Personality disorder pathophysiology
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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]
Overview
The exact pathogenesis of personality disorder is not fully understood. Personality disorders are related to multifactorial causes. Throughout time, a multitude of theories has been developed to explain the origin of these disorders. However still, the pathophysiology of PDs remains enigmatic. The five-factor model of personality was developed in the 1980s and 1990s, which demonstrated that it comprises five distinct traits. PDs are primarily the result of positive correlation with Neuroticism and negative association with Agreeableness. Extraversion is associated in both ways. It is a well-known fact that personality develops during childhood and interpersonal experiences and social interactions play a significant role in the development of PDs. Parental maltreatment, stress, and traumatic life events influence the personality adversely. In addition, genetic and prenatal factors also constitute a major role. Genetic factors with mutations in genes involving dopamine and serotonin pathways such as DRD2, COMT, DTNBP1, DAAO, 5-HTTLPR, MAOA, DRD3,TPH1 and TPH2. Perinatal injuries like trauma, infections like encephalitis, and hemorrhage may also be contributing factors. Genetic factors interact with environmental stresses to result in PDs. Various parental behavior like excessive attachment, parental insensitivity or emotional neglect, physical and sexual abuse, and substance use disorders causes an essential impact on PDs development. Social bullying, racial discrimination, frequent dislocations during childhood, and lack of peer support are other risk factors.
Pathophysiology
Physiology
The personality development is a dynamic process that starts early in life and continue to evolve and change when subjected to environmental factors and consequential events. It results in establishing an organized pattern of behaviors and attitudes which are unique to every individual.
The theories to explain personality development has been presented throughout time. Freud's Psychoanalytic Theory was the pioneer. As discussed in historical perspectives, it is based on ideas of the id, the ego and the superego.[1] The interaction and conflict among these is responsible for the creating the personality in an individual. He also proposed five stages of psychosexual development. Following it, new-Freudians (followers of Feud) elaborated the concept of Feud to formulate many new theories. However, the major problem was lack of ways to test the theories on wide variety of patients due to differences in dealings by different individuals and due to vague predictions made by it regarding defense mechanisms. Thus, it fails to pass empiricism. The five-factor theory/model is a remarkable widely-accepted model of personality development. It suggests personality constitutes of five traits; Conscientiousness, Agreeableness, Neuroticism, Openness to Experience, and Extraversion. [2] Each personality trait is a spectrum and an individual can fall anywhere on this scale. The other trait theories just utilized binary values instead of a continuum. Each trait is influenced by genetic and environmental factors. The biological theories explain this as well.
Pathogenesis
Throughout time, a multitude of theories has been developed to explain the origin of these disorders. However still, the pathophysiology of PDs remains enigmatic. The five-factor model of personality was developed in the 1980s and 1990s, which demonstrated that it comprises five distinct traits. These include extraversion, Neuroticism, openness to experience/intellect, Agreeableness, and conscientiousness. A meta-analysis conducted by Saulsman and Page in 2004 reveals the association of personality disorders with the five-trait model. It concludes that extraversion is positively associated with disorders characterizing assertiveness or gregariousness like Histrionic and Narcissist. Neuroticism is positively associated with disorders causing emotional distress like Paranoid, Schizotypal, Borderline, Dependent, and Avoidant. Agreeableness is negatively associated with disorders characterized by interpersonal difficulties like Paranoid, Schizotypal, Antisocial, Borderline, and Narcissist. Those disorders which are distinguished by orderliness are positively associated with conscientiousness, like Obsessive-compulsive disorder. Schizoid is negatively associated with extraversion. Hence, PDs are primarily the result of positive correlation with Neuroticism and negative association with Agreeableness. Extraversion is associated in both ways [3]. This remains the most widely accepted explanation for development of personality disorder. Other theories are as follows:
Object Relations Theory of Personality Disorders
Melanie Klein describes that during infant stage of life, each individual develops "internal representations" of self and others. This later results in formulating "self concept" and internal images of other people (objects). This is, in turn, responsible for "affects", which are feelings experienced in presence of others similar to ones previous "representations." The object relations refer to the internal representation of relationship of self and object and these form the building blocks for organizing a person inner personality. [4]
Attachment Theory of Personality Disorder
John Bowlby describes the person's characteristic ways of relating in close relationships. It endorses that every individual develops internal representations of relationships throughout their correspondence with early caretakers. The affective bond between infant and caregiver is responsible for developing interpersonal attitudes and relations. The adaptive attachment of a child with caregiver predicts the intrapsychic conflicts that an individual may experience later in life. This early attachment relations mold an individual to maintain an equilibrium between self regulation and stress regulation. [5]
Cognitive-Behavioral Theory of Personality Disorders
It lays the foundation of CBT which is utilized for treatment of many PDs and other psychiatric conditions these days. It is based on aspect that thoughts are responsible for emotions which predicts the behavior. Core beliefs regarding self and others are formulated which are, in turn, responsible for thoughts, feelings and behavior exhibited by an individual. The theory predicts that the core beliefs are influenced by the biological factors or temperament (Nature) and social environment or childhood experiences (Nurture). This infers that any distortion in core beliefs will result in deformation of personality. This supports the cognitive behavioral therapy designed as a management technique for personality disorders, which aims to create an awareness among patients of their dysfunctional core beliefs and restructure them. [6]
Structural Analysis of Social Behavior (SASB)
It is a model to study and analyze different types of social interactions. Lorna Smith Benjamin developed it using object relations and attachment theory as the basis. It endorses that infants have an innate desire to form attachments, which are dependent on interactions with caregivers and influence the future relationships of that individual. SASB provides a way to measure these representations using two behavioral dimensions; need for affiliation, and need for interdependence. [7] They are then plotted orthogonally. the normal personality is indicated by a circular region closer to intersection point along both axis while rest will be due to personality disorder or inflexible behaviors. Moreover, according to SASB, there are three perspectives to interpret relationship dynamics; self, others and introject. These influence both the dimensions and hence, each of the dimension is plotted thrice using each of the perspectives.
Risk Factors
It is a well-known fact that personality develops during childhood and interpersonal experiences and social interactions play a significant role in the development of PDs. Parental maltreatment, stress, and traumatic life events influence the personality adversely. In addition, genetic and prenatal factors also constitute a major role. injuries like trauma, infections like encephalitis, and hemorrhage may also be contributing factors. Genetic factors interact with environmental stresses to result in PDs. Various parental behavior like excessive attachment, parental insensitivity or emotional neglect, physical and sexual abuse, and substance use disorders causes an essential impact on PDs development. Social bullying, racial discrimination, frequent dislocations during childhood, and lack of peer support are other risk factors.
Genetics
Genetic factors constitute a major role.
- Cluster-A PDs can have polymorphisms associated with the gene coding for dopamine 2-receptor (DRD2), catechol-0-methyltransferase (COMT), Dysbindin (DTNBP1), and D-aminoacid oxidase (DAAO). These genes are also associated with the development of schizophrenia, implying that both schizophrenia and schizotypal PD are related to dopaminergic dysfunction.
- Cluster B PDs have been found linked to polymorphisms in genes encoding serotonin transporter (5-HTTLPR), catabolic enzyme monoamine oxidase (MAOA), and tryptophan hydroxylase enzyme related genes TPH1 and TPH2. This demonstrates the relation of the development of borderline personality and antisocial disorder with dysfunction in the serotonin system.
- Cluster-C PDs are linked with polymorphisms of the dopamine 3-receptor (DRD3) gene and COMT, particularly obsessive-compulsive disorder[8].
Associated Conditions
Conditions associated with personality disorder include:
- Substance Use Disorder
- Depression
- Anxiety Disorder
References
- ↑ De Sousa A (2011). "Freudian theory and consciousness: a conceptual analysis**". Mens Sana Monogr. 9 (1): 210–7. doi:10.4103/0973-1229.77437. PMC 3115290. PMID 21694972.
- ↑ Widiger TA, Crego C (2019). "The Five Factor Model of personality structure: an update". World Psychiatry. 18 (3): 271–272. doi:10.1002/wps.20658. PMC 6732674 Check
|pmc=value (help). PMID 31496109. - ↑ Saulsman LM, Page AC (2004). "The five-factor model and personality disorder empirical literature: A meta-analytic review". Clin Psychol Rev. 23 (8): 1055–85. doi:10.1016/j.cpr.2002.09.001. PMID 14729423.
- ↑ Svrakic DM, Zorumski CF (2021). "Neuroscience of Object Relations in Health and Disorder: A Proposal for an Integrative Model". Front Psychol. 12: 583743. doi:10.3389/fpsyg.2021.583743. PMC 8005655 Check
|pmc=value (help). PMID 33790822 Check|pmid=value (help). - ↑ "Attachment Theory: Social, Developmental, and Clinical Perspectives - Google Books".
- ↑ Benjamin LS (1996). "Introduction to the special section on structural analysis of social behavior". J Consult Clin Psychol. 64 (6): 1203–12. doi:10.1037//0022-006x.64.6.1203. PMID 8991306.
- ↑ Reichborn-Kjennerud T (2010). "The genetic epidemiology of personality disorders". Dialogues Clin Neurosci. 12 (1): 103–14. PMC 3181941. PMID 20373672.