Text adapted from: "The adult patient with a personality disorder," in Psychiatry in primary care by Michael Rosenbluth, Matthew Boyle & Lucille Schiffman (CAMH, 2019).
Specific Personality Disorders
Of the 10 personality disorders in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association, 2013), varying degrees of research exist to support their diagnosis. Underlying all of the personality disorders is a deep-seated maladaptive style that is part of the person’s personality. This maladaptive style is pervasive and longstanding, from the teenage years onward.
The most commonly diagnosed personality disorders are borderline personality disorder and antisocial personality disorder. Another personality disorder that primary care practitioners sometimes find difficult to diagnose and treat is narcissistic personality disorder.
Borderline personality disorder
Diagnosing BPD requires that the patient fulfil five out of nine DSM-5 criteria. This means that two people with BPD can have markedly different symptoms and presentations. The mnemonic IMPULSIVE is a helpful way to remember BPD criteria:
- Impulsiveness in two potentially damaging areas (e.g., sex, substance use, shopping)
- Mood instability due to marked reactivity
- Paranoia or dissociation under stress
- Unstable self-image
- Labile intense relationships
- Suicidal gestures
- Inappropriate anger
- Vulnerability to abandonment, frantic efforts to avoid real or imagined abandonment
- Emptiness, chronic feelings of emptiness.
Narcissistic personality disorder features a pervasive pattern of grandiosity, a need for admiration and a lack of empathy beginning in early adulthood and presenting in various contexts.
The diagnosis requires meeting five of the following nine DSM-5 criteria:
- grandiose sense of self-importance
- preoccupation with fantasies of unlimited success, power and brilliance
- belief that one is special and unique and can only be understood by or associate with other special or high-status people
- need for excessive admiration
- sense of entitlement
- interpersonally exploitive behaviour (i.e., taking advantage of others to achieve one’s ends)
- lack of empathy
- envy of others or the belief that others are envious of the person
- arrogant, haughty behaviours or attitudes.
Diagnostic changes in DSM-5
Transition-age youth
According to DSM-5, features of a personality disorder usually begin to manifest during adolescence and early adulthood. In earlier versions of DSM, a personality disorder could not be diagnosed in someone under age 18; however, DSM-5 now allows this diagnosis if the features have been present for at least one year. This change has important implications for treatment. For example, recent research indicates that BPD can be a reliable diagnosis in youth, providing an opportunity to intervene early to improve prognosis (Kaess et al., 2014). The one diagnosis that cannot be made for people under age 18 is antisocial personality disorder.
Axis I and Axis II disorders
With the release of DSM-5 came a major change in how personality disorders are considered in a diagnostic assessment. The previous manual, DSM-IV, featured a system that separated diagnoses into five “axes.” Most of the major psychiatric disorders were classified as Axis I disorders. They included:
- major depressive disorder
- bipolar affective disorder
- schizophrenia
- generalized anxiety disorder
- panic disorder
- posttraumatic stress disorder
- obsessive compulsive disorder
- substance use disorders.
Axis II included the 10 personality disorders and intellectual disability. The multiaxial system was introduced partly because certain disorders, such as personality disorders, received inadequate clinical and research focus, and giving them a separate designation would ensure they received more attention. When DSM-5 was being compiled, it was determined that this situation had changed, so the multiaxial system was no longer needed. DSM-5 retains all 10 personality disorders, with only slight changes to wording in the diagnostic criteria (APA, 2013).
Although Axis I and II no longer exist in DSM-5, this chapter still uses these terms because they are conceptually helpful when discussing diagnosis and treatment of personality disorders.
Diagnostic issues
Making the Axis I diagnosis with a co-occurring personality disorder
Patients with personality disorders often have co-occurring Axis I diagnoses. This is particularly common in BPD. One study found that 96 percent of patients with BPD will have a lifetime Axis I comorbidity with mood disorders: 9 percent with bipolar disorder; 88 percent with anxiety disorders; 55 percent with post traumatic stress disorder; 53 percent with eating disorders; and 64 percent with substance use disorders (Zanarini et al., 1998).
Given this high comorbidity, the challenge is not only to identify and optimally manage the personality disorder, but also to not overlook comorbid Axis I diagnoses. Primary care practitioners may find the Axis I diagnoses easier to deal with; however, patients with both Axis I and Axis II disorders need treatment plans that address both.
Challenges in Identifying Co-occurring Axis I Disorders
Clinicians, including primary care practitioners, often overlook the comorbid Axis I diagnoses. The typically chaotic presentation of patients with personality disorder—and clinicians’ reactions to them—make it difficult to assess and diagnose an Axis I disorder. The frustration that some clinicians experience may preclude careful review of the patient’s longitudinal history that would clarify the Axis I diagnosis. Clinicians may feel frustrated by a patient who is disruptive in the waiting room, threatens self-harm or has a history of emotional reactivity, responding to slights with self-harm and impulsive behaviours. Overlooking such a diagnosis means that the patient may not receive appropriate treatment for the Axis I condition.
Distinguishing Between a Personality Disorder and an Axis I Disorder
One strategy for clarifying the presence of a personality disorder versus an Axis I diagnosis is to review whether the patient has a longstanding history of negative maladaptive behaviours, or whether these behaviours are restricted to when the Axis I diagnosis began.
Some patients may look personality disordered when they are dealing with characteristic stressors that are difficult for them. For example, when people are depressed, it can bring out the worst in their personality. They may appear to have a personality disorder as they become more demanding, inappropriately persistent, emotionally reactive and irritable. However, if the patient’s history or the people in the patient’s support system indicate that the maladaptive behaviours are limited to a response to the difficult stressors, then it is not a personality disorder. If the onset of personality difficulties is recent, you must consider whether an Axis I diagnosis may be the correct diagnosis because these conditions can cause patients to appear to have a personality disorder.
Remember that our clinical assessments tend to be cross-sectional, whereas personality disorders require a longitudinal review of functioning. It is best to defer a personality assessment until the acute Axis I disorder has been successfully treated.
Ask patients to describe their personality prior to their depression. Get a collateral history from family members or significant others who can confirm whether the maladaptive behaviours occur exclusively in the context of an Axis I diagnostic state, or whether they are long-standing from childhood.
Keep in mind that no matter how suggestive the presentation, the diagnosis is unlikely to be a personality disorder if there is no supportive evidence from earlier in life.