section name header

Information

Editors

AkiRovasalo

Personality Disorders

Essentials

  • Psychiatric treatment is usually sought in a crisis or due to some other mental disorder, such as depression or substance abuse.
  • The possibility of a personality disorder should be kept in mind if the person treating the patient notices that the patient arouses emotional responses differing from their normal responses, any very strong negative or positive emotions, or if the patient makes the treating person deviate from their routines in the therapeutic relationship.
  • Disorders are classified according to the predominant behaviour patterns.
  • Personality disorders affect the prognosis of both psychiatric and somatic diseases because they typically affect treatment compliance.
  • Treatment is always voluntary and requires motivation from the patient.

Characteristics

  • Personality disorders appear in adolescence or no later than early adulthood in the person's thoughts, emotions and behaviour, affecting these comprehensively and repeatedly, if not constantly.
    • The disorders appear and affect every sector of life: home, hobbies and work.
  • The causes include genetic, interactional and biological factors.
  • The line between personality disorder and behaviour that is considered normal is indistinct.
    • In adolescence in particular, there may be emotionally labile phases. These typically pass within a few months with adolescent development.
  • For differential diagnosis, it should be determined whether the patient has a personality disorder or a personality change. Personality changes are often caused by external factors (dementia, sequela of brain injury, long-term intoxicant abuse).

Diagnosis

  • The diagnosis should be based on as many sources of information as possible (such as the next of kin) and on comprehensive assessment of psychological function.
  • Semi-structured interviews (such as the SCID II interview based on the American DSM-5 classification of disorders) are often used to help with the diagnosis. SCID II differs to some extent from the official ICD-10 classification of disorders.
  • DSM-5 classifies personality disorders into three clusters (respective terms used in ICD-10 indicated in [brackets]).
    • Cluster A (paranoid, introverted (schizoid), with psychotic features, or schizotypal personality): The behaviour is typically odd or eccentric.
    • Cluster B (antisocial [dissocial], borderline [emotionally unstable], histrionic, narcissistic): The behaviour is guided by emotional lability or impulsivity.
    • Cluster C (avoidant [anxious], dependent, obsessive-compulsive [anancastic]): Function is restricted by anxiety and fear. Working ability is often better than in the other clusters.
  • The fact that any patient usually has features of several personality disorders or what is called a mixed disorder presents a diagnostic problem. To present this in a slightly pointed way, everyone has different personality features to a greater or lesser extent but pure, extreme states are rare.
  • The diagnostic system is currently being developed so that instead of individual personality disorders, or in addition to these, the person's functional ability and various personality features would be assessed.

Types of disorder

Paranoid personality (F60.0)

  • Pervasive suspicion of other people or their motives
  • Due to suspicion, the person is unwilling to confide in others and may interpret even innocent remarks or events as threatening to themselves.
  • Difficulty forgiving, recurrent, unjustified suspicion that their partner is unfaithful
  • In contrast to what is called delusional disorder Psychosis in the Elderly, the person's thinking shows a sense of reality even though suspicion is emphasized, recurrent and inappropriate.

Schizoid (introverted) personality (F60.1)

  • Extensive withdrawal from interpersonal relationships and restricted emotional expression
  • No need for intimacy and no seeking of pleasure from external sources. In this sense, the disorder is close to what are called attachment disorders.
  • Often bizarre looks or dressing, suspicious and socially isolated, sometimes a “hermit/drop-out” who removes themselves from society.
  • It is difficult or sometimes impossible to distinguish between schizoid personality and mild autism spectrum disorders Autism Spectrum Disorder. In more severe autism spectrum disorders, the patient's social engagement is even worse and there is stereotypical behaviour and a restricted range of interests.

Schizotypal personality (F21)

  • This is a personality disorder or similar state with some genetic association with schizophrenia that still does not represent schizophrenia or even the state of being psychotic.
  • The clinical picture involves experiences and beliefs typical for schizophrenia without representing a psychosis. The key word is “odd”; the person's thinking and beliefs are hard to follow, their behaviour difficult to understand.
  • The person may feel that other people's gestures refer to them (ideas of reference), they may be very superstitious and believe in, for example, clairvoyance or other magical thinking. They may have unusual perceptual experiences or experiences of depersonalization or derealization.
  • Their looks are often bizarre or they dress strangely. Cultural differences alone do not justify diagnosis.

Dissocial (antisocial) personality (F60.2)

  • Antisocial Personality Disorder
  • Begins with conduct disorder already before the age of 15 years.
  • There is disregard for other people's rights, and inability or unwillingness to take other people into consideration.
  • The person will not shun risks, is impulsive, deceitful and easily irritated, repeatedly guilty of misdemeanour, with no repent.
  • Dissocial people often have what are called psychopathic features (being unemotional, with little empathy, self-centred, superficially attractive and slick, showing no remorse, shame or feelings of guilt, and using other people). Such people are normally diagnosed with “dissocial personality with psychopathic features”.

Emotionally unstable personality (F60.3)

  • Personality Disorders
  • Pervasive instability of moods and self-image and significantly impulsive behaviour
  • Interpersonal relationships are intensive and unstable, varying from strong admiration to complete disparagement.
  • These people are typically afraid of being rejected, easily irritated, find it difficult to control their anger, show self-destructive impulsivity and repeated suicide attempts.
  • Their identity is chronically confused or unruly. The border between self and other fluctuates even though the person is not psychotic.
  • In contrast with bipolar disorder Bipolar Disorder, emotional instability is quicker to change, more zigzagging and often reactive, whereas in bipolar disorder fluctuation is slower. The same person may of course have both disorders at the same time.

Histrionic personality (F60.4)

  • Dramatic or theatrical emotional expression and attention-seeking are emphasized.
  • Emphasizing looks, and situationally inappropriate sexually seductive behaviour are typical.
  • The person often experiences their interpersonal relationships as more intimate than they actually are, and they can be easily guided by other people.

Anancastic personality (F60.5)

  • Perfectionism and obsessive-compulsive symptoms
  • Typical features include suspicion, excessive conscientiousness and attention to detail, carefulness, stubbornness, cautiousness, stiffness and lack of openness. Such features may be useful in certain academic professions, for example, but, on the other hand, they cause recurrent conflicts in families and at work.
  • Seeking order and perfection, the person appears stiff, closed and ineffective. They are overly conscientious and inflexible in moral matters. Details, rules and schedules are important for them.
  • Nevertheless, the symptom entity is milder than in actual obsessive-compulsive disorder Obsessive-Compulsive Disorder (Ocd).

Anxious (avoidant) personality (F60.6)

  • Very inhibited in interpersonal relationships, reserved in social situations, suffers from constant feelings of inadequacy, and is overly sensitive to negative criticism directed at them.
  • The symptom entity is very close to what is called social phobia Anxiety Disorder but milder and appears in various sectors of life.

Dependent personality (F60.7)

  • Appears as an excessive need for others to take care of them, leading to submissive and clinging behaviour, avoidance of social conflicts and a strong fear of separation.
  • When alone, they feel helpless, and if an intimate relationship ends, they try to rapidly find another relationship providing care and support.
  • The disorder begins in adolescence or early adulthood. If submissive behaviour begins later in consequence of domestic violence, for instance, the symptoms may rather be post-traumatic Acute Stress Reaction and Post-Traumatic Stress Disorder.

Other personality disorders (F60.8)

  • Narcissistic personality
    • Different types of grandiosity, a strong need for admiration and lack of empathy are typical. Seeking positions of power helps to cover feeling basically very helpless.
    • The person feels entitled to special treatment, is envious or arrogant and can use other people without scruples. Being “ordinary” does not feel sufficiently safe.
  • Immature personality
  • Passive-aggressive personality
  • Psychoneurotic personality

Treatment

  • In most personality disorders, it is not necessary to assess the need for treatment in specialized care.
  • A psychiatrist should be consulted during treatment in primary health care.
  • Patients often fail to recognize the disorder and see no need for treatment.
  • A confidential treatment relationship with clear and safe limits is needed.
  • The personality disorder and the resulting problems are often alleviated with age.
  • In severe personality disorders, any concomitant substance abuse problem will worsen the prognosis significantly.

Psychotherapy

  • If the person suffers from the way they typically experience things or from their typical behaviour, they may well benefit from psychotherapy. There are many different psychotherapeutic methods available. In most cases, the personality disorder cannot be cured but the symptoms and harmful behaviour can be alleviated if the patient commits to treatment and treatment is provided professionally.
    • The aim of brief supportive psychotherapy is usually to solve the current emotional crisis and to restore the person's feeling of security and their ordinary functional ability.
    • The purpose of more long-term psychotherapy is to support empathy towards both themselves and other people and to learn to recognize and manage in a new way the emotional memories underlying the rigid behaviours.

Pharmacotherapy

  • To put it a bit bluntly, experiments with medication are often just shots in the dark and must be assessed critically. Medication should be targeted according to the symptoms and any other disorders.
  • Antipsychotic drugs, antidepressants or certain antiepileptics can be used, particularly if other concomitant psychiatric disorders cause symptoms affecting daily life.
  • Benzodiazepines should basically be avoided because they cause paradoxical reactions and increase impulsivity in many patients with personality disorders.

    References

    • Sinkkonen J. [The many faces of psychopathy]. Duodecim Publishing Company 2021. Available in Finnish.
    • Koivisto M, Korkeila J, Stenberg J, Taiminen T. [Borderline personality]. Duodecim Publishing Company 2020. Available in Finnish.
    • [Borderline personality]. A Current Care Guideline. Working group appointed by the Finnish Medical Society Duodecim, and the Finnish Psychiatric Association. Helsinki: the Finnish Medical Society Duodecim, 2020 (accessed 29 November 2023). Available in Finnish at http://www.kaypahoito.fi/hoi50064/.