Personality refers to a relatively stable set of tendencies in behaviors, cognitions, and emotional patterns, which together constitute a person’s unique character. One person may, for example, be described as extroverted, flamboyant and dominant, while another may be described as introverted, shy and submissive.
People tend to have a relatively good sense of who they are with respect to these characteristics. They are aware of the effect of their personality on others and how their environment shapes them. This awareness helps people make decisions and manage their relationships. In some people, however, tendencies in behaviors, cognitions, and emotional patterns are extreme and maladaptive, indicated by problems in self-regulation and unstable relationships, with a compromised ability to function at work or school. From a psychiatric point of view, such people may have a personality disorder.
There are two parallel classification systems for personality disorders in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).1 Section II of the DSM-5, which contains diagnostic criteria and codes for mental disorders , maintains the tradition of previous editions, considering personality disorders as discrete and categorical entities.
Ten categories of disorders are described : paranoid, schizoid, schizotypal, antisocial, borderline, histrionic, narcissistic, avoidant, dependent, and obsessive-compulsive personality disorders. The predominant characteristics of each personality disorder are summarized in Table 1. This system has been criticized due to evidence of continuity between normal and abnormal personalities, heterogeneity within personality disorder categories, a high co- occurrence among personality disorders, a high prevalence of personality disorder not otherwise specified, arbitrary diagnostic thresholds, and a restricted clinical ability to predict treatment effectiveness.2,3
Additionally, studies have questioned the validity of the 10 categories of personality disorders, leading to the view that they cannot be considered something that a person either has or does not have, but rather that personality functioning can be described along a severity continuum.2-5 Therefore, in Section III of the DSM-5, an approved alternative system for diagnosing personality disorders has been proposed, as summarized in Table 2.
Instead of viewing personality disorders as categorical entities, this system, called the alternative model for personality disorders, proposes a combination of categorical and “dimensional” approaches , forming a hybrid diagnostic scheme.
The dimensional approach recognizes individual differences in the manifestation of personality traits, from mild to moderate and severe, with underlying dimensions (constructs) that explain high levels of overlap between personality disorders. For example, all 10 categories of personality disorders involve problems with self-regulation and maintaining stable relationships, and therefore it makes sense to identify a unifying construct that allows for a more parsimonious diagnosis. Based on the alternative model for personality disorders, the clinician first assesses the underlying dimension shared by all personality disorders (criterion A): maladaptive autonomic functioning (meaning disordered identity and self-direction) and interpersonal functioning (meaning which means disordered empathy and intimacy).
Next, the clinician assesses the severity of the pathological personality traits in five domains of maladaptive traits (criterion B): negative affectivity, detachment, antagonism, disinhibition, and psychoticism. In a third step, the clinician has the option to specify one of six discrete categories of personality disorders: schizotypal, antisocial, borderline, narcissistic, avoidant, and obsessive-compulsive. The other four disorders that were in the traditional categorization (paranoid, schizoid, histrionic, and dependent personality disorders) were not retained in the alternative model for personality disorders due to insufficient data to validate them as distinct entities.6- 8
Another perspective is provided by the diagnostic scheme for personality disorder in the 11th revision of the International Classification of Diseases (ICD-11),9,10 endorsed by the World Health Organization. This scheme, which is also summarized in Table 2, reflects the alternative model for personality disorders in its initial assessment of the criteria for maladaptive autonomic functioning and interpersonal functioning, as well as its use of the maladaptive trait domains, but the ICD-11 rules out all traditional categories of personality disorders except borderline personality disorder (BPD). This category has been retained as a specifier in order to give mental health services time to adjust their systems to the dimensional model, after which the TLP specifier is expected to be removed.
Although the transition to an alternative model for the diagnosis of personality disorders is supported by the clinical and research communities,4,11 the treatment literature still predominantly focuses on the categorical approach. The highest quality evidence for several treatments concerns BPD, which is the personality disorder most frequently diagnosed in clinical settings12-14 and the most researched personality disorder.15,16
There is also support for the idea that BPD represents features of personality dysfunction that are shared across all manifestations of the personality disorder,17,18 meaning that information about BPD may be relevant to all other disorders. of personality. This review therefore focuses predominantly on BPD, with perspective provided by considering the other five categories of disorders that have been retained in the alternative model.
| Epidemiology of BPD |
A meta-analysis has suggested that BPD has a community point prevalence of 0.7 to 2.7%,19 which is similar to the prevalence of other personality disorders in the general population. A systematic review has estimated the mean prevalence of BPD to be 22.4% among inpatients in psychiatric units and 11.8% among patients in outpatient psychiatric settings.20
Some studies have suggested that rates of BPD are higher than rates of other personality disorders. Furthermore, analyzes have suggested that up to half of psychiatric patients may meet criteria for a personality disorder.21,22 Data are lacking on the prevalence of personality disorders among adolescents, with the exception of BPD, which it has been reported to have a prevalence of 11% among adolescents in outpatient psychiatric settings.23 The rate of BPD among adolescents in inpatient psychiatric settings is generally higher than the rate among adults, with two studies showing prevalences of 35.6 % and 32.8%.24.25
Less is known about the prevalence of personality disorders in primary care because they are not routinely assessed in this setting. A misdiagnosis of personality disorder in a primary care setting can have serious consequences, given the associated risks of suicide (2 to 5% among people with BPD)26 and impaired social functioning20 and the high burden of personal distress, health care costs, and loss of productivity.27-29
Prevalence studies of personality disorders have suggested that the rate among men is similar to the rate among women in the general population,19 but in clinical psychiatric settings, the prevalence has been higher among women, with little evidence suggesting that this is the result of gender bias in assessment.30 Although most prevalence studies have not shown systematic racial or ethnic differences, some studies are addressing this issue.20
| Clinical features |
Diagnostic criteria for personality disorders are assessed through an interview conducted by a clinician, which may be supplemented by semi-structured interviews or patient-reported measures. Several of these measures can also be used to screen patients for other personality disorders. Additionally, the International Consortium for Health Outcomes Measurement has a battery of patient-reported measures that can be used to assess outcomes of personality disorders.31
BPD is characterized by a pervasive pattern of inadequate emotional regulation, a poor or inconsistent sense of self and identity, and disordered interpersonal relationships.32
The disorder was first included in the third edition of the Diagnostic and Statistical Manual of Mental Disorders, published in 1980. 33 According to Section II of the DSM-5, the diagnosis of BPD can be established when an adult or adolescent turns at least five of the nine diagnostic criteria, listed in Table 3.
The coexistence of personality disorders and other mental disorders is common. For example, an analysis of data from the National Epidemiologic Survey on Alcohol and Related Conditions showed that among patients with BPD, the lifetime prevalence of anxiety disorders is 84.5%, mood disorders 82%. .7% and substance use disorders 78.2%.14 High rates of post-traumatic stress disorder (30.2%), attention deficit hyperactivity disorder (33.7%), bipolar I (21.6%), bipolar II disorder (37.7%) and somatic disorders among patients with BPD.32
The overlap of BPD with other psychiatric disorders and with other personality disorders supports the idea that there are characteristics shared by all of these disorders, including characteristics of internalizing behavior (e.g., depression, anxiety, and stress-related disorders ) and externalizing behavior (e.g., substance use and antisocial behavior).34
| Start and course |
For decades, it was thought that personality disorders could not be diagnosed in adolescence. Opponents of early diagnosis argued that personality was not yet stable enough to justify any diagnosis, and it would be stigmatizing to diagnose a personality disorder in a young person. However, more recent empirical research on BPD has altered this view.35
There is evidence that BPD in adolescents is a coherent syndrome,36 that valid and reliable measures of this syndrome are available,37,38 that it is separate from other disorders in course and outcome,39,40 and that it is similar to BPD in adults with respect to prevalence,41 stability,42 and risk factors.43 There is also preliminary support for the effectiveness of BPD treatment in adolescents, although more studies are needed.44
Adolescence is a risk period for the onset of personality disorders, and advocacy groups have made progress in destigmatizing these disorders in adults and adolescents, as well as promoting prevention and early intervention.45 Given Since personality stability increases with age, it may make sense to intervene early, when personality is more malleable, but this has not been established empirically.
Prospective cohort studies have shown different rates of stability of the BPD diagnosis (i.e., the consistent presence of BPD) from adolescence to adulthood, with the rate of stability depending on how the disorder is measured.32 Rates of Stability for the categorical diagnostic range ranges from 14 to 40%. Naturalistic follow-up studies have shown that the severity of BPD decreases over time , with a mean remission rate of 60%.26 In contrast, when BPD traits are counted dimensionally rather than categorically, the average stability of the diagnosis at over time is higher, with estimates of 39 to 59%.
When a person’s classification in terms of the level of BPD traits is compared to the classification of other people of the same age, the stability of BPD is reported to have been even higher (53 to 73%). Low stability rates for categorical diagnosis, along with treatment outcomes, have challenged the notion that BPD is an untreatable and untreatable disorder. However, even when a patient no longer meets the clinical threshold (i.e., five of nine criteria) for BPD and the disorder is considered to be in remission, functional impairment persists.
| Causes and pathophysiological correlates |
Twin studies have suggested that BPD is approximately 55% heritable.46 Although data on other personality disorders are sparse, some reports have suggested moderate heritability.47 Theoretical models of the development of personality disorders They are based on the idea that there are interactions between biological predispositions and environmental factors.48,49
According to these models, children who are born with a sensitive temperament and who are raised in families in which caregivers struggle to meet children’s emotional needs are at greater risk of developing personality disorders,46,50 -55 and prospective studies have shown that harsh or insensitive parenting, emotional neglect, physical or sexual abuse, and bullying victimization are associated with the development of personality disorders.43 The specificity of these risk factors and the role of the child’s temperament in the evocation of parenting behaviors are unclear.
Data on the physiological factors associated with personality disorders are lacking for most conditions. However, cross-sectional studies suggest that correlates of BPD exist in three domains.
First, a meta-analysis showed that, compared to healthy or depressed people, people with BPD have pronounced amygdala hyperreactivity in response to negative emotional stimuli that has been associated with emotional dysregulation. However, people with PTSD have even more pronounced amygdala hyperreactivity than those with BPD, 56 indicating that these findings may be nonspecific. This meta-analysis also showed that BPD patients have greater activation of the medial cingulate gyrus during the processing of negative emotional stimuli.
Second, a meta-analysis showed that, compared to healthy controls and people with other personality disorders, people with BPD have abnormalities in stress responses, indicated by continued cortisol production and a blunted cortisol response. to stress. Although these studies have generally been of low quality, they point to directions for research into the functioning of the hypothalamic-pituitary-adrenal axis and BPD.57
Third, people with BPD have abnormal functional neuroimaging findings in areas of the brain associated with social cognition, self-functioning, and identity functioning. Such areas include regions of the orbitofrontal, medial prefrontal, and anterior cingulate cortices; regions of the precuneus and posterior cingulate cortex; cortical and subcortical regions of the temporal lobes, including the amygdala; and somatosensory cortices.58 These findings may not be specific to BPD and require replication.
| Treatment |
Few disorder-specific randomized treatment trials have been conducted for schizotypal, antisocial, narcissistic, avoidant, and obsessive-compulsive personality disorders. However, treatment protocols for BPD have been developed and several randomized controlled trials have been conducted to evaluate them. Although psychotropic medications, such as mood stabilizers, antidepressant agents, and antipsychotic medications, are routinely prescribed to people with BPD, no medications have been approved by regulatory agencies for the treatment of BPD, and the effect of medications is uncertain.
Pharmacotherapy has been used to relieve symptoms of co-occurring disorders , such as depression, anxiety, impulsivity, and psychosis, with little evidence that they address symptoms specific to BPD.32
A Cochrane review59 and national treatment guidelines60, 61 suggest that psychotherapy may be an effective approach for the treatment of BPD. The Cochrane review included randomized controlled trials of psychotherapy that enrolled a total of 4,507 patients, predominantly women aged 15 to 46 years in outpatient settings, with treatment lasting only up to 36 months. Compared with treatment as usual, psychotherapy had modest but clinically relevant effects on symptom severity, self-harm, suicidality, and impaired psychosocial functioning (listed in order of approximately decreasing effectiveness). Although approximately 16 different types of psychotherapy have been evaluated for the treatment of BPD, one-third of the trials have used dialectical behavior therapy,62 followed in frequency by trials of mentalization-based therapy.63
Dialectical behavior therapy aims to reduce emotional dysregulation by discussing and building emotional regulation skills. The goal of mentalization-based therapy is to help patients view problems and their interpretations of interactions from multiple perspectives, with the goal of improving self-regulation and the quality of interpersonal relationships.
Other treatment approaches, with fewer trials, include good psychiatric management for BPD, 64,65 schema-focused therapy, 66 transference-focused psychotherapy, 67 and Systems Training for Emotional Predictability and Problem Solving (STEPPS), 68 all of which have adherents, but are not as widely accepted as dialectical behavior therapy and mentalization-based therapy.
| Conclusions and future directions |
Cost-effective treatments that require fewer and shorter psychotherapy sessions delivered by less specialized mental health professionals are needed, as current approaches require considerable resources and patient involvement. Although the benefits of prevention and early intervention are generally accepted, few high-quality randomized controlled trials have focused on personality disorders in adolescents.
The field is in transition and continues to grapple with the question of whether a categorical personality disorder diagnostic system or a dimensional model is more beneficial to patients.
The lack of data on treatment outcomes for many personality disorders, as well as data on the alternative model for personality disorders, has made it difficult to draw conclusions about the value of various treatments. The understanding of personality disorders continues to evolve.
Comment
|
Table 1. Predominant characteristics of personality disorders as described in DSM-5, Section II.* Category and characteristics paranoid Distrust and suspicion, tendency to interpret other people’s motives as malevolent Schizoid Detachment from social relationships and restricted range of emotional expression schizotypal Acute discomfort in intimacy and interpersonal relationships, cognitive or perceptual distortions, and behavioral eccentricities Antisocial Indifference and violation of the rights of others Limit Instability in interpersonal relationships, self-image and emotions and marked impulsivity Histrionic Excessive emotionality and attention seeking Narcissistic Grandiosity, need for admiration and lack of empathy Avoidant Social inhibition, feelings of inadequacy and hypersensitivity to negative evaluation Dependent Excessive need to be cared for, resulting in submissive and clinging behavior Obsessive-compulsive Concern for order, perfectionism and control |
| * DSM-5 denotes fifth edition of the Diagnostic and Statistical Manual of Mental Disorders |
Table 2. Abbreviated Diagnostic Criteria for Personality Disorder, according to DSM-5, Section III, and ICD-11.* DSM-5, Section III (Alternative Model for Personality Disorders) The patient has moderate or greater impairment in personality functioning (self-functioning and interpersonal functioning), rated >2 on a 5-point severity scale (0 to 4), indicated by difficulty in at least two of the following four areas: identity, self-direction, empathy or intimacy The patient has maladaptive traits in one or more of the following five trait domains (or trait facets within the domains): negative affectivity, detachment, antagonism, disinhibition, or psychoticism (strange, eccentric, or unusual behaviors or cognitions) Personality dysfunction and trait expression are relatively inflexible and pervasive across multiple contexts (i.e., symptoms do not occur only at home or during certain times) Personality dysfunction is stable over time and the onset dates back to adolescence or early adulthood. The dysfunction is not better explained by another mental disorder The dysfunction cannot be attributed to the physiological effects of a substance or another medical condition Impairments are not best understood as normal for the person’s developmental stage or sociocultural environment ICD-11 Patient has deficits in aspects of self-functioning and interpersonal functioning, described as mild, moderate, or severe personality disorder Personality disorder and personality difficulty can be described in terms of five trait domain specifiers: negative affectivity, detachment, dissocial behavior (lack of empathy, callousness, or meanness), disinhibition, or anankastia (obsessive-compulsive behavior). The disorder has persisted for a prolonged period (e.g., ≥2 years) The disorder manifests in patterns of cognition, emotional experience, emotional expression, and behavior that are maladaptive (e.g., inflexible or poorly regulated). The disorder manifests itself in a variety of mental and social situations, although it may be consistently evoked by particular types of circumstances and not by others. The symptoms are not due to the direct effects of a medication or substance, including withdrawal effects, and are not better explained by another mental disorder, a disease of the nervous system, or another medical disorder The disorder is associated with substantial distress or marked impairment in personal, family, social, educational, occupational, or other important areas of functioning. Personality disorder should not be diagnosed if the behavioral patterns that characterize the personality disorder are developmentally appropriate or can be explained primarily by social or cultural factors, including sociopolitical conflicts * ICD-11 indicates the 11th revision of the International Classification of Diseases |
Table 3. Categorically defined borderline personality disorder, according to DSM-5, section II The patient has a generalized pattern of instability in interpersonal relationships, self-image and affects and marked impulsivity, indicated by at least five of the following nine personality traits: Frantic efforts to avoid abandonment Unstable and intense interpersonal relationships Identity alteration Impulsivity in at least two areas (e.g., spending, substance abuse, reckless driving, or binge eating) Recurrent suicidal or self-mutilating behavior emotional instability Chronic feelings of emptiness Intense, inappropriate anger or difficulty controlling anger Transient paranoid ideation related to stress or severe dissociative symptoms Symptoms are relatively inflexible and pervasive across multiple contexts (i.e., symptoms do not occur only at home or during certain times) Symptoms cause significant distress or impairment in functioning. The symptoms or behavioral patterns are stable over time and their onset dates back to adolescence or early adulthood. The symptoms are not better explained by another mental disorder. The symptoms are not attributable to the physiological effects of a substance or other medical condition. |
