Personality Disorders
W Klugh Kennedy, PharmD, BCPP, FASHP, FCCP
Clinical Professor of Pharmacy Practice and Psychiatry
Mercer University, Savannah Georgia
kennedy_wk@mercer.edu
Medications
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No medications specifically approved by the Food and Drug
Administration (FDA) to treat personality disorders.
Antidepressants. Antidepressants may be useful for have a
depressed mood, anger, impulsivity, irritability or hopelessness,
which may be associated with personality disorders.
Mood stabilizers. May help even out mood swings or reduce
irritability, impulsivity and aggression.
Antipsychotic medications. may be helpful if symptoms include
losing touch with reality (psychosis) or in some cases if you have
anxiety or anger problems.
Anti-anxiety medications. These may help if you have anxiety,
agitation or insomnia. But in some cases, they can increase
impulsive behavior, so they're avoided in some personality
disorders.
Personality Disorder
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Enduring pattern of inner experience and behavior that deviates markedly from
expectations of individual's culture. Pattern is manifested in two (or more) of the
following areas:
 Cognition (i.e., ways of perceiving and interpreting self, others, and events)
 Affectivity (i.e. range, intensity, lability, and appropriateness of emotional response)
 Interpersonal functioning
 Impulse control
Inflexible and pervasive across a broad range of personal and social situations
Clinically significant distress or impairment in one or more area of functioning
The pattern is stable and of long duration, and its onset can be traced back at least to
adolescence or early adulthood
Not better accounted for as a manifestation or consequence of another mental disorder
Not due to the direct physiological effects of substance abuse or a general medical
condition
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Other Criteria
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If less than 18 years old, must have features for greater than or equal to one year
Ego-syntonic in nature (i.e, belief that there is dysfunction with the outside world, but not within
one's self)
Personality Style
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enduring pattern of inner experience and
behavior that deviates markedly from the
expectations of the culture of the individual
who exhibits it
 long-lasting rigid patterns of thought and
behavior. inflexibility and pervasiveness of
these patterns
 They do not cause significant problems and
impairment of functioning for the persons who
are afflicted with these disorders
Clusters
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Cluster A, B, C
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Mad, Bad, Sad
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Weird, Wild, Worried
Cluster A
Schizoid
 Schizotypal
 Paranoid
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Paranoid Personality Disorder
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Diagnosis: 4 or more
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Suspicion that others are deceiving him or her
Preoccupation with doubts of loyalty of
acquaintances
Reluctance to confide in others
Interpretation of benign remarks as threatening or
demeaning
Persistence of grudges
Perception of attacks on his/her character
Recurrence of suspicions regarding fidelity of
spouse or lover
Paranoid Personality Disorder
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Epidemiology
Prevalence: 0.5%-2.5%
 Men>Women
 Higher incidence in family members of
schizophrenics
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Course: defined by personality DO
 Treatment
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Schizoid Personality Disorder
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Diagnosis: 4 or more
Neither enjoying nor desiring close
relationships
 Choosing solitary activities
 Little interest in sexual activity
 Taking pleasure in few activities
 Few close friends
 Indifference to praise or critism
 Detached
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Schizoid Personality Disorder
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Epidemiology
Prevalence: 7%
 Men>Women
 No increased incidence of schizoid
personality in families with hx of
schizophrenia
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Course: defined by personality DO
 Treatment
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Schizotypal Personality Disorder
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Diagnosis: 5 or more
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Ideas of reference
Magical thinking
Unusual perceptual experiences
Suspiciousness
Inappropriate or restricted affect
Odd or eccentric appearance or behavior
Few close friends
Odd thinking or speech
Excessive social anxiety
Schizotypal Personality Disorder
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Epidemiology
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Prevalence: 3%
Course: defined by personality DO
 Treatment
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Cluster B
Antisocial
 Borderline
 Histrionic
 Narcissistic
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Antisocial Personality Disorder
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Diagnosis: 3 or more
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Failure to conform to social norms
Deceitful/manipulative
Impulsive
Irritable/aggressive
Recklessness and disregard for safety of self or
others
Lack of remorse for actions
Irresponsibility/failure to sustain work or honor
financial obligations
Antisocial Personality Disorder
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Epidemiology
Prevalence: 3% in men and 1% in women
 Higher incidence in poor urban areas
 Genetic component: Five times increased
risk among first-degree relatives
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Course: defined by personality DO
 Treatment
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Borderline Personality Disorder
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Diagnosis: 5 or more
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Desperate efforts to avoid real or imagined abandonment
Unstable, intense interpersonal relationships
Unstable self image
Impulsive in at least 2 potentially harmful ways (spending,
sexual activity, CD, etc.)
Recurrent suicidal threats/attempts or self mutilation
Unstable mood/affect
General feeling of emptiness
Difficulty controlling anger
Transient, stress related paranoid ideation or dissociative sx
Borderline Personality Disorder
Epidemiology
 Course: defined by personality DO
 Treatment
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Histrionic Personality Disorder
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Diagnosis: 5 or more
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Uncomfortable when not the center of attention
Inappropriately seductive
Uses physical appearance to draw attn to self
Uspech is impressionistic and lacking in detail
Dramatic
Easily influenced by others
Perceives relationships as more intimate than they
are
Histrionic Personality Disorder
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Epidemiology
Prevalence: 2-3%
 Women>Men
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Course: defined by personality DO
 Treatment
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Narcissistic Personality Disorder
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Diagnosis: 5 or more
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Exaggerated sense of self-importance
Preoccupied with fantasies of unlimed money, success,
brillance
Believes that he/she/ is “special” and can only associate with
other high status people
Needs excessive admiration
Sense of entitlement
Takes advantage of others for self-gain
Lacks empathy
Envious of others or believes others are envious of him/her
Arrogant or haughty
Narcissistic Personality Disorder
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Epidemiology
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Prevalence: <1%
Course: defined by personality DO
 Treatment
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Cluster C
Avoidant
 Dependent
 Obsessive-compulsive
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Avoidant Personality Disorder
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Diagnosis: At least 4 of the following
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Avoids occupation that involves interpersonal
contact due to fear of criticism
Unwilling to interact unless certain of being liked
Cautious of intrapersonal relationships
Preoccupied with being criticized or rejected in
social situations
Inhibited in new social situations b/c he/she feels
inadequate
Believes he/she is socially inept
Reluctant to engage in new activities for fear of
embarrassment
Avoidant Personality Disorder
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Epidemiology
Prevalence: 1-10%
 Sex ratio unknown
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Course: defined by personality DO
 Treatment
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Dependent Personality Disorder
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Diagnosis: At least 5 of the following
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Difficulty making everyday decisions without reassurance from
others
Needs others to assume responsibilities for most areas of life
Cannot express disagreement because of fear of loss of
approval
Difficulty initiating projects b/c of lack of self-confidence
Goes to excessive lengths to obtain support from others
Feels helpless when alone
Urgently seeks another relationship when one ends
Preoccupied with fears of being left to take care of self
Dependent Personality Disorder
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Epidemiology
Prevalence: Approx. 1%
 Women>Men
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Course: defined by personality DO
 Treatment
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Obsessive Compulsive Personality
Disorder
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Diagnosis: At least four of the following
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Preoccupation with details
Perfectionism that is detrimental to completion of
task
Excessive devotion to work
Excessive conscientiousness about morals
Will not delegate tasks
Unable to discard worthless objects
Miserly
Rigid and stubborn
Obsessive Compulsive Personality
Disorder
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Epidemiology
Prevalence unknown
 Men>Women
 Most often in eldest child
 Increased incidence in first degree relatives
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Course: defined by personality DO
 Treatment
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Personality
Disorder
Prevalence Rates
Gender Incidence
(ratio)
General
Population
Paranoid
Males > females
Schizoid
Males > females
0.5-2.5%
Inpatient
Psychiatric Setting
Outpatient
Psychiatric Setting
2-10%
10-30%
Uncommon and undocumented
own
Schizotypal
Males > females
Antisocial
Males > females
3%
3% (males)
1% (females)
Unknown
Unkn
10-30%
3 -30%*
*Higher prevalence in substance abuse treatment settings and prison/forensic settings (50- 60%
prevalence rate in correctional settings)
Narcissistic
Males> females (2:1)
Histrionic
Females> males
Borderline
Females> males (3:1)
Avoidant
Males = females
Dependent
Females> males
Obsessive- compulsive
Males> females (2:1)
<1%
2-3%
Unknown
2-16%
10-15%
10-15%
2%
0.5-1.0%
10%
20%
10%
Unknown
Undocumented: most frequently reported personality disorder in mental health clinics
1%
Unknown
3-10%
Pharmacologic Treatment (Evidence Based)
No medications are FDA-approved for the treatment of personality
disorders
Medications may be useful for the treatment of target symptoms (i.e.,
depressed mood, impulsivity, and anxiety) as an adjunct to
psychotherapy
Clusters A and C: no established pharmacological treatments
Cluster B Evidence-based Pharmacotherapy:
Antisocial Personality Disorder
Anticonvulsant/mood stabilizers and target dosages: used to treat symptoms of
impulsivity and violent behavior (Refer to the Bipolar and the Neurology chapters
for a more detailed description on the pharmacology of mood stabilizers and
anticonvulsants.)
a. Lithium carbonate 1200 mg/day (0.6 -1.5 mEq/L)
b. Phenytoin 300 mg/day
c. Divalproex 750 mg/day
d. Carbamazepine 450 mg/day
Stimulants: target symptoms of inattention, irritability, and impulsivity. Rarely used
because of abuse potential. Methylphenidate: dosages mimic those used for
treatment of attention deficit hyperactivity disorder (ADHD)
Selective Serotonin Reuptake Inhibitors (SSRis): target symptoms of hostility,
impulsivity, and violent behavior
a. Sertraline 150-200 mg/day b. Fluoxetine 60 - 80 mg/day
Borderline Personality Disorder
Symptom clusters responsive to medications:
Affective dysregulation (e.g., mood lability, anger, depressed mood, temper
outbursts)
Impulsive-behavioral dyscontrol (e.g., impulsive aggression, self-damaging
behavior)
Cognitive-perceptual symptoms (e.g., suspiciousness, referential thinking,
paranoid ideation)
Evidence Based Treatment precautions – Cluster B
Polypharmacy should be minimized
Benzodiazepines are considered high risk treatments because of suicidality,
emotional dyscontrol, and abuse potential
Bupropion should not be used in a patient with a co-occurring eating disorder,
because of increased seizure risk
Tricyclic antidepressants (TCAs) should be avoided in patients with suicidality
because of the risk of lethality in overdose
Antidepressants
TCAs and monoamine oxidase inhibitors (MAOis) have inconsistent results and
may cause a paradoxical reaction in patients with BPD. Therefor SSRIs if an
antidepressant appears to be indicated
Treatment Summary:
RCT evidence supports the use of Interpersonal Therapy plus fluoxetine for the
treatment of depression and impulsive aggression associated with borderline
personality disorder.
Mixed results for TCAs and MAOs for the treatment of depressive symptoms
Antipsychotics and mood stabilizers may be consider if SSRI is ineffective
Reserved for patients who display temper outbursts, irritability, anger, or poor
impulse control
Antipsychotic Pharmacologic Treatment Summary: Moderate evidence supports
the use of olanzapine or aripiprazole for the treatment of depression, anger, and
anxiety. Case reports and open studies exist for the use of clozapine and
quetiapine in the treatment of BPD. Ziprasidone has one failed study.
RCT of conventional antipsychotics have demonstrated mixed results in the
treatment of anger, depression, and suicidality, with haloperidol being studied the
most.
Mood Stabilizer Pharmacologic Treatment Summary: Mixed results suggest not
using lithium or carbamazepine for target symptoms of BPD. Divalproex should
be considered for patients with co-occurring bipolar disorder. Positive studies with
topiramate and lamotrigine indicate that they are effective for specific BPD target
symptoms of anger, anxiety, aggression, and impulsivity.
Less well studied Pharmacotherapy of Personality
Disorders
Naltrexone 50-200 mg/day Case reports and open trials suggest it may be
helpful for self-injurious behavior, flashbacks associated with trauma, and
dissociative symptoms
Clonidine 0.15 mg every morning; 0.3 mg at bedtime. A study in 2009 indicates
that clonidine may be advantageous for symptoms of hyperarousal, subjective
sleep latency, and anxiety; however a diagnosis of PTSD is likely necessary.
It is unlikely to be efficacious for primary BPD symptoms, such as affective
dysregulation, impulsive-behavioral dyscontrol, and cognitive-perceptual
symptoms.
Methylphenidate?