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| {{Personality disorder}} | | {{Personality disorder}} |
| {{CMG}}{{AE}}{{Ayesha}} | | {{CMG}}{{AE}}{{Ayesha}} |
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| | ==[[Personality disorder overview|Overview]]== |
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| ==[[Personality disorder historical perspective|Historical Perspective]]== | | ==[[Personality disorder historical perspective|Historical Perspective]]== |
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| ==Diagnosis== | | ==Diagnosis== |
| ===[[Personality disorder diagnostic criteria|Diagnostic Criteria]]===
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| 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.
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| *In [[DSM-5]], the following criteria must be met:
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| **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.
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| **This maladaptive pattern causes significant distress and impaired responses in social, occupational, and other areas.
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| **The onset is in early adolescence or early adulthood, and hence, the duration of symptoms is long.
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| **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.
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| **The symptomatology cannot be explained with any other [[psychological]] or [[neurological]] abnormality, and [[substance abuse disorders]] have been ruled out.
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| *In [[ICD-10]], World Health Organization (WHO) lists the following criteria:
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| **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.
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| **The PDs may co-exist with other [[mental disorders]]; however, the behavior is continuous and not limited to episodes of mental illness.
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| **The inflexible attitude started in adolescence or early adulthood and diagnosed later in life.
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| **It is of long duration and follows a stable course.
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| **The symptoms are responsible for considerable personal distress and significant [[social impairment]]. <ref name="urlrepository.poltekkes-kaltim.ac.id">{{cite web |url=http://repository.poltekkes-kaltim.ac.id/657/1/Diagnostic%20and%20statistical%20manual%20of%20mental%20disorders%20_%20DSM-5%20%28%20PDFDrive.com%20%29.pdf |title=repository.poltekkes-kaltim.ac.id |format= |work= |accessdate=}}</ref>
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| 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.'<ref name="urlwww.who.int">{{cite web |url=https://www.who.int/classifications/icd/en/bluebook.pdf |title=www.who.int |format= |work= |accessdate=}}</ref>
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| ===[[Personality disorder history and symptoms|History and Symptoms]]===
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| 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.
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| 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.
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| ===[[Personality disorder physical examination|Physical Examination]]===
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| 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.
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| ===[[Personality disorder laboratory findings|Laboratory Findings]]===
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| These investigations are carried out to rule out other diagnosis. No definite abnormalities are associated with PDs. The laboratory tests conducted comprises:
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| #[[Vitamin B12]], [[Vitamin D]] and [[ferritin levels]].
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| #[[Thyroid function tests]], fasting [[glucose]] and [[cortisol]] levels.
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| #[[Toxicology]] screen is done to differentiate [[substance abuse disorder]] from PD and also, as substance abuse is common with PSs.
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| #[[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.
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| ===[[Personality disorder imaging|Imaging]]===
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| [[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 <ref name="pmid32163818">{{cite journal| author=Davies G, Hayward M, Evans S, Mason O| title=A systematic review of structural MRI investigations within borderline personality disorder: Identification of key psychological variables of interest going forward. | journal=Psychiatry Res | year= 2020 | volume= 286 | issue= | pages= 112864 | pmid=32163818 | doi=10.1016/j.psychres.2020.112864 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32163818 }} </ref>. [[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 <ref name="urlElectroencephalogram abnormalities in borderline personality disorder Shankar S, Selvaraj C, Sivakumar S - Ann Indian Psychiatry">{{cite web |url=https://www.anip.co.in/article.asp?issn=2588-8358;year=2019;volume=3;issue=2;spage=110;epage=115;aulast=Shankar |title=Electroencephalogram abnormalities in borderline personality disorder Shankar S, Selvaraj C, Sivakumar S - Ann Indian Psychiatry |format= |work= |accessdate=}}</ref>.
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| ===[[Personality disorder assessment tools|Assessment tools]]===
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| Following assessment tools are considered:
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| *[[Suicide risk screening tool]]
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| *[[Minnesota Multiphasic Personality Inventory–II]]
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| *[[Standardised assessment of personality abbreviated scale]]
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| *[[Million clinical multiaxial inventory-III]]
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| *[[International Personality Disorder Examination]]
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| *[[Structured clinical interview for DSM-IV and axis II PDs]]
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| ==Treatment== | | ==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.
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| 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.
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| 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.
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| 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
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| ==[[Personality disorder psychotherapy|Psychotherapy]]== | | ==[[Personality disorder psychotherapy|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 <ref name="pmid17541052">{{cite journal| author=Clarkin JF, Levy KN, Lenzenweger MF, Kernberg OF| title=Evaluating three treatments for borderline personality disorder: a multiwave study. | journal=Am J Psychiatry | year= 2007 | volume= 164 | issue= 6 | pages= 922-8 | pmid=17541052 | doi=10.1176/ajp.2007.164.6.922 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17541052 }} [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=&cmd=prlinks&id=18223059 Review in: Evid Based Ment Health. 2008 Feb;11(1):24] </ref>. 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.
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| ==[[Personality disorder medical therapy|Medical Therapy]]== | | ==[[Personality disorder medical therapy|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.
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| 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.
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| 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 <ref name="urlpsychiatryonline.org">{{cite web |url=https://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/bpd.pdf |title=psychiatryonline.org |format= |work= |accessdate=}}</ref>. British guidelines recommend against the use of medications for these symptoms <ref name="urlEuropean guidelines for personality disorders: past, present and future | Borderline Personality Disorder and Emotion Dysregulation | Full Text">{{cite web |url=https://bpded.biomedcentral.com/articles/10.1186/s40479-019-0106-3 |title=European guidelines for personality disorders: past, present and future | Borderline Personality Disorder and Emotion Dysregulation | Full Text |format= |work= |accessdate=}}</ref>.
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| 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.
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| == Case Studies == | | == Case Studies == |