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Personality Disorders

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🧠 About Personality Disorders

Personality Disorders are enduring mental health conditions with rigid, maladaptive patterns of thinking, feeling, and behaving.
They affect how people perceive, relate, and function in relationships, often leading to distress and impaired quality of life.
Onset is usually in adolescence/early adulthood, and symptoms are persistent across situations.

📊 Categories of Personality Disorders

Grouped into three clusters (DSM-5/ICD-10):

🔹 Cluster A: Odd / Eccentric

🔒 Paranoid: Distrust, suspicion, hypersensitivity → relationship difficulties.
😶 Schizoid: Social detachment, flat affect, preference for solitude.
✨ Schizotypal: Eccentric thoughts/behaviours, perceptual distortions, interpersonal discomfort.

🔸 Cluster B: Dramatic / Emotional / Erratic

🚫 Antisocial: Disregard for others’ rights, deceit, aggression, irresponsibility.
⚖️ Borderline: Emotional instability, impulsivity, unstable relationships, fear of abandonment, self-harm risk.
🎭 Histrionic: Excessive emotionality, attention-seeking, shallow affect.
👑 Narcissistic: Grandiosity, entitlement, need for admiration, lack of empathy.

🟢 Cluster C: Anxious / Fearful

🙈 Avoidant: Social inhibition, feelings of inadequacy, hypersensitivity to criticism, but desire closeness.
🫂 Dependent: Submissive, clingy, excessive reliance on others for decision-making.
📏 Obsessive-Compulsive Personality Disorder (OCPD): Preoccupation with order, perfectionism, rigidity (differs from OCD as no intrusive obsessions/compulsions).

🧬 Etiology

🧬 Genetic: Heritability of temperament traits.
🌪️ Environmental: Early trauma, neglect, dysfunctional attachment.
🧠 Neurobiological: Abnormalities in serotonin/dopamine systems, fronto-limbic dysfunction.

🩺 Diagnosis

Based on psychiatric assessment of enduring, pervasive patterns.
Requires distress/impairment across life areas.
DSM-5 or ICD-10/11 diagnostic frameworks used.
Must be distinguished from episodic conditions (e.g., mood disorders, psychosis).

🛠️ Management

Psychological therapies (mainstay):
- 🧠 CBT – restructuring dysfunctional beliefs.
- 💬 DBT – evidence-based for Borderline PD (emotion regulation, distress tolerance).
- 🔍 Psychodynamic/Schema therapy – exploring deep-rooted patterns.
Medications: Not curative; used symptom-targeted:
- 💊 Antidepressants for comorbid depression/anxiety.
- 💊 Antipsychotics for impulsivity, perceptual distortions.
- 💊 Mood stabilisers for affective dysregulation.
Supportive care: 🫂 Family education, structured services, crisis plans.
Peer/self-help: Group support reduces isolation, fosters recovery skills.

📈 Prognosis

Highly variable; depends on subtype, comorbidities, and support.
⚖️ Borderline PD: Many improve substantially over 10–15 years with therapy.
🛠️ Early intervention and long-term therapeutic engagement improve outcomes.

🔗 References

🧩 Personality Disorders – Clinical Cases

Case 1 – Emotionally Unstable (Borderline) Personality Disorder A 27-year-old woman presents after an impulsive overdose following an argument with her partner. She describes unstable relationships, intense fear of abandonment, and rapid mood swings. Her childhood was marked by neglect and sexual abuse. She reports self-harm as a coping mechanism but no sustained psychosis. Teaching point: Borderline PD is characterised by emotional dysregulation, impulsivity, identity disturbance, and self-destructive behaviour. Management: DBT (Dialectical Behaviour Therapy), crisis planning, and collaborative safety work. Avoid long-term benzodiazepines or antipsychotics unless comorbid illness.

Case 2 – Anankastic (Obsessive–Compulsive) Personality Disorder A 45-year-old accountant struggles with perfectionism and over-attention to detail. He re-checks his work repeatedly and becomes irritable when others do not follow his standards. He has difficulty delegating and misses deadlines due to over-analysis. No intrusive obsessions or compulsions as seen in OCD. Teaching point: Anankastic PD involves rigidity, perfectionism, and control at the expense of flexibility and efficiency. CBT focusing on cognitive restructuring and behavioural flexibility is useful; SSRIs may help comorbid anxiety.

Case 3 – Dissocial (Antisocial) Personality Disorder A 33-year-old man with multiple past convictions for theft and assault reports “no guilt” about hurting others. He is manipulative, aggressive when challenged, and lacks empathy. He describes a chaotic childhood with early conduct disorder. Teaching point: Dissocial PD features disregard for social norms, deceitfulness, impulsivity, and absence of remorse. Risk assessment and structured supervision are essential. Therapy focuses on behaviour management, anger control, and addressing substance misuse.

Case 4 – Anxious (Avoidant) Personality Disorder A 29-year-old man avoids social gatherings for fear of embarrassment or criticism. He longs for companionship but believes others will reject him. He underperforms at work due to fear of evaluation. Teaching point: Avoidant PD involves social inhibition, low self-esteem, and hypersensitivity to criticism. CBT and gradual exposure help build confidence and correct distorted self-beliefs. SSRIs may aid comorbid anxiety or depression.

💡 Clinical pearl: Personality disorders are enduring patterns of inner experience and behaviour deviating from cultural expectations. They usually become evident by early adulthood and cause functional impairment or distress. Effective management requires consistent boundaries, psychological therapy, and multidisciplinary collaboration. 🌿

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