Jama 1994;272:1770

Cause:Genetic vulnerability and life experiences

Pathophys:Pervasive lifelong character styles not viewed as pathological by patient (except in obsessive-compulsive personality d/o), unlike neurotic sx, which are. Some pts have less extreme pathology of axis I disorders, eg, schizophrenia, manic-depressive disorders, etc.

Prevalence 6-10% of general population, ~50% of psych hospital pts

Sx:
Odd/eccentrics cluster: paranoid, schizoid, and schizotypal types

Dramatic/emotional/erratic cluster: antisocial, borderline, histrionic, and narcissistic types

Anxious/fearful cluster: avoidant, dependent, ob/compulsive types

Si:Functional impairments in relationships, education, and occupational pursuits

Onset in adolescence, impairment in early to mid adulthood

r/o active axis I disorders, neurosis (pt can identify problem and complains about it), and chemical dependency chronic or in early recovery

Lab:Organic w/u if enduring shifts in personality later in life

Rx:

Psychotherapy is the core of treatment for personality disorders. Psychodynamic, CBT and DBT approaches all have some evidence of efficacy (Am J Psych 2003;160:1223)

Time-limited benzodiazepines for anxiety

of self-sacrifice (dependent, passive-aggressive, and depressive types): Listen to sx and anticipate pts’ ambivalence re improvement

of manipulative/antisocial types: Firm limits; if impulsive, lithium or carbamazepine may assist

of dependency and demanding type (dependent and borderline types): Empathic recognition of pts’ need for reassurance and anxiety about being alone; plus limit-setting consistency, clarity, and structure, referral to experienced psychotherapist; for borderline PD, meds like olanzapine, fluoxetine, or divalproate (APA Practice Guideline 2005)

of obsessive-compulsiveness: Respect need for control by providing information, eg, test results asap, plus engaging pts in rx plan; meds: SSRIs or clomipramine not effective, unlike in OCD

of dramatization (histrionic type): Disallow inappropriate familiarity w a respectful, professional manner without shortening time w pt

of self-importance (narcissistic type): Nondefensive acceptance of earlier consultation and referral

of detachment and paranoia (schizoid, schizotypal, avoidant types): Allow privacy, consider antipsychotic