How are Personality Disorders Clustered?

Patient Presentation
A 15-year-old male came to clinic for his health supervision visit. He was known to be a high achiever in school and his mother expressed pride in his academic accomplishments. However, since starting 10th grade, he had stopped his sports and music activities stating he wasn’t as good at them, and wanted to “concentrate on what I’m good at.” He had continued math team and an academic knowledge team. His mother said that he was spending more and more time by himself everyday studying for math and knowledge competitions. “And I have to do that so I can win them. Remember last time I was only 5th place,” he interrupted. “But you’re also not sleeping or eating well and I’m worried about you,” she countered.

The past medical history showed that he was identified for the school’s gifted and talented program in first grade and had been involved with competitive soccer, swimming and had been taking private music lessons since age 5. These activities had stopped over the past year.

The pertinent physical exam showed a thin male with normal vital signs and his weight was 50% and tracking for age. He examination was normal and he had Tanner IV genitalia. The diagnosis of of a teen with concerning behaviors was made.

In a private interview with the adolescent, he acknowledged that he had stopped the activities because he felt he “had to get perfect grades,” and “had to win the competitions.” He would go to bed at night but then set an alarm to wake up in the middle of the night to do more studying and math problems or general knowledge quizzes. His friend group had diminished to only a few people but he interacted with them only at club meetings and would be studying during lunchtime at school. He said it really bothered him when he got any homework or math problems wrong. He talked about his study schedule and how he had it organized to the minute using a calendar tool and timer on his phone. He organized his books and pens/pencils on his desk before starting his work and would re-organize them several times while working. “If I don’t organize it, it really bothers me and I can’t get anything done until I get my highlighters and pens in order and check the timer,” he noted. The teen said that he did feel some pressure from his parents to perform, but most of what he did, he felt he had to do because of himself. The pediatrician was concerned about his perfectionistic tendencies along with what might be compulsions with his schedule and tools. He also seemed to be becoming more obsessed with his homework and math competitions and was becoming more isolated. The pediatrician was concerned for a possible obsessive-compulsive disorder. The teen agreed that he was having more anxiety if he couldn’t adhere to his schedule and therefore he was becoming less efficient. He also agreed that he missed spending time with some of his friends. After discussion with the parent and patient, the teen agreed to see a counselor who could help him to continue to achieve his goals but to help him learn to do it in a way that would let him see his friends, and do other activities he might want to do. At 6 month follow up, he was seeing a therapist but was still struggling.

Discussion
Personality traits (PT) represent patterns of thinking, perceiving, reacting, and relating that are relatively stable over time. There are 5 major PT:

• Extraversion (e.g. tendency to be sociable)
• Neuroticism (e.g. susceptibility to negative thoughts and distress)
• Conscientiousness (e.g. self-regulation and being able to look at long term goals)
• Agreeableness (e.g. self-regulations and relationship maintenance)
• Openness to experience (e.g. imaginative, creative, curiosity).

Personality disorders (PD) occur when these personality traits become so conspicuous, rigid and maladaptive that they cause impairment in life and work. PDs are “enduring patterns of inner experience and behavior that deviates markedly from the expectations of the individual’s culture, with onset in early adulthood, leading to pervasive, stable and inflexible behavior over time, and causing stress or impairment.” PDs classification is evolving and the DSM-V currently has 10 different ones.

PDs have a prevalence in the US of ~9% in adults. They are highly co-morbid conditions (~40-80%) with other mental illness especially with major depressive disorder. People with PDs have more social dysfunction and an increased risk of disability including risky sexual behavior, violence, suicide and problems in school, work and relationships.

Diagnosis includes that the traits are persistent, maladaptive and involve at least two areas of functioning including affectivity, cognition, impulse control, and interpersonal functioning. There must also be significant impaired functioning or distress caused by the maladaptive traits, and the traits must be relatively stable with onset at least by adolescence or early adulthood. PDs are generally not diagnosed in children and youth < 18 years but can be if present for more than 1 year.
An adolescent study found that PD prevalence is estimated at 6-17% with median of 11%. PT do vary over time and are considered moderately stable by adolescence. The stability of PD diagnosis in adolescence though is modest. However the more persistent the PD symptoms, the more likely the patient is to have impairment in adulthood.

Learning Point
PDs are grouped based on similar characteristics but if these clusters are clinically useful has not been established. While patients should be considered as individuals, an aide-memoire for remembering the clusters is: Mad, Bad, Sad.

• Cluster A are PDs where the patients are considered eccentric or odd.
  • Paranoid – distrusts and is suspicious, intentions of others are interpreted as malevolent
  • Schizoid – disinterested in other people, has perceptual or cognitive distortions
  • Schizotypal – has eccentric behavior and ideas, social relationships are detached and have limited range of emotions
• Cluster B are PDs where patients are characteristically emotional, dramatic or erratic. Is characterized by appearing dramatic, emotional, or erratic.
  • Antisocial – has marked disregard for others, is socially irresponsible, will manipulate and be deceitful of others for personal gain
  • Borderline – has intolerance of being alone and has emotional dysregulation, marked impulsivity, unstable self image and relationships
  • Histrionic – seeks attention
  • Narcissistic – here is overt grandiosity with a fragile self-esteem and/or underlying dysregulation, lacks empathy, needs admiration
• Cluster C are PDs where the person is anxious or fearful.
  • Avoidant – very sensitive to rejection so will avoid interpersonal contact, feels inadequate, socially inhibited
  • Dependent – is submissive, and needs others to take care of them, clingy behaviors
  • Obsessive-compulsive – can be rigid, have obstinacy and perfectionism, must have order and control

In a study of adults within a primary care setting, the most common PDs in order were borderline PD, dependent PD, obsessive-compulsive PD, and unspecified PD.

Questions for Further Discussion
1. What are psychoses and how common are they in the pediatric population?
2. What are the diagnostic criteria for different depressive illnesses?
3. How are personality disorders treated?

Related Cases

Disease: Personality Disorders

Symptom/Presentation: Behavior Problems | Health Maintenance and Disease Prevention

Specialty: Psychiatry and Psychology

Age: Teenager

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Personality Disorder and Topics.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Shiner RL. The development of personality disorders: Perspectives from normal personality development in childhood and adolescence. Development and Psychopathology. 2009;21(3):715-734. doi:10.1017/S0954579409000406

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. Fifth Edition (DMS-5). Washington, DC: American Psychaitric Association; 2013.

Angstman KB, Seshadri A, Marcelin A, Gonzalez CA, Garrison GM, Allen J-S. Personality Disorders in Primary Care: Impact on Depression Outcomes Within Collaborative Care. J Prim Care Community Health. 2017;8(4):233-238. doi:10.1177/2150131917714929

Bach B, Sellbom M, Skjernov M, Simonsen E. ICD-11 and DSM-5 personality trait domains capture categorical personality disorders: Finding a common ground. Aust N Z J Psychiatry. 2018;52(5):425-434. doi:10.1177/0004867417727867

Overview of Personality Disorders – Psychiatric Disorders. Merck Manuals Professional Edition. Accessed July 14, 2020. https://www.merckmanuals.com/professional/psychiatric-disorders/personality-disorders/overview-of-personality-disorders

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa