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The colorful world of personality disorders - (11/21/2019)

By Dr. Ron Gasbarro

What is a personality?
Perhaps the best way to define personality is to say what it is not. The closest thing in real life to not having a personality is someone who has a “flat affect.” A flat affect is the muting or complete lack of an emotional reaction to an event or situation that would generally elicit some form of emotion: 1) Neither happy nor sad; 2) Both unresponsive and uncommunicative; 3) Neutral and devoid of any character; 4) Speaks in a monotone voice. People with flat affect do not lack emotion, but rather their feelings go unexpressed. The absence of visual or verbal emanations can be caused by conditions that include autism, depression, schizophrenia, and brain injury. Various medications can be used to reverse flat affect, depending on its etiology.

Hence, a “normal” personality is what gives a person character, for good or for evil. You have something to say. You have convictions and beliefs. You love, and you hate. You are generous, or you are greedy. You respond to stimuli. You have a purpose in life.

What is a personality disorder?
According to the American Psychiatric Association, a personality disorder is a means of thinking, feeling, and behaving that varies from the expectations of the culture, causes distress or functioning problems, and endures over time [APA, 2018]. Such disorders are long-term patterns of conduct and inner experiences that differ significantly from what society expects. Personality disorders begin by late adolescence or early adulthood. Without treatment, personality disorders can be long-term. Personality disorders involve two or more of these areas:
How one thinks about oneself and others
How one responds emotionally
How one relates to others
How one controls one’s behavior

Ten specific types of personality disorders exist [APA, 2018; Mayo Clinic, 2019].
Paranoid personality disorder
You may:
Find it difficult to confide in others
Find it very hard to trust other people
Watch others closely, seeking signs of hostility or betrayal
Incorporate threats and dangers into everyday situations.
Karen is very secretive. She believes that people are watching her every move. 

Schizoid personality disorder
You may:
Be apathetic about forming close relationships with other individuals, including your family
Feel that relationships cause problems
Get little joy from life
Be emotionally distant towards others
Walt feels that people are too much to bother with, so he stays alone in his apartment. 

Schizotypal personality disorder
You may:
Find forging close relationships tremendously difficult
Behave in ways that others find peculiar
Believe that you are a thought reader or that you have special powers such as clairvoyance
Feel tense and anxious with others who do not share your beliefs
Lois finds that her extreme faith in and fear of ghosts make others laugh at her.

Antisocial personality disorder (ASPD)
You are 18 years or older. You may:
Put yourself in dangerous or risky situations 
Behave dangerously and illegally
Behave in ways that are distasteful to others
Feel easily bored and act on impulse – you may find it difficult to hold down a job for long
Behave aggressively and get into fights easily
Not feel guilty if you have mistreated others
People tend to avoid Tom because of his combative ways of dealing with others. 

Borderline personality disorder (BPD)
You may:
Find it difficult to initiate and maintain stable relationships
Have suicidal thoughts or self-harming behavior
Continuously feel lonely and empty 
Become very angry and struggle to control your anger.
Claire has been married three times and is about to give up on all relationships.

Histrionic personality disorder

You may:
Be uncomfortable if you are not the center of attention
Feel that you have to entertain people
Have a reputation for being dramatic and self-pitying
Feel dependent on the approval of others
Harry gets jealous when someone gets the last laugh.

Narcissistic personality disorder
You may:
Have fragile self-esteem, so that you count on others to identify your worth and needs
Feel upset if others ignore you 
Resent other people’s successes
Put your wishes above other people’s, and expect them to also
Marie lies about others to make her feel better about herself.     

Avoidant (or anxious) personality disorder
You may:
Avoid work or social activities with others
Expect criticism and disapproval and be hypersensitive to it
Worry constantly about being rejected
Agonize over being ridiculed or shamed by others
Kyle does not go to parties because he feels he is not good enough to socialize.

Dependent personality disorder
You may:
Need much emotional support and only makes decisions or functions with help 
Let others assume control many areas of your life
Fear being left to fend for yourself
Possess low self-confidence
Brenda extinguishes every relationship with her habit of being extremely clingy.

Obsessive-compulsive personality disorder (OCPD)
You may:
Need to keep yourself and your life in order and under control
Think your way is the best way of making things happen
Be frugal with yourself or others
Be inclined to hoard items with no apparent value
Bob has 150 pairs of shoes that he has gotten from the Goodwill.

Causes
Personality takes shape during childhood, formed through an interaction of:
Genetics. You can inherit some personality traits from your parents. These traits are sometimes called your temperament. 
Environment. The impact of your environment involves the surroundings in which you were raised, events that happened, and relationships with family and others.
A combination of these genetic and environmental influence causes personality disorders, state researchers. One’s genes cause may make one susceptible to developing a personality disorder, and a life situation (e.g., sexual abuse) may trigger the actual development.

Risk factors
Scientists do not know the precise etiology of personality disorders. However, certain factors appear to heighten the risk of developing or triggering personality disorders, including:
Family history of personality disorders or other mental illness
Abusive, unstable, or chaotic family life during childhood
A diagnosis of childhood conduct disorder
Differences in brain chemistry and structure

Treatment strategy
If a patient’s life appears to be disrupted, then consider a diagnosis for a personality disorder. 
Be careful to differentiate such symptomatology and diagnosis from more distinct psychiatric conditions such as anxiety and depression. 
Refer a patient with a personality disorder for psychotherapy, considered to be the gold standard in such cases. 
Employ pharmacotherapy prudently as an adjunctive treatment. 


Medications
No medications are specifically approved by the US Food and Drug Administration (FDA) to treat personality disorders, states the Mayo Clinic. However, several types of psychiatric medications may control various symptoms of a personality disorder.
Antidepressants. These agents may be useful for a depressed mood, anger, impulsivity, irritability, or hopelessness, which may be associated with a personality disorder. Examples: Cymbalta® (duloxetine); Brintellix® (vortioxetine); Effexor® (venlafaxine).
Mood stabilizers. These pharmaceuticals can level mood swings or lessen irritability, impulsivity, and aggression. Examples: Lithium; Tegretol® (carbamazepine); Depakote® (valproate)
Antipsychotic medications. Also called neuroleptics, these drugs may be valuable if symptoms include psychosis (losing touch with reality), or if anxiety issues or anger problems exist. Examples: Abilify® (aripiprazole); Vraylar® (cariprazine); Seroquel® (quetiapine)
Anti-anxiety medications. Anxiolytics may be helpful for symptoms of anxiety, agitation or insomnia. In some cases, they can increase impulsive behavior, so they are avoided in certain types of personality disorders. Examples: Xanax® (alprazolam); Lunesta® (eszopiclone); Klonopin® (clonazepam).

The full spectrum of personality disorders is a severe health issue that affects millions of people. A 2018 meta-analysis examined the prevalence of personality disorders in 113,993 individuals [Volkert, 2018]. While prevalence rates were relatively high for all known personality disorders (12.2%), the frequency was highest for obsessive-compulsive disorders (4.3%). The diagnosis is difficult, elusive, with some types of disorders overlapping. Treatment for these individuals must be improved, and this will only happen through early recognition and intervention programs as well as continued research in the areas of neurobiology and psychiatry. 

Ron Gasbarro, PharmD, is a registered pharmacist, medical writer, and principal at Rx-Press.com. Read more at Rx-Press.com.

References
Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Washington, DC: American Psychiatric Association; 2013.

Volkert J, Gablonski TC, Rabung S. Prevalence of personality disorders in the general adult population in Western countries: systematic review and meta-analysis. Br J Psychiatry. 2018;213:709-15.

 

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