Summary

Personality is difficult to define, and personality disorders are thus not easy to identify. For the past two centuries, a lot of discussion has taken place about the issue and the definition and classification of personality disorders. At present, different types or categories of personality disorders have their unique features. However, they often present themselves to the clinician in disguise, and the unaware doctors may get into an entangled and awkward relationship with their patients. This may result in damaging effects to all parties concerned. Awareness of the existence of such disorders is an important step when encountering these patients. The appropriate use of supportive psychotherapy and medications can be therapeutic for some of these disorders.

摘要

人格難以定義，人格疾病也因此不易識別。在過去的兩個世紀中，人們對人格疾病的定義和分類進行了廣泛的討論。現在，不同的人格疾病的類型或範疇各有其特點。但多數是以隱藏偽裝的形式出現，如果醫生不察覺，與病人的關係就會變得扭曲不正常，令雙方都受到傷害。診治此類病人的一個重要步驟就是留意有無人格疾病。恰當地應用支持性心理療法和藥物對某幾類人格疾病，很有治療效果。

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Introduction

Personality, character and temperament were regarded as synonymous for a long time, and are even more so in artistic literatures. This Greek viewpoint has dominated the field of western thinking for many centuries.

Rutter et al¹ considered personality as involving the integration of relationships, certain habitual cognitive sets and motivating traits that go beyond the dispositional aspects of temperament. Stone,² a psychoanalyst, considered that personality is the confluence of both character and temperament. In this aspect, character and temperament are defined as follows:³

Character
-	The learned, psychosocial influences on personality, especially the socialisation process and the mirroring process that helped develop self-image and purpose in life.
Temperament
-	The innate, genetic and constitutional influences on personality, a rather biological dimension consisting of novelty-seeking, harm-avoidance, reward-dependence, persistence, and even impulsivity and aggressivity.

If these attributes of the person significantly affect the social adjustment of his/her life, or the daily functioning of his/her acquaintance, a personality disorder may be diagnosed.

What is personality disorder?

By the early nineteenth century, doctors started to separate a group of patients who have behaviour that is different from the conventional types of mental illness. Prichard⁴ called it 'moral insanity' when in the absence of obvious illness patients show gross behavioural or character disturbances. Later, Kraepelin⁵ defined personality disorders as 'morbid mental states in whichthe peculiar disposition of the personality must be considered the real foundation of the malady'. Cloninger⁶ hypothesized three dimensions of personality, that of 'novelty seeking', 'harm avoidance' and 'reward dependence', and that personality disorders resulted from the imbalance between these three areas, thereby creating 8 distinguishable types - antisocial, histrionic, passive-aggressive, passive-dependent, explosive, obsessional, schizoid and cyclothymic.

The current diagnostic criteria are defined in the ICD-10⁷ and the DSM-IV,⁸ and they are relatively similar to one another, with the following common requirements:

1. An enduring pattern of inner experience that deviates markedly from the expectations of the individual's culture, manifested in either cognition, affectivity, interpersonal functioning or impulse control.
2. This pattern is inflexible and pervasive across a broad range of personal and social situations.
3. The pattern leads to clinically significant distress and/or impairment in social, occupational, or other important areas of functioning.
4. The pattern is stable and of long duration and its onset can be traced back at least to adolescence or early childhood.
5. The enduring pattern is not better accounted for as a manifestational consequence of another mental disorder.

Classification of personality disorders

What is confusing is that there is still no very satisfactory and scientifically valid classification system. Theophrastus, a pupil of Aristotle, did present 30 different types of personal characters.⁹ Schneider¹⁰ grouped all personality types under 'psychopathic disorders' with 10 personality types - hyperthymic, depressive, insecure, fanatic, self-seeking, emotionally unstable, explosive, affectless, weak-willed and asthenic psychopathic. Krestschner¹¹ described the 'pyknic' type of personality that was linked more to the manic depressive illness, and the 'asthenic' type that was linked to schizophrenia. Partridge¹² listed out three broad categories, that of 'inadequate', 'egocentric' and 'psychopathic' that are still often used non-scientifically today. This concept of 'psychopathic disorder' was in 1959 incorporated into the Mental Health Act of England, and was defined as 'persistent disorders of mind which resulted in abnormally aggressive or seriously irresponsible conduct on the part of the patients, and require or are susceptible to medical treatment'.

>From a psychoanalytic point of view, Freud¹³ developed the concept of special personality types according to 'fixation' at certain stages of psychosexual development - the oral (the erotic type), anal (the anankastic type), and the genital (narcissistic type). Kernberg¹⁴ abandoned the psychosexual concept and preferred a structural approach, assigning personalities to different levels - a lower 'borderline' level with antisocial, impulsive and narcissistic personalities, and a higher level with histrionic and compulsive personalities. Finally, the famous psychologist Eysenck¹⁵ identified three dimensions of personality - N (neuroticism-stability), E (extraversion-introversion) and P (psychoticism-normality).

These constant changes could be reflected in the various versions of standard classification systems, like the DSM of the American Psychiatric Association or the ICD of the World Health Organisation. The DSM-I version contained 5 headings that were removed in the DSM-II. In the DSM-III, distinction was made between personality disorders and other formal psychiatric disorders. The current DSM-IV laid down specific criteria for diagnosis, though evidence-based research validation had not been found. The ICD-10 is less rigid than the DSM-IV about operational criteria (Table 1). However, ICD considers personality disorder as one form of mental disorder that can co-exist with others, while the DSM considered personality disorders as another axis of classification altogether.

Table 1: The ICD-10 and DSM-IV classifications of personality disorders
ICD-10		DSM-IV
Code	Diagnosis	Cluster	Code	Diagnoses
		A
F60.0	paranoid		301.0	paranoid
F60.1	schizoid		301.20	schizoid
			301.22	schizotypal
		B
F60.2	dissocial		301.7	antisocial
F60.30	impulsive
F60.31	borderline		301.83	borderline
F60.4	histrionic		301.50	histrionic
			301.81	narcissistic
		C
F60.5	anankastic		301.4	obsessive-compulsive
F60.6	anxious (avoidant)		801.82	avoidant
F60.7	dependent		301.6	dependent

Clinical presentation

Personality disorders often go undetected, especially during the initial clinical visits. Very few patients present themselves purely or clearly as having problems with their personality. What is interesting is that they would present with other medical and psychiatric illnesses, or with enduring maladaptive social or behavioural difficulties such as repeated self-injury or fighting, multiple drug abuse, etc. The personality disorder becomes increasingly apparent usually after a number of sessions. After the initial courteous interviews, the patient can become very dependent, manipulative, demanding towards the doctor, and may even be confrontative and dramatic with suicidal threats or gestures. Occasionally, the patient may become seductive and invitatory, and the doctor may find himself/herself making unusual arrangements with the patient with regard to special appointments and having physical contacts outside clinic meetings, etc. It takes an alert and knowledgeable clinician to make a diagnosis. Sometimes, an unaware clinician may get into serious problems with the doctor-patient relationship, thereby putting both himself/herself and the patient at risk of more serious consequences.

Specific personality disorder

Besides the general criteria laid down before, each personality disorder has some interesting features of its own. According to the DSM-IV, the essential features are briefly summarized below.

Cluster A (sometimes called eccentric or odd cluster)

Paranoid personality disorder

The patient suspects, without sufficient basis, that others are exploiting, harming, or deceiving him/her. He/she is preoccupied with unjustified doubts about the loyalty or trustworthiness of friends or associates; is reluctant to confide in others because of unwarranted fear that the information will be used maliciously against him/her; reads hidden demeaning or threatening meanings into benign remarks or events; persistently bears grudges; perceives attacks on his/her character or reputation that are not apparent to others and is quick to react angrily or to counterattack; has recurrent suspicions, without justification, regarding fidelity of spouse or sexual partner.

Schizoid personality disorder

The patient neither desires nor enjoys close relationships, including being part of a family. He/she almost always chooses solitary activities; has little, if any, interest in having sexual experiences with another person; takes pleasure in few, if any, activities; lacks close friends or confidants other than first-degree relatives; appears indifferent to the praise or criticism of others; shows emotional coldness, detachment, or flattened affectivity.

Schizotypal personality disorder

The patient has ideas of reference, and odd beliefs or magical thinking that influences behaviour and is inconsistent with subcultural norms. He/she has unusual perceptual experiences, including bodily illusions; has odd thinking and speech, suspiciousness or paranoid ideation, and inappropriate or constricted affect; has behaviour or appearance that is odd, eccentric or peculiar; a lack of close friends or confidants other than first-degree relatives; excessive social anxiety that does not diminish with familiarity and tends to be associated with paranoid fears rather than negative judgments about self.

Cluster B (sometimes called flamboyant or dramatic cluster)

Antisocial (sociopathic) personality disorder

The patient fails to conform to social norms with respect to lawful behaviour as indicated by repeatedly performing acts that are grounds for arrest. He/she is deceitful, as indicated by repeated lying, use of aliases, or conning others for personal profit or pleasure; impulsive or fails to plan ahead; irritable and aggressive, as indicated by repeated physical fights or assaults; reckless and disregards safety of self or others; consistently irresponsible, as indicated by repeated failure to sustain consistent work behaviour or honour financial obligations; shows a lack of remorse, as indicated by being indifferent to or rationalising having been hurt, mistreated, or threatened by others.

Borderline personality disorder

The patient makes frantic efforts to avoid real or imagined abandonment. He/she has a pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation; identity disturbance with markedly and persistently unstable self-image or sense of self; impulsivity that is potentially self-damaging; recurrent suicidal behaviour, gestures, or threats or self-mutilating behaviour; affective instability due to a marked reactivity of mood, and chronic feelings of emptiness; inappropriate, intense anger or difficulty controlling anger; transient, stress-related paranoid ideation or severe dissociative symptoms.

Histrionic personality disorder

The patient is uncomfortable in situations in which he/she is not the centre of attention. His/her interaction with others is often characterized by inappropriate sexually seductive or provocative behaviour. He/she displays rapidly shifting and shallow expression of emotions; consistently uses physical appearance to draw attention to himself/herself; has a style of speech that is excessively impressionistic and lacking in detail, and shows self-dramatisation, theatrically and exaggerated expression of emotion; is suggestible and he/she considers relationship to be more intimate than actually is.

Narcissistic personality disorder

The patient is preoccupied with fantasies of unlimited success, power, brilliance, etc. He/she believes that he/she is special and unique and can only be understood by, or associate with, other special or high-status people; requires excessive admiration. He/she has a sense of entitlement and is interpersonally exploitative; lacks empathy for others and is often envious of others or believes that others are envious of him/her; shows arrogant, haughty behaviour or/and attitudes.

Cluster C (sometimes called anxious or fearful cluster)

Avoidant personality disorder

The patient avoids occupational activities that involve significant interpersonal contact because of fears of criticism, disapproval or rejection. He/she is unwilling to get involved with people unless certain of being liked; shows restraint within intimate relationships because of the fear of being shamed or ridiculed; is preoccupied with being criticised or rejected in social situations; is inhibited in new interpersonal situations because of feelings of inadequacy; views self as socially inept, personally unappealing, or inferior to others; is unusually reluctant to take personal risks or to engage in new activities because they may prove embarrassing.

Dependent personality disorder

The patient has difficulty making everyday decisions without an excessive amount of advice and reassurance from others. He/she needs others to assume responsibility for most major areas of life, and has difficulty expressing disagreement with others because of fear of loss of support or approval; has difficulty initiating projects or doing things on his/her own; goes to excessive lengths to obtain nurturance and support from others, to the point of volunteering to do things that are unpleasant; feels uncomfortable or helpless when alone, because of exaggerated fears of being unable to care for himself/herself; urgently seeks another relationship as a source of care and support when a close relationship ends; is unrealistically preoccupied with fears of being left to take care of himself/herself.

Obsessive-compulsive personality disorder

The patient is preoccupied with details, rules, lists, order, organisation, or schedules to the extent that the major point of the activity is lost. He/she shows perfectionism that interferes with task completion; is excessively devoted to work and productivity to the exclusion of leisure activities and friendships; is over-conscientious, scrupulous and inflexible about matters or morality, ethics, or values, and is unable to discard worn-out or worthless objects even when they have no sentimental value; is reluctant to delegate tasks or to work with others unless they submit to exactly his or her way of doing things; adopts a miserly spending style toward both self and others and shows rigidity and stubbornness.

Assessment of personality and personality disorders 1. The Eysenck Personality Questionnaire (EPQ),16 based on the concept of a trait or habitual responses which created the personality type. 2. The Cattell Personality Factor Questionnaire (CPFQ),17 also a trait or dimensional based instrument, but not much applied clinically, though quite relevant to current descriptions of personality disorders. 3. The Minnesota Multiphasic Personality Inventory(MMPI)18 has been widely used in the States, but its apparent psychiatric terms (e.g. paranoia, hypomania sub-scales) appear confusing. This instrument has been applied by Morey et al19 to classify personality disorders. However, the 'trait' assessment is quite affected by the current mental 'state' and the trustworthiness of the person at the time of testing. Although some instruments contain the 'lie' scale, deliberate faking is still possible. Furthermore, the validity of these tests is difficult to prove, especially when the results may not fit well into the classification system in clinical psychiatry. Nevertheless, there are a few instruments that measure current personality disorders and meet with the classification in the ICD-10 or the DSM-IV. 1. Millon Clinical Multiaxial Inventory (MCMI)20   - good for recording personality styles, but not too valid for personality disorders. 2. Personality Disorder Questionnaire (PDQ)21   - convenient self-rating questionnaire in use and often good for screening with a cut-off score of 50). 3. Wisconsin Personality Inventory (WISPI)22   - of use in psychotherapy with patients with or without personality disorders. 4. Iowa Personality Disorder Screen (IPDS)23   - a brief, modern screening instrument focusing on DSM personality disorders, useful before a full survey. Many feel that the best assessment is a structured clinical interview. A few of these schedules are listed below: 1. Structural Clinical Interview for DSM-III-R- personality disorder (SCID-II)24   - simple to complete with cut-off points for dimensional assessment. 2. Personality Assessment Schedule (PAS)25   - there is an updated version and also a 'quick' version to identify traits that create significant social dysfunction through direct analysis of traits. 3. International Personality Disorder Examination for either the DSM-IV or the ICD-10 (IPDE)26   - a dimensional approach. Despite the operational criteria in the classification of personality disorders, correlation between the above instruments is not very high. Besides, these tests are not very useful for the extremes of age e.g. adolescents and the elderly persons. Furthermore, Tyrer and Johnson27 categorized personality disorders into different levels of severity: Level 0 - no personality abnormality Level 1 - personality difficulty (sub-threshold criteria for personality disorder) Level 2 - simple personality disorder (one or more personality disorders within the same cluster) Level 3 - complex personality disorder (two or more personality disorders present from different clusters) Level 4 - severe personality disorder (two or more personality disorders from different clusters that create gross societal disturbances).

Epidemiology of personality disorders

It is difficult to assess the exact prevalence of personality disorders, because of its rather imprecise diagnostic criteria. Studies conducted in the clinical setting are often biased by the diagnosis of mental disorders higher in the hierarchy of classification. Therefore, survey in the community would be more accurate. Essen-Moeller²⁸ found 29% of males and 19% of females in a community sample of 2550 to have evident or probable personality disorder, but the terminologies at that time could not be equated to current classification. Srole et al²⁹ found 10% of a Manhattan community having probable personality disorder, using the MMPI.

Weissman et al³⁰ found a lifetime prevalent rate of about 5% in New Haven for 938 adults and followed 511 of them up for 8 to 9 years. Myers et al³¹ investigated the 6-month prevalent rate in three urban cities in the U.S., and the rate was higher for increasing age, in the male sex and in those with lower education. Casey & Tyrer³² using the PAS found 13 % of a general practitioner registered patient population in the U.K., with explosive type being the most common. Last but not the least, Maier et al³³ using the SCID-II in Germany found a prevalent rate of 10.3%, with schizoid and compulsive personality disorders being most common.

Comorbidities with other psychiatric disorders

Personality disorders are often associated with other psychiatric disorders, but such disorders (especially schizophrenia and depression) often distort premorbid personality and make them more abnormal.³⁴ Interestingly, the association between schizophrenia and schizotypal type, depression and the depressive type, obsessive-compulsive disorder and the anankastic type are rather moderate or weak, and not very specific. According to Tyrer,³⁵ there are five areas of strong relationships:

1.	Substance disorders associated with the cluster B (2) personality disorders;
2.	Somatisation disorders and eating disorders associated with clusters B and C;
3.	Neurotic disorders with cluster C (especially social phobia and avoidant type) ;
4.	Post-traumatic stress disorder with cluster B (especially borderline type);
5.	Impulse control disorders (such as pathological gambling) and substance abuse with cluster B.

Management of personality disorders

Because of the unclear nature and causes of personality disorders, treatment for such conditions is difficult and empirical. In a way, psychotherapies are more suitable for clusters B and C personality disorders, while drug therapy is more often applied for cluster A categories.

1.	Supportive psychotherapy
	-	the most often used method to help the majority of these patients. The aim is to help the patients avoid self-endangered consequences and to better manage the situations that provoke the unwanted behaviours. An empathic but 'controlled distant' doctor-patient alliance is important, and the problem-orientated approach is time-saving. However, if no progress is made after a number of sessions, then more specific therapies are indicated.
2.	Psychoanalytic and psychodynamic therapies
	-	in the history of psychiatry these used to be the mainstay of treatment for personality disorders, especially for cluster C categories. The aim was essentially to change the character of the patients, and methods include interpretation, transference and institution of insight, but evidence of success better than placebo has not been found.36 Various modified versions, such as short-term dynamic psychotherapy and brief adaptational psychotherapy, have been developed37 and found to be better than non-treatment.
3.	Cognitive-behavioural therapies
	-	these aim at defining the patients' cognitive and behavioural problems and modify them using behavioural principles and cognitive techniques. In particular, the dysfunctional beliefs about interpersonal relationships are explored and challenged, and more adaptive beliefs are examined and suggested, thereby leading to new ways of behaviour that are reinforced. However, controlled studies of their efficacy are rather scarce, though Linehan et al38 found that their 'dialectical' multi-modal therapy was superior to the usual treatment for borderline personality disordered persons. Evans et al39 found that a brief manualised schema-focused cognitive therapy could reduce the rate of self-harm compared to usual treatment for patients with personality disturbances.
4.	Cognitive-analytical therapy
	-	Ryle40 developed this therapy to identify maladaptive patterns of relationships learned in childhood that are relatively resistant to change. After establishing a therapeutic alliance, the patient is helped to self-aware these 'self-states' and encouraged to change the pattern of thinking and behaviour. This method did find some promise for borderline patients.
5.	Psychosocial therapies
	-	the most famous method is that of the 'therapeutic communities' developed by Jones,41 and is particularly indicated for severe personality disorders.42 In a way, this is continuous group therapy with it's four therapeutic elements of democratization, permissiveness, communalism and reality confrontation. Furthermore, it may be necessary to change the social environment of the patient, and family members are often instrumental in preventing or reducing the triggers of the patient's abnormal behaviour. On occasions, compulsory hospitalisation may be necessary for severe disruptive psychopathic personality disordered patients.
6.	Medications
	-	drug therapy has in the past been targeted as precursors of some formal psychiatric disorders, or when there is a co-existing psychiatric disorder. An example is the use of fluvoxamine for anankastic personality disorder.43 Otherwise, formal pharmacotherapy for pure personality disorders is rare or is ineffective. The most studied groups are for the borderline and the antisocial categories, and antipsychotics, antidepressants (especially the SSRIs for the borderline type) and mood stabilisers have all been tried,44 especially if there is aggressiveness in behaviour. Clear-cut efficacies are uncommon, and even if found are short-term. Benzodiazepines are usually contraindicated because of the relatively ease of developing drug dependence for such patients.

Outcome

Since personality disorders consist of a heterogenous group of disorders, the prognosis for each category would be different, not to mention the contamination by comorbid psychiatric disorders. In fact, the presence of a personality disorder implies a more negative outcome for the comorbid psychiatric disorder. It is true that those personality disorders with an affective element, such as the borderline type, have a better prognosis than the others. It is possible that a certain percentage of these people develop formal psychiatric disorders with time, and some may (especially the borderline type) even change into another type of personality disorder. It has been said that when these patients get older, e.g. at the age of fifty, the characteristics will become more attenuated. But some disorders e.g. the obsessive-compulsive type are rather persistent, and may be more extreme with age. What is more accurate is the mellowing of impulsiveness and aggression (the Cluster B types), while anxiousness and obsessionality (the Cluster C types) remain quite stable over time. Furthermore, the Cluster A types are also relatively persistent with a tendency to worsen with age. Unfortunately, there is usually a high mortality rate for all these patients, and quite a number finally end their lives by suicide and in accidents, especially the borderline personality disorder category.

Conclusion

Personality disorder is still an uncertain concept, with doubtful and complicated aetiology, diagnostic criteria of doubtful validity, and therapies of unknown efficacy. Occasionally, it is really arbitrary to distinguish the normal personality and the abnormal disorder. Hopefully with better research into this topic, more rational therapies could be developed to tackle this rather formidable axis in psychiatry.

Key messages

1. Though personality disorders are varied and confusing in the classification, they are quite disturbing to themselves and to others related to them.
2. These patients often present to their doctors in disguise of other diseases or disturbances, but with time their psycho-pathological features would emerge.
3. Unaware clinicians may find themselves entangled with distorted doctor-patient relationships that are detrimental to all parties concerned.
4. Treatment is not easy, but supportive psychotherapy with a problem-orientated approach is practical; some patients do require specific therapies and even psychotropic medications.

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References