Personality Disorder

Introduction

Personality disorder (PD) was not properly regarded as a diagnosis until the 19th century. People with PDs seem to have a persistent abnormality in social relationships and social functioning in general. They have a more limited range of emotions, attitudes, and behaviors to cope with the stresses of everyday life. Impairment in personality functioning includes deficiencies in self-functioning (self-awareness and self-directedness) or interpersonal functioning (empathy, intimacy, and mutual understanding), or both.

The definition of PD is open to debate. It differs between the two central diagnostic systems used for mental health problems, ICD (International Classification of Diseases) and DSM (Diagnostic and Statistical Manual of Mental Disorders). In the ICD, PD is called emotionally unstable PD, characterized by unstable self, unstable relationships with other people, and unstable emotions. In DSM-III, PD is described as constellations of personality traits that are inflexible and maladaptive and cause either significant functional impairment or subjective distress.

Implications of PDs

People with PDs have far higher morbidity and mortality than do those without. Increased mortality can be explained partly by an increased incidence of suicide and homicide in people with PDs. One systematic study finds that in depression, PDs are essential risk factors for chronicity. Epidemiological research shows that comorbid mental health problems, such as depression, anxiety, and substance misuse, are more common in people with PDs, are more challenging to treat, and have worse outcomes. The cost of treatment for PDs is also very high, especially for those with severe PD who need regular institutional care.

Diagnosis of PDs

Because of the complex issues regarding the classification of PD, its assessment seems to be one of the most challenging tasks in clinical practice. The relational nature of the disorder makes the diagnosis of PD interactive and not solely dependent on individual symptoms or the phenomenology of mental illness. The diagnosis must be made of a lifelong disorder or at least many years' duration. The main element of this disorder affects interaction with others and in which no biological or other independent markers exist to assist in its identification.

Borderline Personality Disorder (BPD)

BPD is a common mental disorder associated with high rates of suicide and severe functional impairment. It is characterized by extreme sensitivity to perceived interpersonal slights, an unstable sense of self, intense and volatile emotions, and impulsive behaviors. In clinical populations, BPD is about a prevalence of 10% of all psychiatric outpatients and between 15% and 25% of inpatients. As efforts to treat patients with BPD are often thwarted by patient anger and recurrent suicidality, the diagnosis has a reputation for being intractable.

Once thought to be an untreatable condition, BPD is now effectively treated by a growing number of evidence-based treatments (EBTs), including DBT, mentalization-based treatment (MBT), schema-focused therapy (SFT), transference-focused psychotherapy (TFP), and systems training for emotional predictability and problem-solving (STEPPS). Most patients recover symptomatically, and the disorder has a biological and genetic basis.

Fig.1 Alterations of brain circuits in BPD. (Gunderson, 2018)

Genetic Factors and Neurobiology in Personality Disorders

PD is now being accepted as an essential condition in mainstream psychiatry across the world. Some evidence has emerged that genetic factors contribute to BPD development; however, no specific genes have been identified as causative. Some studies show an association between a haplotype containing the short allele in the serotonin transporter gene (the serotonin- transporter-linked promoter region [5-HTTLPR] in SLC6A4) and the development of BPD. Another gene implicated in impulsive aggression and suicidal behavior is the tryptophan hydroxylase gene (TPH). Patients with BPD have a higher frequency of polymorphisms in TPH-2 than controls. Future research needs to investigate how genetic factors interact with neurotransmitter function, leading to cognitive and emotional regulations and specific traits.

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Reference

1. Gunderson, J. G.; et al. Borderline personality disorder. Nature Reviews Disease Primers. 2018, 4(1), 1-20.