Section F - Personality disorders
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A personality disorder (PD) is characterized by a stable pattern of inner experience and behaviour that deviates significantly from the expectations of society, and can lead to marked impairments in social and occupational functioning. PDs are considered a major mental health problem because of their prevalence and the disability they produce.69 Ultimately, individuals with a PD have difficulties with interpersonal relationships, and often demonstrate irritability, hostility, and fearfulness. Their personality traits (i.e., attitudes, thoughts, behaviours, temperament) are expressed inappropriately and become maladaptive. According to the DSM-IV,7 there are ten PDs that are distinctively diagnosed and are grouped into three clusters based on descriptive similarities: Cluster A includes Paranoid, Schizoid, and Schizotypal PDs—individuals with these disorders likely appear odd or eccentric; Cluster B includes Antisocial, Borderline, Histrionic, and Narcissistic PDs—individuals with these PDs often appear dramatic, emotional or unpredictable; Cluster C includes Avoidant, Dependent, and Obsessive-Compulsive PDs—individuals with these disorders tend to appear anxious or fearful.7 The functional limitations associated with all personality disorders are similar in terms of attribute levels, therefore only one health state is described for an individual diagnosed with an unspecified personality disorder.
PDs affect between 6% and 15% of the population.125,126 The most common of the PDs are obsessive-compulsive (with a prevalence rate of 7.7% according to DSM-IV criteria), avoidant (6.6%), paranoid (5.6%), borderline (5.4%), and schizotypal (5.2%).126PDs typically become recognizable by adolescence or early adulthood, although some individuals may not seek clinical attention until much later. It is possible for a PD to become exacerbated after the loss of a significant supporting person or situation.7 The course of a PD is relatively stable over time.
The DSM-IV diagnoses a PD if an individual exhibits maladaptive behavioural and cognitive patterns which are evident in at least two of the following areas: cognition, affectivity, interpersonal functioning, or impulse control. In addition, the pattern must be pervasive and inflexible across a wide range of personal and social situations, and cause clinically significant distress in social, occupational, or other areas of functioning. Evidence of the PD must have been present in at least adolescence or early adulthood, with a stable pattern of long duration. The pattern cannot be due to another mental disorder, or due to the physiological effects of a substance or a general medical condition.7 Specific (types of) PDs require their own criteria, which are presented in the DSM-IV manual.7PD diagnoses apply only to the completely formed personality, thus, they are rarely made before age 18 and are therefore not usually assessed in children and adolescents.69
The causes of developing a PD are unknown. Researchers believe that a specific situation or event (e.g., loss of a parent or friend) can trigger the behaviours common in PDs, particularly events in early childhood that have the potential to influence behaviour in later life. A genetic vulnerability to developing a PD has also been suggested.127,128,129 Social factors, such as parental neglect, overprotection, or abuse may contribute to personality or other psychiatric problems in children. Because onset of PDs is usually in adolescence, a time when the personality stabilizes and matures, individuals with PDs are prone to developing maladaptive coping mechanisms and low self-esteem.127,128,129
Overall, there is no cure for a PD, but treatments are available to improve prognosis. Depending on the PD, pharmacological interventions can be targeted at reducing impulsivity (e.g., olanzapine, neuroleptics) and depression (e.g., serotonin reuptake inhibitors); antipsychotics may be used in cases of distorted thinking. Psychotherapy (individual, group, or family) is directed towards management of the disorder, including education about the illness, support, and social skills training. Psychotherapy, however, may be difficult for an individual with a PD because they may be reluctant to build a trusting relationship with the therapist. Character modification may be necessary to improve mood instability and impulsive behaviours, or for the individual to learn ways to cope with rejection and abandonment fears, self-destructive behaviours, or other traits associated with the particular PD being treated. Inpatient care is rarely required.
Due to the generally low rate of compliance with treatment, the following health state describes the functional limitations associated with an individual diagnosed with a PD who is not undergoing treatment.
Personality disorder – unspecified
ICD-9: 301.83 ICD-10 – Personality disorder F60.x
Individuals with a PD exhibit the whole spectrum of personality features that do not allow for adequate social functioning. Some tend to be extremely unstable emotionally - feelings range from intense and inappropriate anger, to feelings of guilt and shame and depression, to feelings of inadequacy and inferiority. Others may show impulsive behaviour, sexual promiscuity or reckless driving, and possibly suicide attempts, particularly at times of crisis (i.e., a change in job or relationships, a therapist's or family member's vacation). Mentally, individuals with a PD may have an unstable self image and identity confusion, or may be hypersensitive to rejection and feel hurt by criticism or disapproval. Interpersonal relationships are extremely unstable as well; attitudes towards family members or friends may suddenly shift from great admiration and love to disappointment, dislike and anger. A major characteristic of a PD is social withdrawal or rejection. Individuals with a PD tend to have an impaired capacity for attachment. Family life is often disrupted, and occupational and social functioning are limited. Anxiety is experienced. Occasionally, individuals with a PD may perform self-harmful behaviours.