Donald W. Black, MD Professor Emeritus Department of Psychiatry University of Iowa Carver College of Medicine Staff Psychiatrist Iowa City Veterans Administration Medical Center Iowa City, Iowa
Disclosure Dr. Black is a consultant to Otsuka. He is an Associate Editor for Current Psychiatry.
Evidence is limited, but these principles and strategies can help guide prescribing.
DSM-5 defines personality disorders (PDs) as the presence of an enduring pattern of inner experience and behavior that “deviates markedly from the expectations of the individual’s culture, is pervasive and inflexible, has an onset in adulthood, is stable over time, and leads to distress or impairment.”1 As a general rule, PDs are not limited to episodes of illness, but reflect an individual’s long-term adjustment. These disorders occur in 10% to 15% of the general population; the rates are especially high in health care settings, in criminal offenders, and in those with a substance use disorder (SUD).2 PDs nearly always have an onset in adolescence or early adulthood and tend to diminish in severity with advancing age. They are associated with high rates of unemployment, homelessness, divorce and separation, domestic violence, substance misuse, and suicide.3
Psychotherapy is the first-line treatment for PDs, but there has been growing interest in using pharmacotherapy to treat PDs. While much of the PD treatment literature focuses on borderline PD,4-9 this article describes diagnosis, potential pharmacotherapy strategies, and methods to assess response to treatment for patients with all types of PDs.
Recognizing and diagnosing personality disorders
The diagnosis of a PD requires an understanding of DSM-5 criteria combined with a comprehensive psychiatric history and mental status examination. The patient’s history is the most important basis for diagnosing a PD.2 Collateral information from relatives or friends can help confirm the severity and pervasiveness of the individual’s personality problems. In some patients, long-term observation might be necessary to confirm the presence of a PD. Some clinicians are reluctant to diagnose PDs because of stigma, a problem common among patients with borderline PD.10,11
To screen for PDs, a clinician might ask the patient about problems with interpersonal relationships, sense of self, work, affect, impulse control, and reality testing. Table 112 lists general screening questions for the presence of a PD from the Iowa Personality Disorders Screen. Structured diagnostic interviews and self-report assessments could boost recognition of PDs, but these tools are rarely used outside of research settings.13,14
The PD clusters
DSM-5 divides 10 PDs into 3 clusters based on shared phenomenology and diagnostic criteria. Few patients have a “pure” case in which they meet criteria for only a single personality disorder.1
Cluster A.“Eccentric cluster” disorders are united by social aversion, a failure to form close attachments, or paranoia and suspiciousness.15 These include paranoid, schizoid, and schizotypal PD. Low self-awareness is typical. There are no treatment guidelines for these disorders, although there is some clinical trial data for schizotypal PD.
Cluster B. “Dramatic cluster” disorders share dramatic, emotional, and erratic characteristics.14 These include narcissistic, antisocial, borderline, and histrionic PD. Antisocial and narcissistic patients have low self-awareness. There are treatment guidelines for antisocial and borderline PD, and a variety of clinical trial data is available for the latter.15
