Personality Disorders Dependent

David Bienenfeld, MD Professor, Departments of Psychiatry and Geriatric Medicine, Wright

State University, Boonshoft School of Medicine

David Bienenfeld, MD is a member of the following medical societies: American Medical

Association, American Psychiatric Association, Association for Academic Psychiatry

Disclosure: Nothing to disclose.

Chief Editor

Iqbal Ahmed, MBBS, FRCPsych(UK) Faculty, Department of Psychiatry, Tripler Army

Medical Center; Clinical Professor of Psychiatry, Uniformed Services University of the
Health Sciences; Clinical Professor of Psychiatry, Clinical Professor of Geriatric Medicine,
University of Hawaii, John A Burns School of Medicine

Iqbal Ahmed, MBBS, FRCPsych(UK) is a member of the following medical

societies: Academy of Psychosomatic Medicine, American Neuropsychiatric
Association, American Society of Clinical Psychopharmacology, Royal College of
Psychiatrists, American Association for Geriatric Psychiatry, American Psychiatric
Association

Disclosure: Nothing to disclose.

Acknowledgements

Jerry Balentine, DO Professor of Emergency Medicine, New York College of Osteopathic

Medicine; Executive Vice President, Chief Medical Officer, Attending Physician in
Department of Emergency Medicine, St Barnabas Hospital

Jerry Balentine, DO is a member of the following medical societies: American College of

Emergency Physicians, American College of Osteopathic Emergency Physicians, American
College of Physician Executives, American Osteopathic Association, and New York
Academy of Medicine

Disclosure: Nothing to disclose.

Michael S Beeson, MD, MBA, FACEP Professor of Emergency Medicine, Northeastern

Ohio Universities College of Medicine and Pharmacy; Attending Faculty, Akron General
Medical Center

Michael S Beeson, MD, MBA, FACEP is a member of the following medical

societies: American College of Emergency Physicians, Council of Emergency Medicine
Residency Directors, National Association of EMS Physicians, and Society for Academic
Emergency Medicine

1
 Disclosure: Nothing to disclose.

Barry E Brenner, MD, PhD, FACEP Professor of Emergency Medicine, Professor of Internal
Medicine, Program Director, Emergency Medicine, Case Medical Center, University
Hospitals, Case Western Reserve University School of Medicine

Barry E Brenner, MD, PhD, FACEP is a member of the following medical societies: Alpha
Omega Alpha, American Academy of Emergency Medicine, American College of Chest
Physicians, American College of Emergency Physicians, American College of
Physicians, American Heart Association, American Thoracic Society, Arkansas Medical
Society, New York Academy of Medicine, New York Academy ofSciences,and Society for
Academic Emergency Medicine

Disclosure: Nothing to disclose.

Robert Harwood, MD, MPH, FACEP, FAAEM Program Director, Department of Emergency
Medicine, Advocate Christ Medical Center; Assistant Professor, Department of Emergency
Medicine, University of Illinois at Chicago College of Medicine

Robert Harwood, MD, MPH, FACEP, FAAEM is a member of the following medical
societies: American Academy of Emergency Medicine, American College of Emergency
Physicians, American Medical Association, Council of Emergency Medicine Residency
Directors, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska

Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Reference Salary Employment

Background
A personality disorder, as defined in the Diagnostic and Statistical Manual of the
American Psychiatric Association, Fifth Edition (DSM-5) is an enduring pattern of inner
experience and behavior that differs markedly from the expectations of the individual's
culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable
over time, and leads to distress or impairment. (See Prognosis and Presentation.)
Although the most common etiologies for personality disorders are multifactorial, these
conditions may also be secondary to biologic, developmental, or genetic abnormalities.
Stressful situations may often result in decompensation, revealing a previously unrecognized
personality disorder. Indeed, personality disorders are aggravated by stressors, external or
self-induced. Individuals may have more than 1 personality disorder. (See Pathophysiology
and Etiology.)
Cluster A
Ten personality disorders, grouped into 3 clusters (ie, A, B, C), are defined in the DSM-
5. [1] Cluster A disorders include the following (see Prognosis and Treatment):
 Paranoid personality disorder

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  Schizoid personality disorder
 Schizotypal personality disorder
Cluster B disorders include the following:
 Antisocial personality disorder
 Borderline personality disorder
 Histrionic personality disorder
 Narcissistic personality disorder
Cluster C disorders include the following:
 Avoidant personality disorder
 Dependent personality disorder
 Obsessive-compulsive personality disorder

Personality
A concept has emerged that personality may be expressed in terms of the following 5 basic
dimensions: [2]
 Extraversion
 Agreeableness
 Conscientiousness
 Neuroticism
 Openness to experience
This model is termed the 5-factor model, and it has developed a significant amount of
acceptance among personality psychologists.
The model has been used to describe the different accepted types of personality disorders.
Most current research suggests that personality disorders may be differentiated by their
interactions among the 5 dimensions rather than differences on any single dimension.

Pathophysiology
In patients with personality disorder, abnormalities may be seen in the frontal,
temporal, and parietal lobes. These abnormalities may be caused by perinatal
injury, encephalitis, trauma, or genetics. Personality disorders are also seen with diminished
monoamine oxidase (MAO) and serotonin levels. However, the relationships of anatomy,
receptors, and neurotransmitters to personality disorders are purely speculative at this point.
Frequently, a history of psychiatric disorders is present. In some cases, the patient has
developmental abnormalities secondary to abuse or incest.

Etiology
The origin of personality disorders is a matter of considerable controversy. Traditional
thinking holds that these maladaptive patterns are the result of dysfunctional early
environments that prevent the evolution of adaptive patterns of perception, response, and
defense. A body of data points toward genetic and psychobiologic contributions to the
symptomology of these disorders; however, the inconsistency of the data prevents authorities
from drawing definite conclusions. [5]
Paranoid personality disorder
A genetic contribution to paranoid traits and a possible genetic link between this
personality disorder and schizophrenia exist. Psychosocial theories implicate projection of
negative internal feelings and parental modeling.
Schizoid personality disorder
Support for the heritability of this disorder exists.

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Schizotypal personality disorder
This disorder is genetically linked with schizophrenia. Evidence for dysregulation of
dopaminergic pathways in these patients exists.
Antisocial personality disorder
A genetic contribution to antisocial behaviors is strongly supported. Low levels of
behavioral inhibition may be mediated by serotonergic dysregulation in the septohippocampal
system. There may also be developmental or acquired abnormalities in the prefrontal brain
systems and reduced autonomic activity in antisocial personality disorder. This may underlie
the low arousal, poor fear conditioning, and decision-making deficits described in antisocial
personality disorder. [6]
Borderline personality disorder
Psychosocial formulations point to the high prevalence of early abuse (sexual,
physical, and emotional) in these patients, and the borderline syndrome is often formulated as
a variant of posttraumatic stress disorder. Mood disorders in first-degree relatives are strongly
linked.
Biologic factors, such as abnormal monoaminergic functioning (especially in serotonergic
function) and prefrontal neuropsychological dysfunction, have been implicated but have not
been well established by research. [7, 8]
Histrionic personality disorder
Little research has been conducted to determine the biologic sources of this disorder.
Psychoanalytic theories incriminate seductive and authoritarian attitudes by fathers of these
patients.

Narcissistic personality disorder

No data on biologic features of this disorder are available. In the classic model,
narcissism functions as a defense against awareness of low self-esteem. More modern
psychodynamic models postulate that this disorder can arise from an imbalance between
positive mirroring of the developing child and the presence of an adult figure who can be
idealized.
Avoidant personality disorder
This personality disorder appears to be an expression of extreme traits of introversion
and neuroticism. No data on biologic causes are available, although a diagnostic overlap with
social phobia probably exists.
Dependent personality disorder
No studies of genetics or of biologic traits of these patients have been conducted.
Central to their psychodynamic constellation is an insecure form of attachment to others,
which may be the result of clinging parental behavior.
Obsessive-compulsive personality disorder
Modest evidence points toward the heritability of this disorder. Psychodynamically,
these patients are viewed as needing control as a defense against shame or powerlessness.

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Epidemiology
Occurrence in the United States
Personality disorders affect 10-15% of the adult US population. The following are
prevalences for specific personality disorders in the general population, across five studies
from 2001 to 2010: [9]
 Paranoid personality disorder - 0.7-2.4%
 Schizotypal personality disorder - 0.6-4.9%
 Antisocial personality disorder - 0.7-4.1%
 Borderline personality disorder - 0.7-2.7%
 Histrionic personality disorder - 0.2-2.0%
 Narcissistic personality disorder - Less than 1%
 Avoidant personality disorder - 0.8-5.2%
 Obsessive-compulsive personality disorder - 0.9-2.4%
Variance in prevalence rates across studies mostly reflects different thresholds of severity
adopted by investigators.
International occurrence
Because the DSM-5 criteria are heavily bound to North American cultural definitions,
epidemiologic data about personality disorders in other countries are notoriously unreliable.
Sex-related demographics
As previously mentioned, personality disorders, grouped into 3 clusters (ie, A, B, C), as
defined in the DSM-5. [1] Sex-related demographics for disorders within these clusters include
the following:
 Cluster A - Schizoid personality disorder is slightly more common in males than in
females
 Cluster B - Antisocial personality disorder is 3 times more prevalent in men than in
women; borderline personality disorder is 3 times more common in women than in
men; of patients with narcissistic personality disorder, 50-75% are male
 Cluster C - Obsessive-compulsive personality disorder is diagnosed twice as often in
men as in women
Age-related differences in incidence
Personality disorders generally should not be diagnosed in children and adolescents
because personality development is not complete and symptomatic traits may not persist into
adulthood. Therefore, the rule of thumb is that personality diagnosis cannot be made until the
person is at least 18 years of age. Because the criteria for diagnosis of personality disorders
are closely related to behaviors of young and middle adulthood, DSM-5 diagnoses of
personality disorders are notoriously unreliable in the elderly population.

Prognosis
Personality disorders are lifelong conditions, although attributes of cluster A and B
disorders tend to become less severe and intense in middle age and late life. Individuals with
a personality disorder are at risk for the following:
 Suicide [10]
 Substance abuse
 Accidental injury
 Depression

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  Homicide - A potential complication, particularly in paranoid and antisocial personality
disorders
Patients with a cluster B personality disorder are particularly susceptible to problems of
substance abuse, impulse control, and suicidal behavior, which may shorten their lives.
Cluster C characteristics tend to become exaggerated in later life
Morbidity and mortality
In patients with a personality disorder, risk of death is usually related to conditions or
behaviors resulting from the disorder. Consequently, death may result from suicide, substance
abuse, trauma from motor vehicle accidents, or injuries from fighting.
Patients with personality disorders are at higher risk than the general population for many
(axis I) psychiatric disorders. Mood disorders are a particular risk across all personality
diagnoses. Some comorbidities are more specific to particular personality disorders and
clusters.

Cluster A
Cluster A disorders and their morbidities include the following:
 Paranoid personality disorder - May appear as a prodrome to delusional disorder or
frank schizophrenia; these individuals are at risk for agoraphobia,
major depression, obsessive-compulsive disorder, and substance abuse
 Schizoid personality disorder - Patients may develop major depression
 Schizotypal personality disorder - Patients may develop brief psychotic disorder,
schizophreniform disorder, or delusional disorder; at the time of diagnosis, 30-50% of
patients have concurrent major depression, and most have a history of at least 1 major
depressive episode

Cluster B
Cluster B disorders and their morbidities include the following:
 Antisocial personality disorder - Associated with a risk for anxiety disorders, substance
abuse, somatization disorder, and pathologic gambling
 Borderline personality disorder - Associated with a risk for substance abuse, eating
disorders (particularly bulimia), and posttraumatic stress disorder; suicide is a particular
risk in borderline patients
 Histrionic personality disorder - Associated particularly with somatoform disorders
 Narcissistic personality disorder - Patients are at risk for anorexia nervosa and
substance abuse, as well as depression

Cluster C
Cluster C disorders and their morbidities include the following:
 Avoidant personality disorder - Associated with anxiety disorders (especially social
phobia)
 Dependent personality disorder - Carries a risk for anxiety disorders and adjustment
disorder
 Obsessive-compulsive personality disorder - Patients may be at risk for myocardial
infarction, because of their common type A lifestyles; they may also be at risk for
anxiety disorders; notably, they are probably not at increased risk for obsessive-
compulsive disorder

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Patient Education
Patients should be advised that their patterns of perception and response result from
some combination of inheritance and personal history and that recovery is therefore likely to
be a prolonged process, requiring effort and attention. The relevance of ongoing
psychotherapy to long-standing vulnerabilities requires frequent reemphasis by the physician.
Alcoholism and drug abuse are not merely complications of personality disorders, they are
also aggravating factors. Patients need constant reminding that yielding to the temptation to
drink or use drugs is likely to make their emotional distress worse and is certain to increase
the risk of complications, including suicide.
With the patient's permission, education can be provided to the family to alert them to
the possibilities of disruptive and destructive behavior and can provide guidelines for limit
setting and safety.
Family support groups exist in some communities, and family support resources, such
as Borderline Personality Disorder Family Groups and Stigma, are available online.
The National Institute of Mental Health provides a fact sheet on borderline personality
disorder that may be of use to families of persons with that condition.
A resource for patients and families dealing specifically with borderline personality disorder
is the National Educational Alliance for Borderline Personality Disorder.