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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 disorders (PD) are described as unique, long-term pervasive patterns of expressing and manifesting emotions, thoughts, and behaviors in an inflexible and maladaptive manner leading to significant functional [[impairment]] in one's life. [[Personality traits]], in contrast, are specific patterns of thinking, perceiving, and responding to different situations in an adaptive and tenaciously stable way throughout life. The personality traits formulate an essential aspect in one's life in facing and dealing with contrasting situations as maladaptive [[personality]] can result in clinical distress and [[psychosocial impairment]]. In order to differentiate normal responses from abnormal or [[pathological]], the criterion employed requires behaviors displayed by a majority in the population as normal and [[pathological]] if they are rare or there is the absence of a sense of contentment and adaptability to the social environment or marked deviation from cultural expectations. Hence, these are relative terms, and therefore, the [[Diagnostic and Statistical Manual of Mental Disorders]] (DSM) has established a set criterion for diagnosing [[personality disorders]]. This is based on the presence of impaired personality functioning and pathological traits. The [[pathophysiology]] of PD remains unclear to date. There are countless complex [[psychodynamic theories]] explaining the development of the disorder. Both [[genetic]] and environmental factors interplay in the causation of PD. A decrease in [[monoamine oxidase]] (MAO), and [[serotonin]] levels are seen with multiple PD. Although mostly recognized and diagnosed in adults, PD is present and develops in youth and adolescence. About 1 in 10 adolescents meets the criteria for PD. There are ten personality traits classified into 3 clusters; A, B, and C, based on similar characteristics. A clinical criterion as set by DSM-V is used for the diagnosis after the exclusion of other similar conditions ([[mental health disorder]], [[substance use disorder]], structural [[central nervous system]] (CNS) disorder). For most personality disorders, an age greater than 18 years is required for the diagnosis. This disorder is retained throughout an individual's life; however, certain types become less intense with age. The presence of PD is associated with increased [[mortality]]. The increased [[mortality]] is associated with unnatural causes like [[suicide]], accidents, [[homicide]], [[substance abuse]], and [[depression]]. Natural death chances may also be enhanced in PD due to negative perspectives and emotions regarding health problems in life and the correlation of impaired mental health with physical health. [[Alcoholism]] and [[substance abuse]] contribute as precipitating factors and complications in PD. [[Psychotherapy]] remains the mainstay of treatment in both [[management]] and preventing complications. Medications are used as adjuncts. [[Cognitive-Behavioral therapy]], [[impulse control]], [[interpersonal psychotherapy]], self-help groups, and family therapy are required. Medical therapy is required to balance and restore the [[neurotransmitter]] abnormalities associated with PD. Among them, [[Selective serotonin reuptake inhibitors]](SSRIs) and newer [[antidepressants]] remain the hallmark. [[Antipsychotics]] and [[mood stabilizers]] also help. Despite individual and supportive [[psychotherapy]], treatment of PD remains challenging and difficult.
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| ==[[Personality disorder historical perspective|Historical Perspective]]== | | ==[[Personality disorder historical perspective|Historical Perspective]]== |
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| [[Personality]] defects were started to be recognized in the 18th century. Previously, all the diseases were a result of abnormalities with four bodily fluids; [[blood]], [[phlegm]], yellow [[bile]], and black [[bile]]. The changes in them were also considered responsible for variations in [[mood]]. However, by the 18th century, [[Phillippe Pinel]] described a group of people having impulsive, irrational ways and behaviors while maintaining understanding, perception, judgment, and memory of the actions. This was the birth of recognition of [[personality disorders]]. In the 18th century, the term [['phrenology']] was used to describe personality characteristics. It was believed that the origin of [[personality traits]] is from various [[facets]] in the [[cranium]]. Despite the discontinuation of the term, it remains significant as it laid the basis for the origin of PDs from the [[cerebral cortex]].
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| In the 19th century and early 20th century, different European psychologists started identifying and describing different personality traits and disorders. The term personality is derived from Greek word, [['persona,']] the mask worn in theatres in ancient times to denote a character or social role. It is now used to define that aspect of the person which is discerned by other individuals. In the 1920s and 1930s, [[Sigmund Freud]], known as the father of [[psychology]] and his colleagues, worked on the [[psychoanalytic]] classification and etiology of personality. They related personality traits with childhood characters. He presented the [[structural theory]] that unconscious mental conflicts influence the development of character and behavior <ref name="urlThe History of Personality Disorders | HealthyPlace">{{cite web |url=https://www.healthyplace.com/personality-disorders/malignant-self-love/history-of-personality-disorders |title=The History of Personality Disorders | HealthyPlace |format= |work= |accessdate=}}</ref>. This comprises three components of the [[brain]]; the [[id]] (primitive urges at birth), [[ego]] (mediator that maintains a balance between id and reality), and [[superego]] (conscience and moral values). They develop at different stages in life, and the interplay among them is responsible for shaping the personality of a person. Any fixation at any stage is responsible for the improper balance of [[id]] and [[ego]] and leads to interference in the appropriate and timely development of the [[superego]]. A person is born with the id and develops ego and superego at last. This laid down the foundation for further theories and explanations of PDs; however, it lacks the interaction and influences of social, cultural, environmental, and [[genetic]] factors in posing the personality in an individual. In the late 1900s, statistics was utilized to group together different definitions of [[personality]] structures. It was pioneered by [[Bernard Cattell]]. This employs a different number of dimensions to delineate personality systems. These dimensional models lead to DSM characterization of personality disorders according to DSM classifications. [[DSM II]] was established in 1986 and listed 10 PDs. It differs from [[DSM I]] due to the recognition stage in life being adolescence, while the former states that these disorders exist lifelong. DSM II was based on concepts of [[psychoanalysis]] and [[neuroses]], while [[DSM II]]I described PDs scientifically and clinically. [[DSM IV]] was established in 1994 with an updated version, [[DSM IV-TR]], and uses a multiaxial approach to describe psychiatric illnesses with axis II reserved for personality disorder. This multiaxial system was abolished in [[DSM 5]] and categorized the various disorders with related disorders <ref name="pmid24174889">{{cite journal| author=Crocq MA| title=Milestones in the history of personality disorders. | journal=Dialogues Clin Neurosci | year= 2013 | volume= 15 | issue= 2 | pages= 147-53 | pmid=24174889 | doi= | pmc=3811086 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24174889 }} </ref>. It classifies PDs into three clusters, with each containing 3-4 disorders.
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| ==[[Personality disorder classification|Classification]]== | | ==[[Personality disorder classification|Classification]]== |
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| There are two approaches used to classify personality disorders; categorical and dimensional. [[Categorical]] classification is based on distinct operational criteria depending on behavioral characteristics. [[DSM-5]] and [[ICD-10]] both uses this approach. As compared to this, [[dimensional]] classification is based on the personality traits and using a quantitative distinction. It places normality at one end and disorder at other.
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| *DSM-5 classifies 10 personality disorders into three clusters due to similar characteristics:
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| **CLUSTER A: odd and eccentric
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| ***[[Paranoid]]-distrust and suspiciousness
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| ***[[Schizoid]]-detachment from social relationships
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| ***[[Schizotypal]]-distortion in interpersonal relationships and cognition, and behavioural eccentrism
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| **CLUSTER B: erratic and emotional
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| ***[[Antisocial]]-disregard and violation of rights of others
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| ***[[Borderline]]-instability in interpersonal relationships, and impulsivity
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| ***[[Histrionic]]-eccessive emotionality and attention-seeking behaviour
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| ***[[Narcissist]]-grandiosity and lack of empathy
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| **CLUSTER C: anxious and fearful
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| ***[[Avoidant]]-social inhibition and fear of criticism
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| ***[[Dependent]]-submissive and excessive need for reassurance
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| ***[[Obsessive-Compulsive]]-preoccupation with perfectionism and orderliness
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| *ICD-10 classifies into 3 clusters as well, which are as follows:
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| **A: Odd/eccentric
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| ***[[Paranoid]]
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| ***[[Schizoid]]
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| **B: Dramatic
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| ***[[Dissocial]]
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| ***[[Emotionally unstable borderline]] type
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| ***[[Emotionally unstable impulsive]] type
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| ***[[Histrionic[[
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| **C: Anxious/fearful
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| ***[[Anxious]]
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| ***[[Dependent]]
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| ***[[Anankastic]]
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| ==[[Personality disorder pathophysiology|Pathophysiology]]== | | ==[[Personality disorder pathophysiology|Pathophysiology]]== |
| 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. 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 <ref name="pmid14729423">{{cite journal| author=Saulsman LM, Page AC| title=The five-factor model and personality disorder empirical literature: A meta-analytic review. | journal=Clin Psychol Rev | year= 2004 | volume= 23 | issue= 8 | pages= 1055-85 | pmid=14729423 | doi=10.1016/j.cpr.2002.09.001 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14729423 }} </ref>. 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. 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]]<ref name="pmid20373672">{{cite journal| author=Reichborn-Kjennerud T| title=The genetic epidemiology of personality disorders. | journal=Dialogues Clin Neurosci | year= 2010 | volume= 12 | issue= 1 | pages= 103-14 | pmid=20373672 | doi= | pmc=3181941 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20373672 }} </ref>. 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.
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| ==[[Personality disorder causes|Causes]]== | | ==[[Personality disorder causes|Causes]]== |
| Causative factors associated with PDs include:
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| #Genetic factors with mutations in genes involving dopamine and serotonin pathways such as DRD2, COMT, DTNBP1, DAAO, 5-HTTLPR, MAOA, DRD3,TPH1 and TPH2.
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| #Environmental factors like stresses, parental treatment, sexual abuse and substance use.
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| ==[[Personality disorder differential diagnosis|Differentiating Personality disorder from other Diseases]]== | | ==[[Personality disorder differential diagnosis|Differentiating Personality disorder from other Diseases]]== |
| Personality disorders present with symptoms which corresponds to other psychiatric illnesses as well. It makes imperative to employ the [DSM-5] criterion to make the diagnosis of PD. Additionally, many patients with PDs also suffer from co-morbid conditions like mood disorders, [[substance abuse]] and organic brain lesions which have overlapping symptoms and signs with PDs. This requires a complete long history including duration of symptoms and developmental history and essential investigations.
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| Boderline disorder needs to be differentiated from mood disorders like [[Bipolar disorder]], [[anxiety]] and [[delusional disorder]].
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| Cluster-A disorders have to distinguished from [[delusional disorder (persecutory type)]], [[schizophreniform]], [[bipolar disorder with psychotic symptoms]] and [[schizophrenia]].
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| [[Post-traumatic stress disorder]] (PTSD) can also have interchangeable presenting complaints to the cluster-C PDs..
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| Thus, [[Axis 1 disorders]] and [[Axis 2 disorders]] have similar presentation and needs to be evaluated and ruled out before making the diagnosis of Axis-2 disorders.
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| ==[[Personality disorder epidemiology and demographics|Epidemiology and Demographics]]== | | ==[[Personality disorder epidemiology and demographics|Epidemiology and Demographics]]== |
| Worldwide pooled prevalence of [[personality disorder]] as found by meta-analysis of studies conducted from 21 countries is 7.8%. Global rates of cluster-A PD is 3.8%, cluster-B is 2.8% and cluster-C PD is 5% <ref name="pmid31298170">{{cite journal| author=Winsper C, Bilgin A, Thompson A, Marwaha S, Chanen AM, Singh SP | display-authors=etal| title=The prevalence of personality disorders in the community: a global systematic review and meta-analysis. | journal=Br J Psychiatry | year= 2020 | volume= 216 | issue= 2 | pages= 69-78 | pmid=31298170 | doi=10.1192/bjp.2019.166 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31298170 }} </ref>. In United States (US), it is around 10%, with major disease burden contributed by [[obsessive-compulsive]] PD followed by [[narcissist]] and [[borderline PD]]. In the rest of countries, it varies <ref name="pmid21637629">{{cite journal| author=Sansone RA, Sansone LA| title=Personality disorders: a nation-based perspective on prevalence. | journal=Innov Clin Neurosci | year= 2011 | volume= 8 | issue= 4 | pages= 13-8 | pmid=21637629 | doi= | pmc=3105841 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21637629 }} </ref>. OCD is twice common in females than males and 75% of individuals diagnosed with BPD are females. No sex predilection is found with rest. [[Narcissist PD]] is found in 20% of military personals, 17% first-year medical students and 6% forensic population.
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| ==[[Personality disorder risk factors|Risk Factors]]== | | ==[[Personality disorder risk factors|Risk Factors]]== |
| Risk in development of PDs is increased with following factors:
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| #Genetic factors
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| #[[Perinatal]] injuries like trauma, infections like [[encephalitis]] and [[hemorrhage]]
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| #Parental attachment, parental misconduct, abuse, insensitivity and emotional neglect
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| #Physical and sexual abuse
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| #Use of illegal drugs or substance abuse
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| #Social bullying and racial discrimination
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| #Frequent displacements in life or a major dislocation
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| ==[[Personality disorder natural history, complications and prognosis|Natural History, Complications and Prognosis]]== | | ==[[Personality disorder natural history, complications and prognosis|Natural History, Complications and Prognosis]]== |
| [[Personality disorders]] usually begin to develop in early adolescence and are diagnosed in early adulthood. The symptoms are usually apparent for a long time, indicating the long-term course of the disorder in life. Moreover, it also affects functioning in several aspects that can cause personal impairment and social distress. [[Stigmatization]] exists after the diagnosis is established and prevents individuals from seeking treatment at an earlier stage. However, with appropriate [[psychotherapy]] and keeping symptoms under control with medications, disease stability is achieved and even complete remission. A follow-along study performed by Skodol et al. demonstrated that remission was seen in the case of [[avoidant]] and [[schizotypal]] PD with a greater number of positive experiences and building interpersonal skills at a young age. Another ten years follow-up study to observe remission in BPD was done by Zanarini et al., which revealed that 80% of individuals achieved remission and their 16 years follow-up showed sustained symptomatic remission <ref name="pmid16648323">{{cite journal| author=Zanarini MC, Frankenburg FR, Hennen J, Reich DB, Silk KR| title=Prediction of the 10-year course of borderline personality disorder. | journal=Am J Psychiatry | year= 2006 | volume= 163 | issue= 5 | pages= 827-32 | pmid=16648323 | doi=10.1176/ajp.2006.163.5.827 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16648323 }} </ref> <ref name="pmid22737693">{{cite journal| author=Zanarini MC, Frankenburg FR, Reich DB, Fitzmaurice G| title=Attainment and stability of sustained symptomatic remission and recovery among patients with borderline personality disorder and axis II comparison subjects: a 16-year prospective follow-up study. | journal=Am J Psychiatry | year= 2012 | volume= 169 | issue= 5 | pages= 476-83 | pmid=22737693 | doi=10.1176/appi.ajp.2011.11101550 | pmc=3509999 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22737693 }} </ref>. The complications can occur at any stage and can add to a worsening [[prognosis]]. Among them, [[suicidality]] is of foremost significance. Others include injuries from fights and accidents, sexually acquired infections from presumptuous sex, and [[substance use disorder]]. It also adds to the morbidity by causing personal functional impairment and affecting family life.
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| The [[mortality in PD]] is more than in the general population. A famous study spanning 24 years was performed on patients with PDs, and it was found that 5.9% of patients with BPD died by suicide vs. 1.4% of the comparison group and 14% vs. 5.5% with other non-suicide causes. In addition, those patients who did not achieve recovery were at higher risk of early death <ref name="pmid30688417)">{{cite journal| author=Temes CM, Frankenburg FR, Fitzmaurice GM, Zanarini MC| title=Deaths by Suicide and Other Causes Among Patients With Borderline Personality Disorder and Personality-Disordered Comparison Subjects Over 24 Years of Prospective Follow-Up. | journal=J Clin Psychiatry | year= 2019 | volume= 80 | issue= 1 | pages= | pmid=30688417) | doi=10.4088/JCP.18m12436 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30688417 }} </ref>. Thus, PDs follow a waxing and waning course throughout life with periods marked by flares and remission. The life expectancy in such individuals is influenced by [[psychotherapy]] initiation, treatment compliance, [[co-morbid conditions]], and social support. In most cases, it is lesser than average in the normal individual.
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| ==[[Personality change due to another medical condition|Personality Change Due to Another Medical Condition]]== | | ==[[Personality change due to another medical condition|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:
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| #Endocrine disorders like [[hypothyroidism]].
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| #Long-term steroid use OR [[hypercortisolism]].
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| #Familial disorder like [[Huntington disease]].
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| #Automimmune disorders involving central nervous system like [[Systemic lupus erythematosus]] (SLE).
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| #CNS infections like [[Meningoencephalitis]].
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| #[[Autoimmune immunodeficiency syndrome]] (AIDS) or [[HIV]].
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| #Traumatic brain injuries like chronic [[sub-dural hematoma]].
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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 == |