Personality disorder

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

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. In 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 19th century,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. 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 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.

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.

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 ^[1]. 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.

• The first DSM was published in 1950 and it characterised all the personality disorders formally. It listed four categories of psychiatric disorder;
  • Disturbances of pattern
  • Disturbances of trait
  • Disturbances of drive, control, and relationships
  • Sociopathic disturbances
• DSM II was established in 1968 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. It included; inadequate, paranoid, cyclothymic, schizoid, hysterical, passive-aggressive, obsessive-compulsive, explosive, antisocial, and asthenic personality disorders.
• DSM III, established in 1980, described PDs scientifically and clinically. DSM III removed the Freud concepts like Id which could not be measured and replace them with observed behaviours and thoughts. A multiaxial approach to describe psychiatric illnesses with axis II reserved for personality disorder was established. Schizoid PD was split into three more sub-categories and boderline PD and narcissistic PD were added.
• DSM IV was established in 1994 with an updated version, DSM IV-TR in 2000. For the first time, general diagnostic criteria for any personality disorder was incorporated. This included the requirements of early onset in adolescence, pervasive and unrelentless course, and prolonged duration of symptoms.
• This multiaxial system was abolished in DSM 5 in 2013 and categorized the various disorders with related disorders. This abolishes the confusion of linking each personality disorder with the diagnosis of Axis 1 disorder due to the presence of symptoms from there. ^[2]. It classifies PDs into three clusters, with each containing 3-4 disorders.

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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]

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. DSM-5 classifies 10 personality disorders into three clusters due to similar characteristics: CLUSTER A is defined as odd and eccentric and include Paranoid, Schizoid, and Schizotypal. CLUSTER B is defined by erratic and emotional behavior and includes Antisocial, Borderline, Histrionic and Narcissist. CLUSTER C PDs patients are anxious and fearful and incorporate Avoidant, Dependent and Obsessive-Compulsive. ICD-10 classifies into 3 clusters as well, which are A, Odd/eccentric and includesParanoid and Schizoid, B, Dramatic and includes Dissocial, Emotionally unstable borderline type, Emotionally unstable impulsive type and Histrionic, and C, Anxious/fearful that include Anxious, Dependent and Anankastic.

• DSM-5 classifies 10 personality disorders into three clusters due to similar characteristics:
  • CLUSTER A: odd and eccentric
    • Paranoid-distrust and suspiciousness
    • Schizoid–detachment from social relationships
    • Schizotypal-distortion in interpersonal relationships and cognition, and behavioural eccentrism
  • CLUSTER B: erratic and emotional
    • Antisocial-disregard and violation of rights of others
    • Borderline-instability in interpersonal relationships, and impulsivity
    • Histrionic-eccessive emotionality and attention-seeking behaviour
    • Narcissist-grandiosity and lack of empathy
  • CLUSTER C: anxious and fearful
    • Avoidant-social inhibition and fear of criticism
    • Dependent–submissive and excessive need for reassurance
    • Obsessive-Compulsive-preoccupation with perfectionism and orderliness
• ICD-10 classifies into 3 clusters as well, which are as follows:
  • A: Odd/eccentric
    • Paranoid
    • Schizoid
  • B: Dramatic
    • Dissocial
    • Emotionally unstable borderline type
    • Emotionally unstable impulsive type
    • Histrionic
  • C: Anxious/fearful
    • Anxious
    • Dependent
    • Anankastic

The DSM-IV lists ten personality disorders, grouped into three clusters. The DSM also contains a category for behavioral patterns that do not match these ten disorders, but nevertheless exhibit characteristics of a personality disorder. This category is labeled Personality Disorder NOS (Not Otherwise Specified).

Cluster A (odd or eccentric disorders)

• Paranoid personality disorder
• Schizoid personality disorder
• Schizotypal personality disorder

Cluster B (dramatic, emotional, or erratic disorders)

• Antisocial personality disorder
• Borderline personality disorder
• Histrionic personality disorder
• Narcissistic personality disorder

Cluster C (anxious or fearful disorders)

• Avoidant personality disorder
• Dependent personality disorder (not the same as Dysthymia)
• Obsessive-compulsive personality disorder (not the same as Obsessive-compulsive disorder)

The revision of the previous edition of the DSM, DSM-III-R, also contained the Passive-aggressive Personality Disorder, the Self-defeating Personality Disorder, and the Sadistic Personality Disorder. Passive-Aggressive Personality Disorder is a pattern of negative attitudes and passive resistance in interpersonal situations. Self-defeating personality disorder is characterised by behaviour that consequently undermines the person’s pleasure and goals. Sadistic Personality Disorder is a pervasive pattern of cruel, demeaning, and aggressive behavior. These categories were removed in the current version of the DSM, because it is questionable whether these are separate disorders. Passive-aggressive Personality Disorder and Depressive personality disorder were placed in an appendix of DSM-IV for research purposes.

The ICD-10 section on mental and behavioral disorders includes categories of personality disorder and enduring personality changes. They are defined as ingrained patterns indicated by inflexible and disabling responses that significantly differ from how the average person in the culture perceives, thinks and feels, particularly in relating to others.^[1]

The specific personality disorders are: paranoid, schizoid, dissocial, emotionally unstable (borderline type and impulsive type), histrionic, anankastic, anxious (avoidant) and dependent.^[2]

There is also an ‘Other’ category involving conditions characterized as eccentric, haltlose (derived from “haltlos” (German) = drifting, aimless and irresponsible),^[3] immature, narcissistic, passive-aggressive or psychoneurotic. An additional category is for unspecified personality disorder, including character neurosis and pathological personality.

There is also a category for Mixed and other personality disorders, defined as conditions that are often troublesome but do not demonstrate the specific pattern of symptoms in the named disorders. Finally there is a category of Enduring personality changes, not attributable to brain damage and disease. This is for conditions that seem to arise in adults without a diagnosis of personality disorder, following catastrophic or prolonged stress or other psychiatric illness.

Some types of personality disorder were in previous versions of the diagnostic manuals but have been deleted. This includes two types that were in the DSM-III-R appendix as “proposed diagnostic categories needing further study” without specific criteria, namely sadistic personality disorder (a pervasive pattern of cruel, demeaning and aggressive behavior) and Self-defeating personality disorder (masochistic personality disorder) (characterised by behaviour consequently undermining the person’s pleasure and goals).^[4] The psychologist Theodore Millon and others consider some relegated diagnoses to be equally valid disorders, and may also propose other personality disorders or subtypes, including mixtures of aspects of different categories of the officially accepted diagnoses.^[5]

* – Not actually to be classified as a personality disorder; classified instead as a form of schizophrenia-spectrum disorder.
** – Originally proposed for deletion; status remains unclear for DSM-5.

Psychologist Theodore Millon, who has written numerous popular works on personality, proposed the following description of personality disorders:

Except for classifying by category and cluster, it is possible to classify personality disorders using such additional factors as severity, impact on social functioning, and attribution.^[8]

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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.

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.

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:

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]

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]

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]

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.

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.

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].

Conditions associated with personality disorder include:

• Substance Use Disorder
• Depression
• Anxiety Disorder

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Causative factors associated with PDs include genetic factors with mutations in genes involving dopamine and serotonin pathways such as DRD2, COMT, DTNBP1, DAAO, 5-HTTLPR, MAOA, DRD3,TPH1 and TPH2 and environmental factors like stresses, parental treatment, sexual abuse and substance use.

A study of almost 600 male college students, averaging almost 30 years of age and who were not drawn from a clinical sample, examined the relationship between childhood experiences of sexual and physical abuse and presently reported personality disorder symptoms. Childhood abuse histories were found to be definitively associated with greater levels of symptomatology. Severity of abuse was found to be statistically significant, but clinically negligible, in symptomatology variance spread over Cluster A, B and C scales.Miller and Lisak. Journal of Interpersonal Violence. June 1999

Child abuse and neglect consistently evidence themselves as antecedent risks to the development of personality disorders in adulthood. In this particular study, efforts were taken to match retrospective reports of abuse with a clinical population that had demonstrated psychopathology from childhood to adulthood who were later found to have experienced abuse and neglect. The sexually abused group demonstrated the most consistently elevated patterns of psychopathology. Officially verified physical abuse showed an extremely strong role in the development of antisocial and impulsive behavior. On the other hand, cases of abuse of the neglectful type that created childhood pathology were found to be subject to partial remission in adulthood. Cohen, Patricia, Brown, Jocelyn, Smailes, Elizabeth. “Child Abuse and Neglect and the Development of Mental Disorders in the General Population” Development and Psychopathology. 2001. Vol 13, No 4, pp981-999. ISSN 0954-5794

In 2005, psychologists Belinda Board and Katarina Fritzon at the University of Surrey, UK, interviewed and gave personality tests to high-level British executives and compared their profiles with those of criminal psychiatric patients at Broadmoor Hospital in the UK. They found that three out of eleven personality disorders were actually more common in managers than in the disturbed criminals:

• Histrionic personality disorder: including superficial charm, insincerity, egocentricity and manipulation
• Narcissistic personality disorder: including grandiosity, self-focused lack of empathy for others, exploitativeness and independence.

They described the business people as successful psychopaths and the criminals as unsuccessful psychopaths. ^[1]

• Pergolide

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Boderline disorder needs to be differentiated from mood disorders like Bipolar disorder, anxiety and delusional disorder. Cluster-A disorders have to distinguished from delusional disorder (persecutory type), schizophreniform, bipolar disorder with psychotic symptoms and schizophrenia. Post-traumatic stress disorder (PTSD) can also have interchangeable presenting complaints to the cluster-C PDs.. 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.

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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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% ^[1]. 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 ^[2]. 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.

The prevalence of personality disorder in the general community was largely unknown until surveys starting from the 1990s. In 2008 the median rate of diagnosable PD was estimated at 10.6%, based on six major studies across three nations. This rate of around one in ten, especially as associated with high use of services, is described as a major public health concern requiring attention by researchers and clinicians.^[3]. According to the National Co-morbidity Study Replication (NCS-R), the prevalence of personality disorders in 18 years and older in the last year was 9.1%. It was a nationally conducted household survey between 2001-2003. ^[4].

The prevalence of individual personality disorders ranges from about 2% to 3% for the more common varieties, such as schizotypal, antisocial, borderline, and histrionic, to 0.5–1% for the least common, such as narcissistic and avoidant.

A screening survey across 13 countries by the World Health Organization using DSM-IV criteria, reported in 2009 a prevalence estimate of around 6% for personality disorders. The rate sometimes varied with demographic and socioeconomic factors, and functional impairment was partly explained by co-occurring mental disorders.^[5] In the US, screening data from the National Comorbidity Survey Replication between 2001 and 2003, combined with interviews of a subset of respondents, indicated a population prevalence of around 9% for personality disorders in total. Functional disability associated with the diagnoses appeared to be largely due to co-occurring mental disorders (Axis I in the DSM).^[6]. According to the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), the most common PD in US is Obsessive-compulsive PD which is 7.9% followed by narcissistic 6.2% and boderline PD 5.9%. ^[2]

A meta-analysis conducted to calculate global prevalence of personality disorders in 2020 by Winsper et al. revealed the worldwide pooled prevalence to be around 7.8%. ^[1].

The studies regarding epidemiology of individual types of PDs are lacking. According to National Institute of Health (NIH), the point prevalence of BPD is 1.6% and lifetime prevalence is 5.9%. ^[7] The data by NESARC revealed no difference in gender for prevalence of BPD. The prevalence of paranoid in US ranges between 2.3-4.4% and more common in males. ^[8] The 2004-2005 Wave 2 National Epidemiologic Survey on Alcohol and Related Conditions demonstrated that the prevalence of schizotypal PD to be around 3.9% with greater rate in males as compared to females. ^[9]. For Narcissistic PD, the prevalence was found to be 6.2% in US people aged 18 years and above with higher rates for male population. ^[10].

The prevalence of PDs according to NCS and NESARC are summarised as follows: ^[11]

There are also some gender differences in the frequency of personality disorders. They are shown in the table below.

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The exact cause of personality disorder remains unknown. However, it usually results from the interplay of genetic and environmental factors. The risk of development of personality disorder is increased by the presence of certain factors such as perinatal injuries, family history, history of substance abuse, childhood abuse and other psychosocial factors.

Risk in development of PDs is increased with following factors:

1. Genetic factors
2. Perinatal injuries like trauma, infections like encephalitis and hemorrhage ^{[1] [2]}
3. Parental attachment, parental misconduct, abuse, insensitivity and emotional neglect ^[3]
4. Physical and sexual abuse ^[4]
5. Use of illegal drugs or substance abuse
6. Social bullying and racial discrimination ^[5]
7. Frequent displacements in life or a major dislocation

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Personality disorders usually begin to develop in early adolescence and are diagnosed in early adulthood. The complications can occur at any stage and can add to a worsening prognosis. Suicidality is the most common complication. 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. The mortality in PD is more than in the general population. The life expectancy in such individuals is influenced by psychotherapy initiation, treatment compliance, co-morbid conditions, and social support.

• The symptoms of personality disorder usually develop in the first decade of life and in adolescence. An age of at least 18 years is required for diagnosis of personality disorder.
• The symptoms of personality disorder are typically present for a long duration before diagnosis is made.
• If left untreated, individuals tend to develop multiple complications which can prove a social and financial burden. Conflict-filled relationships, manifold legal issues, poor interpersonal correspondence, and frequent changes in jobs. The co-occurring substance abuse and eating disorder can prove hazardous for health. Frequent alcohol abuse can cause liver cirrhosis, chronic liver failure, dilated cardiomyopathy and heart failure. Tobacco usage can result in chronic obstructive pulmonary disease, permanent lung damage and multiple visceral malignancies. Moreover, acute problems like acute encephalopathy, delirium, seizures, motor vehicle accidents, and heart arrhythmias can result. Intravenous drug abuse can result in infective endocarditis, septic embolism and multi-organ failure.

• Common complications of personality disorder include:
  • Suicide
  • Homicide
  • Substance Abuse
  • Depression
  • Sexually Transmitted diseases like HIV, hepatitis C, Syphilis.
  • Pathological gambling
  • Anorexia Nervosa and Bulimia
  • Schizophreniform disorder and Delusional disorder
  • Somatization Disorder

• 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.
• 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 ^{[1] [2]}. 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.

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 ^[3]. 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 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.

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.

• Another mental disorder due to another medical condition

• Depressive disorder due to brain tumor

• Chronic medical conditions associated with pain and disability
• Delirium or major neurocognitive disorder
• Other mental disorders

• Bipolar disorder
• Conduct disorders
• Delusional disorder
• Depressive disorder
• Panic disorder
• Schizophrenia

• Other personality disorders
• Substance use disorders^[1]

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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.

• 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 behavioural 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 ^[1]. British guidelines recommend against the use of medications for these symptoms ^[2].

• 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.

The route of administration of medications used in personality disorders is oral in most cases. The doses of drugs (antidepressants and mood stabilisers) in PDs is same as used for clinical depression and bipolar disorder. As compared to this, the doses of antipsychotics like neuroleptics is lower than used for psychotic disorders like schizophrenia.

Preferred regimen (1): drug name 100 mg PO q12h for 10-21 days

• Preferred regimen (1): Fluoxetine 20 mg PO qd initially, and then increase weekly by 20 mg up to a maximum of 80 mg/day.
• Preferred regimen (1): Escitalopram-10 mg PO qd initially, and then increased to 20 mg after a week.
• Preferred regimen (1): Sertraline-25 mg PO qd initially, and then increased weekly to 50 mg weekly to a maximum of 200 mg/day. Safer in pregnancy.
• Preferred regimen (1): Duloxetine-20-30 mg PO BID initially, and then increased to 60 mg qd after one week.
• Preferred regimen (1): Venlafaxine (extended release)-37.5 to 75 mg PO qd initially, and then increased by ≤75mg/day over 4-7 days, maximum dose is 225 mg/day. (immediate release)- 75mg PO q8-12 hr and can be titrated over 4-7 days.

• Preferred regimen (1): Lamotrigine-25 mg/day PO for two weeks, 50 mg/day PO for next two weeks, 100 mg/day PO for next (5th week) and 200 mg/day POfrom next week (6th week) and onwards.
• Preferred regimen (1): Lithium-started at 100- 200 mg/day PO and titrated over next few months to 600 mg/day PO. Lower initial doses are used to prevent adverse effects and gradually it is increased to maintain the levels between therapeutic window of 0.8-1.0 mEq/L.
• Preferred regimen (1): Valproic acid-500-750 mg/day PO; started with 250 mg/day PO and increased over 1 to 3 days to 500-1000 mg/day PO.

• Preferred regimen (1): Quietiapine-25 mg/day PO, initially increments in dosage is done daily and after day 4, it is done after days to maximum of 150 mg/day.
• Preferred regimen (1): Risperidone-0.5 mg/day PO initially, and increased to 1mg/day PO after a month.
• Preferred regimen (1): Aripiprazole-2.5 mg/day PO

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