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Mind Matters
Vol. 20 No 3 | Spring 2018
Feature
Personality disorders in clinical practice
Prof Louise Newman AM
BA(Hons), MBBS(Hons), PhD, FRANZCP Royal Women’s Hospital, Melbourne

Individuals with a personality disorder (PD) have persistent difficulties in functioning and social relationships. PD occurs in 4–12 per cent of the adult population. Affected individuals are high users of clinical services, with increased rates of medical morbidity, mental illness and mortality.1

PD refers to enduring qualities of a person that influence interpersonal functioning, self-concept and emotional control. Disturbances in personality development are influenced by genetic factors, early attachment experiences and parenting, and neurodevelopmental factors. Individuals with vulnerable personalities are less able to cope with stressful experiences, such as illness and clinical treatment, presenting challenges for clinicians in terms of engagement and rapport. They are also at risk of experiencing anxiety, depression and distress as a result of limited coping strategies. Difficulties with interpersonal functioning affect one’s ability to use others for support, avoid conflict and maintain healthy relationships. Many clinicians are familiar with the challenges of treating these individuals, who have high levels of service use and excess medical morbidity and mortality.

Classification

The Diagnostic and Statistical Manual of Mental Disorders (DSM-5)2 system of psychiatric classification gives a definition of general PD as the enduring pattern of inner experience and behaviour that is inflexible, pervasive and not within cultural norms. These conditions impact at least two of the following domains:

  • Cognition – ways of perceiving and interpreting self, others and events
  • Affectivity – the range, intensity, lability and appropriateness of emotional response
  • Interpersonal functioning
  • Impulse control

Personality disorders are developmental disorders with several early risk factors, usually evident in adolescence and young adulthood, although earlier features may present in childhood. The diagnosis of PD requires an evaluation of long-term patterns of function and a clear history of early onset of particular features of personality difficulty. It is important to exclude transient difficulties that may be an acute response to stress, the impact of mental illness or substance abuse. Diagnosis should also take into account cultural influences and differences in the management of self, relationships and emotional expression. PD as a label should be avoided when seeing distress and disturbance in individuals experiencing difficulty in acculturation or asylum-seeking.

The DSM system describes 11 specific types of PD, with three clusters of themes. Similarities and overlaps are common between the groups and the discrete types are sometimes difficult to define in a clinical setting:

  • Cluster A: Eccentric – paranoid, schizoid, schizotypal
  • Cluster B: Emotional – antisocial, borderline, histrionic, narcissistic
  • Cluster C: Anxious – avoidant, dependent, obsessive compulsive, passive aggressive
  • Cluster A disorders

Cluster A disorders include individuals with: a pervasive distrust and suspiciousness of others, interpreting motives as malevolent (paranoid); a pattern of detachment from social relationships and restricted range of emotional expression (schizoid); and discomfort in relationships, cognitive distortions and eccentricities (schizotypal). Clinicians find it difficult to establish a therapeutic relationship with these individuals, who may be anxious, guarded and suspicious. Clear and formal communication, avoiding familiarity, may be a helpful approach. Cluster A disorders are found in 0.5–3 per cent of the general population, with increased rates in mental health settings.

Cluster B disorders

Cluster B disorders include individuals with: disregard for and violation of the rights of others (antisocial); instability in relationships, self-image, emotional regulation and impulsivity (borderline); patterns of grandiosity, need for admiration and lack of empathy (narcissistic); and patterns of excessive emotionality and attention seeking (histrionic).

Borderline PD occurs in around two per cent of the general population and is one of the most studied in terms of aetiology and response to psychological and psychopharmacological treatment. Clinical issues managing borderline PD relate to the rapid shifts in emotional states, angry outbursts and demands, and interpersonal crises. These women are particularly at risk during pregnancy and the perinatal period, with major challenges in transition to parenthood.

Cluster C disorders

Cluster C disorders include: patterns of feelings of inadequacy and hypersensitivity to negative evaluation (avoidant); preoccupation with orderliness, perfectionism and control (obsessive compulsive); and patterns of submissive, clinging behaviour with an excessive need to be taken care of (dependent). Cluster C disorders are found in 0.5–2.4 per cent of the general population.

Personality disorder in everyday practice

PD impacts the doctor-patient relationship, compliance with treatment recommendations and clinical outcomes. Commonly described as severe PD, patients with borderline personality disorder (BPD) are frequently seen as chaotic, crisis-prone, self-defeating and emotionally unstable. They have poor stress tolerance and may engage in self-harm and suicidal behaviour. People with PD can develop clinical depression, anxiety and substance abuse problems. Women with BPD and a history of childhood abuse and trauma are more likely to experience abusive patterns in current relationships and parenting difficulties.

Maternity care and BPD

BPD is associated with significant difficulties in maintaining healthy relationships, emotional fluctuations and poor impulse control. Many women describe histories of child abuse and attachment disruptions, which have a long-term impact on function and increase risk of post-traumatic symptoms and difficulties in parenting. Pregnancy may be complicated by significant anxiety and memories of child abuse. The pregnancy is more likely to be unplanned or the result of sexual assault. Supportive relationships may be limited, increasing psychosocial stress.

Cohort studies of women diagnosed with BPD in pregnancy report higher rates of smoking, drug and alcohol use, financial stress and co-morbid mood disorder. Rates of obstetric complications are elevated, including gestational diabetes, premature rupture of membranes, chorioamnionitis, caesarean delivery and preterm birth.3

Australian data found a similar range of obstetric issues and poor neonatal outcomes, including low Apgar scores and need for special care nursery admission. Importantly, the data found 30 per cent of women reported the pregnancy to be traumatic, increased rates of request to end the pregnancy early, and low levels of engagement in antenatal care.

Women with severe PD raise concerns around parenting capacity and child protection.4 The broad range of complications highlights the need for integrated multidisciplinary management, involving mental health services in the maternity setting. Early discussion with women about the psychological stress of pregnancy and involvement of supportive interventions is an important preventive strategy.

High rates of protective concerns underlie the challenges for women in parenting, particularly when there is a history of child abuse and/or current relationship trauma. Women with severe PD may have core difficulties in transition to parenthood and in function as a consistent attachment figure for their infant. They may also have difficulty in understanding infant communication and tolerating negative emotional responses in the infant, becoming distressed themselves.5 Rates of postnatal depression are elevated in women with histories of child abuse, contributing to parenting difficulties and resulting attachment insecurity in the infant.6 While there is limited evidence for the efficacy of clinical interventions for BPD, current approaches aim to improve the parent’s emotional understanding of the child and support them in their role as an attachment figure. Emphasis is placed on building the parent’s capacity to focus on the child, as well as supporting recovery from early trauma.7,8 There is clear evidence for the effectiveness of structured psychological therapies, including dialectical behaviour therapy, mentalisation based treatment and cognitive analytic therapy, as reviewed in the National Heath and Medical Research Council (NHMRC) clinical guidelines.9

Overall, these approaches promote emotional regulation, relationship function and reduction in impulsivity. Psychopharmacological interventions may be useful to target specific severe symptoms, such as depression and agitation, and include mood stabilisers and antipsychotics. These are usually prescribed following psychiatric assessment.10

Principles of management

The general principles of management of PD aim to maintain a clear and consistent treatment plan and provide support for the individual, who may be anxious, angry or emotionally volatile. Recognition of the personality, vulnerability and anxiety, and avoidance of an overreaction to difficult behaviour helps to maintain the therapeutic relationship. It is important to clarify emergency and crisis supports for women with a history of decompensation or self-harming behaviours and to liaise with existing mental health services. Consistent and available supports, with clear parameters for regular contact, help to contain anxiety and should be coordinated across community and hospital services.

References

  1. Yang M, Coid J, Tyrer P. Personality pathology recorder by severity: national survey. Br J Psychiatry 2010;97:193-9.
  2. American Psychiatric Association, Diagnostic and statistical manual of mental disorders. 5th ed. American Psychiatric Publishing, 2013.
  3. Pare-Miron V, Czuzoj-Shulman N, Oddy L, et al. Effect of borderline personality disorder on obstetrical and neonatal outcomes. Women’s Health Issues 2016;26:190-5.
  4. Blankley G, Galbally M, Snellen M. Borderline personality disorder in the perinatal period: early infant and maternal outcomes. Australasian Psychiatry 2015;23:688-92.
  5. Newman L, Stevenson C, Bergman L, Boyce P. Borderline personality disorder, mother-infant interaction and parenting perceptions: preliminary findings. Australian and New Zealand Journal of Psychiatry 2007;41(7):598-605.
  6. Eyden J, Winsper C, Dieter W, et al. A systematic review of the parenting and outcomes experienced by offspring of mothers with borderline personality pathology: potential mechanisms and clinical implications. Clinical Psychology Review 2016; 47:85-105.
  7. Barlow J, Bennett C, Midgley N, et al. Parent-infant psychotherapy: a systematic review of the evidence for improving parental and infant mental health. Journal of Reproductive and Infant Psychology 2016;34:5,464-482.
  8. Newman L, Mares S. Recent advances in the theories of and interventions with attachment disorders. Current Opinion in Psychiatry 2007;20(4):343-8.
  9. National Health and Medical Research Council. Clinical practice guidelines for the management of borderline personality disorder. National Health and Medical Research Council, Melbourne 2012.
  10. Lieb K, Vollm B, Rucker G, Timmer A, Stoffers J. Pharmacotherapy for borderline personality disorder. Cochrane Data Base Syst Rev 2010:8:CDO7667.

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