Personality disorder

Personality disorder is defined in the ICD10 as: ‘Deeply ingrained and enduring behaviour

patterns manifesting themselves as inflexible responses to a broad range of personal and social situations.


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I. Personality Disorders:
Personality disorder is defined in the ICD 10 as: `Deeply ingrained and enduring behaviour
patterns manifesting themselves as inflexible responses to a broad range of personal and social
situations. They represent either extreme or significant deviations from the way an average
individual in a given culture perceives, thinks, feels and particularly relates to others. Such
behaviour patterns tend to be stable and to encompass multiple domains of behaviour and
psychological functioning. They are frequently, but not always, associated with various
degrees of subjective distress and problems in social functioning and performance... They
are developmental conditions, which appear in childhood or adolescence and continue into
adulthood.' 1
However, there are some criticisms of the concept of personality disorder as a diagnosis.
· Instability in raters when diagnosing PD
· Personality may not be a stable concept ­ changes with time and situation
· Dimensional vs categorical ­ many PDs overlap
· Stigmatising ­ the diagnosis is often applied to patients that psychiatrists do not like
(shown by a famous paper by Lewis and Appleby, 1988) 2
· The disorder vs. illness debate ­ are PDs treatable? Important with respect to the
treatability criterion for detention under the MHA (category of psychopathic disorder
within MHA will disappear when the new Mental Health Act comes into force)
Rates vary according to the population studied:
· Community prevalence ­ 2 3% (according to some studies, up to 10%)
· GP attenders ­ 20%
· Psychiatric outpatients ­ 40%
· Psychiatric inpatients ­ 50%
· Male prisoners ­ 60%
There is an excess of PD amongst males, urban communities and younger age. People with
PD have higher rates of mortality and morbidity due to suicide (suicide rate is 3 times
higher than in those with out PD), accidents and homelessness. They are more likely to be
unemployed and have higher rates of crime and violence. 3
There is a high comorbidity between PD and other mental disorder:
· Affective disorder ­ 57%
· Anxiety disorder ­ 41%
· Substance misuse ­ 56%
· Any axis I disorder ­ 50%
PDs have historically been classified according to aetiological theory. Jung (dispositions),
Ketschmer (ectomorph, endomorph, mesomorph), Eysenck (introversion extroversion,
neuroticism, psychoticism) and Cloninger (novelty seeking, harm avoidance, reward
dependence) saw personality as varying components of dimensional traits or characteristics.
The ICD and DSM use categorical definitions outlined below, which broadly correlate :
Cluster A
Paranoid Paranoid
Schizoid Schizoid

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Schizotypal ­ grouped with Schizotypal
psychotic disorders in ICD)
Cluster B
Dissocial Antisocial
Emotionally unstable (2 subtypes) Borderline
Histrionic Histrionic
Cluster C
Anankastic Obsessive compulsive
Anxious (avoidant) Avoidant
Dependent Dependent
Cluster A
These disorders have a familial relationship to the schizophrenia spectrum. Stress
decompensation into psychosis can occur. Studies of these disorders are hard to perform as
the nature of cluster A PDs almost precludes study.
· 0.…read more

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· Aetiology ­ dynamic theory (the border between neuroses and psychoses, splitting,
projective identification and projection are seen in borderline personality disorder),
attachment disorder, childhood abuse in >75%, low serotonin model and impulsive
· High comorbidity with affective, anxiety, somatisation, PTSD and substance misuse
· Suicide in 8 10%
· Marriage rates are half the average and odds of having children, one quarter
· Outcome more favourable than previously thought: 5
2/3 clinically well at follow up at 10 30 years (some residual…read more

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Some evidence for the use of low dose neuroleptics in cluster B and schizotypal disorders
· Carbamazepine may be of use in behavioural dyscontrol in borderline PD 7
· Lithium may be of benefit for aggressive behaviour (although the majority of patients
with borderline personality disorder do not respond to lithium therapy)8
· Evidence for use of SSRIs in impulsive behaviour (Serotonin is known to be implicated in
the mechanism of self mutilation and impulsivity) 9
· Some evidence for use of MAOIs or…read more

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There is a high level of co morbidity between personality disorder and other
mental disorders. 15
Children of parents with personality disorder are more likely to have a mental disorder than
children of parents with schizophrenia.
Mental illness in pregnancy
The first trimester is associated with an increase in minor mental illness e.g. mild anxiety
symptoms. However, depression in pregnancy is approximately one third as common as
depression starting post natally.…read more

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antidepressants have lower known risks during pregnancy than other antidepressants.
Fluoxetine is the SSRI with the lowest known risk during pregnancy. Breastfeeding does not
appear to be a problem with TCAs and the more limited data on SSRIs suggest they are
probably safe. Imipramine, nortriptyline and sertraline are present in breast milk at
relatively low levels. Citalopram and fluoxetine are present in breast milk at relatively high
levels.…read more

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Extrapyramidal symptoms in the neonate especially with depot medication (these are usually selflimiting).
Actions to take
· Advise women taking antipsychotics who are planning a pregnancy that raised prolactin levels
reduce the chances of conception. If levels are raised, consider an alternative drug.
· If prescribing olanzapine to a pregnant woman, consider risk factors for gestational diabetes and
weight gain, including family history, existing weight and ethnicity.…read more

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Risks to consider
· Cleft palate and other fetal malformations.
· Floppy baby syndrome in the neonate.
Paper III: General Adult Psychiatry - III Diet II: 2008
Actions to take
· Do not routinely prescribe to pregnant women, except for the short term treatment of extreme
anxiety and agitation.
· Consider gradually stopping in pregnant women.…read more

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The efficacy of SSRIs in the treatment of both physical and psychological symptoms of
premenstrual syndrome has been confirmed and studies have shown that these drugs also
reduce functional impairment.19 The onset of improvement is more rapid than that in SSRI
treatment of depressive disorder. Treatment can be given throughout the menstrual cycle,
but several studies now support dosing during the luteal phase alone, as this appears to be
equally efficacious.…read more


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