Personality Disorders

Inflexible and maladaptive personality disorders cause distress or social or occupational impairment. A patient with a personality disorder typically has problems in at least two of these areas: cognition, affectivity, interpersonal functioning, and impulse control. Pervasive manifestations occur across a range of situations. A personality disorder is stable and of long duration, typically begins in adolescence or early adulthood, and is diagnosed in adulthood.

The two primary classification approaches to personality disorders are categorical and dimensional. The categorical approach, currently represented in DSM-IV-TR, describes people as having clusters of associated traits, symptoms, or behaviors that form discrete "prototypes," or categories of personality. The dimensional approach, likely the wave of the future, assesses multiple traits or dimensions of a personality that are present, absent, or have varying degrees of intensity; measurable dimensions of personality might include novelty seeking, harm avoidance, reward dependence, coopera-tiveness, and self-directedness. Categorical approaches have the advantage of colorfully describing and differentiating distinct groups of different personality types. This classification convention remains popular with family physicians because it follows the concept of disease categories within general medicine. The Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision (DSM-IV-TR), uses a categorical personality disorder classification as part of a multiaxial system that encourages physicians to consider personality variables in every patient (American Psychiatric Association [APA], 2000).

The preliminary diagnosis of a personality disorder begins by identifying the appropriate cluster or dimension, because it is easiest to recognize the broad traits of a cluster diagnosis first. The three clusters of personality disorders are cluster A, odd and eccentric; cluster B, dramatic, emotional, or erratic; and cluster C, anxious or fearful. These clusters or dimensions are subdivided into specific personality subtypes with general characteristics (Box 46-1). Because personalities are complicated, it is not unusual for a patient to meet the criteria for two cluster diagnoses and more than one specific personality disorder diagnosis.

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