 

The etiology of OCD is not fully understood, but the basis appears to be related to predisposing factors combined with the presence of environmental stresses. The patient with OCD may be more inclined to view his or her symptoms as ego-dystonic. The patient with OCD is therefore more likely to experience the symptoms as occurring as a war with the self, in which the intruding symptoms feel somewhat foreign or alien to the personality structure of the individual involved. 

Obsessive-Compulsive Personality Disorder, on the other hand, typically shows less acute symptomatology, but with the signs and symptoms more fully integrated into the personality structure of the individual. The presentation of the obsessive and compulsive features are therefore typically more ego-syntonic for the OCPD, and wrapped up somewhat in the person's overall sense of self. 

Sometimes, criteria for both OCD and OCPD are met, and both should be recorded.

 

Key Knowledge Point to Follow: 

Differential Diagnosis Schizophrenia, Schizophreniform, and Schizoaffective Disorders are psychotic disorders. The array of problems will have a basis in some form of neurochemical dysfunction.

Schizoid and Schizotypal Disorders are personality disorders. The suspiciousness and inappropriate affect/behavior will have a basis in poor personality organization, usually due to some combination of pre-disposing personality fragility and environmental/family stresses experienced during early developmental periods.

 

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