Personality disorder

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Ayesha Anwar, M.B.B.S[2]

Personality Change Due to Another Medical Condition

Personality changes are also associated with other medical conditions, such as frontal lobe lesions. The lesions (tumors, abscess, granuloma, or cystic lesion) present with changes in personality. Substance use disorders like marijuana, alcohol, amphetamine or cannibis) also manifest personality changes. Old patients in hospitals or home may develop delirium and exhibit personality changes. Other conditions associated with personality changes include:

1. Endocrine disorders like hypothyroidism.
2. Long-term steroid use OR hypercortisolism.
3. Familial disorder like Huntington disease.
4. Automimmune disorders involving central nervous system like Systemic lupus erythematosus (SLE).
5. CNS infections like Meningoencephalitis.
6. Autoimmune immunodeficiency syndrome (AIDS) or HIV.
7. Traumatic brain injuries like chronic sub-dural hematoma.

Diagnosis

Diagnostic Criteria

The diagnosis of personality disorder is intricate as most patients present with symptoms related to depression and anxiety, and many times, two or more personality disorders co-exist. Also, an overlap in certain personality characteristics among different personality disorders. Therefore, the diagnosis of a personality disorder requires a specific criterion after a complete evaluation of cognitive, behavioral, interpersonal, and social features in an individual.

• In DSM-5, the following criteria must be met:
  • A persistent and enduring pattern of behavior and traits that do not comply with one's culture involving  2 of the following: cognition (ways of perceiving and interpreting self, others, or events), affectivity (degree or range of a person's emotional response), interpersonal functioning and impulse control.
  • This maladaptive pattern causes significant distress and impaired responses in social, occupational, and other areas.
  • The onset is in early adolescence or early adulthood, and hence, the duration of symptoms is long.
  • The symptoms should be present for greater than one year if age is less than 18 years, and for antisocial PD, age should be greater than 18 years.
  • The symptomatology cannot be explained with any other psychological or neurological abnormality, and substance abuse disorders have been ruled out.
• In ICD-10, World Health Organization (WHO) lists the following criteria:
  • The deeply engrained and enduring pattern of behavioral tendencies in various aspects of personality, including affectivity, impulse control, arousal, perception and thinking, and style of relating to others, producing personal and social disruption.
  • The PDs may co-exist with other mental disorders; however, the behavior is continuous and not limited to episodes of mental illness.
  • The inflexible attitude started in adolescence or early adulthood and diagnosed later in life.
  • It is of long duration and follows a stable course.
  • The symptoms are responsible for considerable personal distress and significant social impairment.

At least 3 of these criteria must be met, and ICD-10 adds that 'for different cultures, it may be necessary to develop specific sets of criteria with regards to social norms, rules, and obligations.'

History and Symptoms

History constitutes the first step in assessing for the personality disorder in any individual. An age of 18 years for a patient is essential in the diagnosis of personality disorders. Duration of symptoms is also critical. Details of education, employment, and personal and social relationships give an insight into interpersonal functioning. Conducting a clinical interview also helps in providing a comprehensive understanding of self-identity issues if present. Family history and history of substance abuse can provide a valuable contribution in assessment for diagnosis. Such patients usually present with symptoms like frequent mood swings, anger outbursts, unstable self-image, waning social relationships, suspiciousness towards others, over-emotionality, in-sensitivity and irresponsibility towards self and others, and inconsistency in goals. They are usually ignorant towards their own behavior and have ego-syntonic symptoms. All these symptoms need to present in more than one setting.

Physical Examination

There are no specific physical signs associated with personality disorders. The physical exam is essential to rule out organic disorders and substance use disorders. Depression and anxiety need to be ruled out by conducting their assessment tools. Patients with borderline personality disorders have an increased risk of suicide, and they may have self-inflicted wounds on the body or signs of attempted suicide attempts. A complete mental status examination needs to be conducted. The first is to examine appearance and behavior. Borderline personality disorder patients may exhibit defensive behavior. Those with a paranoid personality disorder will fail to maintain eye contact. The second is mood and affect; borderline personality disorder may reveal fleeting mood and emotional states with different questions or scenarios. This is also vital to assess suicide risk in the patient. Antisocial personality disorders may be homicidal and display a hostile attitude. Cognitive functions like attention, memory, orientation, language, and intelligence are normal. Mini-mental state examination (MMSE) can be conducted for this. Histrionic PD may manifest a ‘la belle indifference,’ meaning showing an apparent lack of concern regarding their own symptoms. Perception is normal though. Moreover, the thought process is usually unremarkable. It is imperative in paranoid personality disorder to ascertain that no thoughts of harm to others are present. However, insight and judgment may be affected depending on different scenarios in patients with variable personality disorders.

Laboratory Findings

These investigations are carried out to rule out other diagnosis. No definite abnormalities are associated with PDs. The laboratory tests conducted comprises:

1. Vitamin B12, Vitamin D and ferritin levels.
2. Thyroid function tests, fasting glucose and cortisol levels.
3. Toxicology screen is done to differentiate substance abuse disorder from PD and also, as substance abuse is common with PSs.
4. Sexually Transmitted disease screening is required. HIV patients may also present with personality changes. Moreover, PD patients have impulse control disorder and may get introduced with such infections.

Imaging

Computed Tomography scan (CT scan) and Magnetic resonance imaging (MRI) are essential to rule out organic neurological causes of the presenting symptomatology. The changes observed in borderline PD are found in hypothalamus and limbic system, if the childhood trauma was the triggering event for the disorder. Impulsivity in PD is associated with changes in frontal structures and aggression with changes in hippocampal and frontal structures . Electroencephalographic (EEG) changes are observed in BPD, however, they are not diagnostic. A recent study conducted by Shankar et al, demonstrated the presence of sharp and spike waves in severe BPD and nonspecific slowing waves in mild and moderate form of BPD .

Assessment tools

Following assessment tools are considered:

• Suicide risk screening tool
• Minnesota Multiphasic Personality Inventory–II
• Standardised assessment of personality abbreviated scale
• Million clinical multiaxial inventory-III
• International Personality Disorder Examination
• Structured clinical interview for DSM-IV and axis II PDs

Treatment

PD affects all aspects of individual life and causes interference with psychological and behavioral growth. It causes emotional distress and social impairment. It affects the quality of life grimly and has dire consequences on life years. Early recognition is crucial to start appropriate management and prevent complications from this debilitating condition. Management of PDs lacks evidence-based guidelines, and health authorities across the world have formulated their independent guidelines. American Society of Psychiatry guidelines exists only for BPD, while European guidelines are present for BPD, ASPD, and PD general. It includes acute treatment by hospitalization if there is a risk of self or other people harm and chronic management of the disorder. Indications for inpatient management include; suicidal intent and plan, impulse control loss, imminent danger to self and others, and severe symptoms impairing functioning and unresponsive to outpatient treatment. An initial assessment should be performed. The second step is designing a treatment plan and discussing it with the patient. Family support and patient education play a vital role in effective management. Prior to starting the therapy, it is essential to rule out PTSD, depression, and anxiety and manage them if these conditions co-exist. Substance use disorder needs to be recognized and treated as well

Psychotherapy

Psychotherapy is the mainstay and core management for PDs. It is a collaborative treatment that aims to improve the perception of the disease and rectify the response to social and personal problems with ameliorated behavior. Psychodynamic psychotherapy (PDT) focuses on self-reflection and the identification of perceptual distortions. It then enables an individual to develop adaptive responses to varying stimuli. Emotional conflicts, defence mechanisms and unconscious thoughts are recognised and analysed. This is then used to counter and resolve the unconscious conflicts and relational difficulties. It is performed twice to four weeklies for many months. Cognitive-behavioral therapy (CBT) is based on recognizing distortion in thought processes and rectify the cognition pattern, thus establishing emotional stability and behavioral regulation. It is done once weekly for many months to years. It is used in ASPD, BPD, and substance use disorder. Dialectical-behavioral therapy is s subtype of CBT that reinforces and integrates positive emotions, thoughts, and behaviors by changing the negative thinking patterns. The word 'dialect' means 'synthesis or integration of opposites.' It equips patients with new enhanced coping skills to manage their painful conflicting emotions and control their impulses and self-destructing behavior. It is a significant therapy in cluster-B PDs. Interpersonal therapy comprises individual sessions that focus on improving interpersonal and social relationships. It involves finding triggers such as adjustment difficulty, role transition or dispute, and interpersonal deficit; and working together with the individual to challenge them and establish new positive roles. It is used for mood disorders and can be used in BPD. It is conducted weekly for 6-12 months. Dynamic Group psychotherapy harnesses the dynamic existing among individuals and utilizes it to bring out constructive and optimistic behaviors. Feedback from patients is beneficial to produce a therapeutic response. It is also carried out weekly for months. A multi-wave study done by Clarkin et al. in 2007 studied the PDT, Dialectal behavioral therapy, and dynamic supportive therapy in the management of BPD. It demonstrated that PDT and DST were associated with improvement in anger and impulsivity, PDT and dialectical behavioral therapy lead to improvement in suicidality, and only PDT was found to be a predictor of verbal and direct assault . European guidelines have the strongest recommendation for psychotherapy for BPD. Cognitive-behavioral therapy for ASPD is recommended by British and German guidelines. American society of Psychiatry recommends dialectical behavioral therapy and psychodynamic therapy for BPD.

Medical Therapy

No medical therapy is approved by Food and Drug administration, FDA for treatment of personality disorders. Pharmacotherapy is utilised to manage symptoms during acute decompensation and trait vulnerabilities. Mood dysregulatory symptoms like emotional lability, anger outbursts, depressive crashes, and other affective dysregulation symptoms are managed with (selective serotonin reuptake inhibitors) SSRIs or selective norepinephrine reuptake inhibitors (SNRIs) like venlafaxine. Mood stabilizers like lithium, valproate, carbamazepine, lamotrigine or topiramate are used as second line. Impulse control dyscontrol symptoms are self-mutilation, aggression, eroticism, reckless sex, extravagant spending and uncontrolled substance use. They are managed with SSRIs as first line and monoamine oxidase inhibitors (MAOIs) as second line . British guidelines recommend against the use of medications for these symptoms . Cognitive perceptual symptoms incorporate paranoia, delusions, hallucination, derealisation, depersonalization and suspiciousness. Low dose neuroleptics or antipsychotic medications are used. They help with psychotic symptoms as well as mood issues.

Case Studies

Case #1

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