Personality disorders (PD) are deeply ingrained, maladaptive patterns of behaviour which appear from late childhood to early adulthood.
- the definition of the term “personality” is still a controversial concept.
- most commonly used definition is;
“an enduring pattern of thoughts, feelings, and behaviour in an individual which makes us differ from one another” (1).
- people with PD demonstrate an enduring pattern of perceiving, relating to, and thinking about the outside world and the self that is inflexible and deviates markedly from cultural expectations, and is exhibited in a wide range of social and personal contexts
- in addition they have limited range of feelings, attitudes, and behaviours with which to cope with the stresses of everyday life (1)
- suggested indicators for personality disorder in non-specialist settings include (2):
- strong indicators
- negative affectivity and affective dysregulation (rapid mood changes, low mood, anxiety, anger, detachment)
- impulse dysregulation (risk taking behaviours, sexual promiscuity, alcohol and substance misuse)
- interpersonal problems:
- a) In "outside" life (eg, turbulent relationships, violence, dependence, avoidance, isolation);
- b) In the clinical encounter (eg, increased use of resources, recurrent crises, feeling stuck). In particular, turbulence and volatile relationships tend to be characteristic of borderline personality disorder difficulties
- strong emotional reactions in the clinician during the clinical encounter
- unusual departures from established clinical practice (eg, prescribing out of the ordinary, allocation of clinical time, working outside expertise)
- poor responses to evidence based treatments for other mental health conditions (anxiety, depression, post-traumatic stress disorder)
- additional possible indicators to consider:
- cognitive-perceptual symptoms (rigid or bizarre ideas, antagonism, lack of trust, unusual dissociative or quasi-psychotic symptoms)
- evidence of self-injurious behaviours (scars, marks on skin), significant history of deliberate self-harm and suicidal behaviours
- having medically unexplained symptoms
- parents of children presenting with evidence of deficits in the home environment (eg, neglect, abuse, social adversity, or trauma)
- early adversity and history of trauma (but do not adopt a mechanistic approach, assuming or excluding a diagnosis based on the presence or absence of adversity and trauma)
- childhood diagnosis of emotional disorder, disrupted behaviours, or conduct disorder
These disorders are characterised by very longstanding symptoms which have been present more or less unchanged throughout the patient's adult life. This is the principle distinguishing factor between personality disorders compared to a neurotic or psychotic illness which results from a morbid process of some kind and has a more recognisable onset and time course (1).
Cause of PD is thought to be a result of multiple interacting genetic and environmental factors.
- studies suggest that the heritability of personality traits and personality disorders range from 30% to 60%
- family and early childhood experiences play an important role, including experiencing abuse (emotional, physical, and sexual), neglect, and bullying (1).
Management in primary care
- caring for people with personality disorders in primary care requires a person centred approach that promotes open dialogue and reduces stigma (2)
- goal is not to provide a cure, or "fix" some underlying fault, but to engage in a curious and compassionate way with the person experiencing distress in their attempt to understand and manage their painful experience, even when their wishes and expectations may initially seem unclear or confusing
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