Personality disorders

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

at risk for harming self or others, or unable to attend to basic self-needs

1st line – partial hospitalisation or inpatient hospitalisation referral

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1st line –

partial hospitalisation or inpatient hospitalisation referral

Patients in need of this high-level, structured treatment may present with: severe disturbances of thinking, mood, and/or impulse control; aggression; hopelessness; extremely poor judgement.

Inpatient hospitalisation may need to take place on an involuntary basis.

It is imperative that close communication take place between providers of acute psychiatric services and the primary care physician. See Suicide risk mitigation.

with substance use disorder

Plus – referral for assessment

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Plus –

referral for assessment

Treatment recommended for ALL patients in selected patient group

Patients with acute alcohol or other substance intoxication and/or highly problematic substance use patterns may require inpatient treatment for detoxification and subsequent monitoring. This may be particularly necessary for patients with a history of self-injurious behaviour or impulsive behavioural dyscontrol. Those with histories of complicated substance withdrawal or serious comorbid medical conditions warrant consideration for inpatient treatment.

This treatment can occur concurrently with psychiatric stabilisation.

Following the period of inpatient treatment, referral to a residential or intensive outpatient substance use disorder treatment programme, including a 12-step programme such as Alcoholics Anonymous or Narcotics Anonymous, will provide for continuity of care.

ONGOING

cluster A (odd/eccentric): non-life-threatening

paranoid, schizoid, or schizotypal

1st line – patient communication and relationship management strategies

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1st line –

patient communication and relationship management strategies

Establishment of a stable, supportive physician-patient relationship lies at the core of the approach to managing personality-disordered patients.

Communication that is straightforward with an unintrusive style is recommended in this group. The physician should display interest in those concerns that the patient is willing to share.

Dearth of research precludes conclusions about efficacy of psychotherapy; therefore, a trusting relationship with primary care physician can be particularly important.

Consider – low-dose antipsychotics

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Consider –

low-dose antipsychotics

Additional treatment recommended for SOME patients in selected patient group

There is a striking paucity of pharmacotherapy studies for schizoid and paranoid personality disorders. Many patients with personality disorders present with problems related to self-harm and suicidality, which makes prescribing problematic, and the side effects can be substantial. These are important factors when pharmacotherapy is being considered.

Antipsychotics have some usefulness in reducing psychotic-like symptoms in the treatment of schizotypal personality disorder.[90][91]

First-generation antipsychotic agents (e.g., haloperidol, perphenazine) are associated with hyperprolactinaemia and early (akathisia and parkinsonism) and late (tardive dyskinesia) movement abnormalities, as well as the neuroleptic malignant syndrome. A careful consideration of the risks versus the benefits needs to be performed for individual patients.

Second-generation antipsychotics (e.g., aripiprazole) are associated with the metabolic syndrome and are not free of the same risks as first-generation antipsychotics: acute and tardive movement disorders and neuroleptic malignant syndrome.

Primary options

aripiprazole: 2.5 to 5 mg orally once daily initially, increase by 5-10 mg/day increments at weekly intervals according to response, maximum 30 mg/day

haloperidol: 1-2 mg orally every 6-8 hours

perphenazine: 2-4 mg orally every 6-8 hours

Consider – antidepressants

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Consider –

antidepressants

Additional treatment recommended for SOME patients in selected patient group

Antidepressants may help self-injurious behaviour and depressive and psychotic-like symptoms, as suggested by some open-label studies.[94][95]

Primary options

fluoxetine: 10 mg orally once daily initially, increase by 10 mg/day increments at weekly intervals according to response, maximum 80 mg/day

sertraline: 25 mg orally once daily initially, increase by 25 mg/day increments at weekly intervals according to response, maximum 200 mg/day

venlafaxine: 37.5 to 75 mg orally (extended-release) once daily initially, increase by 75 mg/day increments at weekly intervals according to response, maximum 225 mg/day

Consider – substance use disorder treatment programme referral

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Consider –

substance use disorder treatment programme referral

Additional treatment recommended for SOME patients in selected patient group

Ideally, referral can be made to a treatment programme that is multi-modal in nature with medical, psychiatric, psychological, counselling, and skill-training components available, as indicated. Additionally, encouragement to attend 12-step programme meetings (e.g., Alcoholics Anonymous [AA] or Narcotics Anonymous [NA]) is indicated.

For promotion of abstinence from substances, pharmacotherapy may be employed.

Where access to specialty substance use disorder treatment is limited, primary care physicians can utilise behavioural counselling interventions and indicated pharmacotherapies.[68][115]

cluster B (dramatic): non-life-threatening

borderline

1st line – patient communication and relationship management strategies

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1st line –

patient communication and relationship management strategies

Establishment of a stable, supportive physician-patient relationship lies at the core of the approach to managing personality-disordered patients.

Simple communication with clear and consistent boundaries is recommended. Physicians should have a calm demeanour in response to inevitable crises, and prepare the patient for any changes in care arrangements (such as coverage during vacation). Agreement with the patient about crisis management (commitment to treatment) is important.[116]

There should be coordination of care with other treatment providers in order to avoid patient use of splitting (a defence mechanism where the patient views others as all good or all bad; it can lead to disagreements among those treating the patient).

A practice protocol with regard to after-hours coverage and use of e-mail communication may be considered.

Plus – psychotherapy

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Plus –

psychotherapy

Treatment recommended for ALL patients in selected patient group

Borderline disorder is the only personality disorder for which there is a Cochrane review concluding that despite limitations, psychotherapy is considered an effective treatment for this condition.[77]

Evidence-based therapies for borderline personality disorder are: mentalisation-based therapy; transference-focused therapy; dialectical behaviour therapy; and general psychiatric management.[80]

Consider – mood stabilisers or anticonvulsants

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Consider –

mood stabilisers or anticonvulsants

Additional treatment recommended for SOME patients in selected patient group

There is paucity of evidence concerning pharmacotherapy for personality disorder. Many patients with personality disorders present with problems related to self-harm and suicidality, which makes prescribing problematic, and the side effects can be substantial. These are important factors when pharmacotherapy is being considered. People with borderline personality disorder may also engage in risky sexual activity and may become pregnant. Therefore, the possibility of teratogenicity should be considered for any drugs used.

The NICE guidelines on borderline personality disorder state that drug treatment should not be used specifically for borderline personality disorder or for the individual symptoms or behaviour associated with the disorder (e.g., repeated self-harm, marked emotional instability, risk-taking behaviour, and transient psychotic symptoms).[97] However, the NICE guidelines also suggest that drug treatment may be considered in the overall treatment of co-morbid conditions in patients with personality disorders.[97]

Mood stabilisers, such as lithium, and anticonvulsants (e.g., topiramate, valproate semisodium, lamotrigine), may have some effectiveness in treating impulsivity and aggression in borderline personality disorder. Mood stabilisers and anticonvulsants have demonstrated a moderate effect in treating depression in borderline personality disorder.[98][99] However, a 2018 two-arm, double-blind, placebo-controlled individually randomised trial of lamotrigine versus placebo showed that the addition of lamotrigine to the usual care of people with borderline personality disorder was not clinically effective and did not provide a cost-effective use of resources.[100]

Patients need to be closely monitored because many patients tolerate these medications poorly, which also limits the titration of the medications. Although impulsivity and aggression may be responsive to these treatments, there is a paucity of evidence that interpersonal and identity disturbances are improved.

The possibility of teratogenicity should be considered for any of the drugs used. Of particular note, valproic acid and its derivatives may cause major congenital malformations, including neurodevelopmental disorders and neural tube defects, after in utero exposure. These agents must not be used in female patients of childbearing potential unless other options are unsuitable, there is a pregnancy prevention programme in place, and certain conditions are met. Precautionary measures may also be required in male patients owing to a potential risk that use in the 3 months leading up to conception may increase the likelihood of neurodevelopmental disorders in their children. Regulations and precautionary measures for female and male patients may vary between countries, with some countries taking a more heightened precautionary stance, and you should consult your local guidance for more information. In some countries, it is also recommended that topiramate should only be used in women of childbearing potential if there is a pregnancy prevention programme in place.

Primary options

topiramate: 25 mg orally once or twice daily initially, increase by 25-50 mg/day increments at weekly intervals according to response, maximum 400 mg/day given in 2 divided doses

valproate semisodium: 250-500 mg/day orally (immediate-release) given in 2-3 divided doses initially, increase by 250-500 mg/day increments at weekly intervals according to response, maximum 2500 mg/day

lithium: 150 mg orally (immediate-release) twice daily initially, increase by 150-300 mg/day increments every 3-5 days according to response, maximum 1500 mg/day

Secondary options

lamotrigine: 25 mg orally once daily for weeks 1 and 2, followed by 50 mg once daily for weeks 3 and 4, followed by 100 mg once daily for week 5, may increase to maximum of 200 mg/day given in 2 divided doses beginning week 6

Consider – substance use disorder treatment programme referral

Back

Consider –

substance use disorder treatment programme referral

Additional treatment recommended for SOME patients in selected patient group

For promotion of abstinence from substances, pharmacotherapy may be employed.

Where access to specialty substance use disorder treatment is limited, primary care physicians can utilise behavioural counselling interventions and indicated pharmacotherapies.[68][115]

narcissistic

1st line – patient communication and relationship management strategies

Back

1st line –

patient communication and relationship management strategies

Establishment of a stable, supportive physician-patient relationship lies at the core of the approach to managing personality-disordered patients.

Recommended communication between physician and patient includes acknowledging the patient as special, conveying self-confidence in interactions, and avoiding power struggles.

Most psychotherapy studies focus on borderline personality disorder only, and this is an acknowledged weakness in the literature.

There is no evidence to support any pharmacotherapy recommendations in narcissistic personality disorder.

Consider – substance use disorder treatment programme referral

Back

Consider –

substance use disorder treatment programme referral

Additional treatment recommended for SOME patients in selected patient group

For promotion of abstinence from substances, pharmacotherapy may be employed.

Where access to specialty substance use disorder treatment is limited, primary care physicians can utilise behavioural counselling interventions and indicated pharmacotherapies.[68][115]

histrionic

1st line – patient communication and relationship management strategies

Back

1st line –

patient communication and relationship management strategies

Establishment of a stable, supportive physician-patient relationship lies at the core of the approach to managing personality-disordered patients.

Recommended communication between physician and patient includes maintaining professional distance, providing reassurance, addressing seductive behaviours in a straightforward manner while maintaining a professional boundary.

Most psychotherapy studies focus on borderline personality disorder only, and this is an acknowledged weakness in the literature.

There is no evidence to support any pharmacotherapy recommendations in histrionic personality disorder.

Consider – substance use disorder treatment programme referral

Back

Consider –

substance use disorder treatment programme referral

Additional treatment recommended for SOME patients in selected patient group

For promotion of abstinence from substances, pharmacotherapy may be employed.

Where access to specialty substance use disorder treatment is limited, primary care physicians can utilise behavioural counselling interventions and indicated pharmacotherapies.[68][115]

antisocial

1st line – patient communication and relationship management strategies

Back

1st line –

patient communication and relationship management strategies

Establishment of a stable, supportive physician-patient relationship lies at the core of the approach to managing personality-disordered patients.

Simple, straightforward communication between physician and patient is recommended, with clear and consistent boundaries. Caution should be exercised when prescribing controlled substances due to the potential for illegal use. In addition, the physician should be aware of tendencies of these patients to be less than truthful and to disregard rules.

Consider – psychotherapy

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Consider –

psychotherapy

Additional treatment recommended for SOME patients in selected patient group

Contingency management treatment (a behavioural therapy where adaptive behaviours are rewarded) may be used. Research focusing on key symptoms is needed.[117]

A review concluded that cognitive behavioural therapy (CBT) implemented in a residential setting was more effective at reducing criminal behaviour than standard treatment, but was no more effective than other treatment modalities.[83]

Consider – substance use disorder treatment programme referral

Back

Consider –

substance use disorder treatment programme referral

Additional treatment recommended for SOME patients in selected patient group

For promotion of abstinence from substances, pharmacotherapy may be employed.

Where access to specialty substance use disorder treatment is limited, primary care physicians can utilise behavioural counselling interventions and indicated pharmacotherapies.[68][115]

cluster C (anxious): non-life-threatening

avoidant

1st line – patient communication and relationship management strategies

Back

1st line –

patient communication and relationship management strategies

Establishment of a stable, supportive physician-patient relationship lies at the core of the approach to managing personality-disordered patients.

Physicians should take care to avoid critical comments and reinforce appropriate help-seeking behaviours.

Plus – psychotherapy

Back

Plus –

psychotherapy

Treatment recommended for ALL patients in selected patient group

Social skills training results in most improvement at follow-up.[84]

There are conflictual results regarding the relative efficacy of other treatments. However, cognitive behavioural therapy (CBT) and psychodynamic approaches have also been found to be effective.[84]

Consider – pharmacotherapy

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Consider –

pharmacotherapy

Additional treatment recommended for SOME patients in selected patient group

Patients with avoidant personality disorder have shown a favourable response to venlafaxine and the selective serotonin-reuptake inhibitors (SSRIs). However, sertraline may have less effectiveness if the symptoms began in childhood.[108]

The above listed medications would be first-line options due to their favourable side-effect profile. Gabapentin and pregabalin have demonstrated some efficacy in social phobia and may benefit patients with avoidant personality disorder.[109][110]

Reversible monoamine oxidase inhibitors (MAOIs), such as moclobemide, have support for their use.

Phenelzine, if used, requires great caution regarding serious risks and side effects.

The use of any combination of these medications is not recommended due to potential dangerous drug interactions, such as serotonin syndrome, and also due to lack of efficacy data.

Primary options

fluoxetine: 10 mg orally once daily initially, increase by 10 mg/day increments at weekly intervals according to response, maximum 80 mg/day

sertraline: 25 mg orally once daily initially, increase by 25 mg/day increments at weekly intervals according to response, maximum 200 mg/day

venlafaxine: 37.5 to 75 mg orally (extended-release) once daily initially, increase by 75 mg/day increments at weekly intervals according to response, maximum 225 mg/day

Secondary options

gabapentin: 300 mg orally three times daily initially, increase according to response, maximum 1800 mg/day

pregabalin: 75 mg orally twice daily initially, increase according to response, maximum 600 mg/day

Tertiary options

phenelzine: 15 mg orally three times daily initially, increase according to response, maximum 90 mg/day

Consider – substance use disorder treatment programme referral

Back

Consider –

substance use disorder treatment programme referral

Additional treatment recommended for SOME patients in selected patient group

For promotion of abstinence from substances, pharmacotherapy may be employed.

Where access to specialty substance use disorder treatment is limited, primary care physicians can utilise behavioural counselling interventions and indicated pharmacotherapies.[68][115]

dependent

1st line – patient communication and relationship management strategies

Back

1st line –

patient communication and relationship management strategies

Establishment of a stable, supportive physician-patient relationship lies at the core of the approach to managing personality-disordered patients.

Physicians should tolerate repeated requests for reassurance; provide helpful resources and support patient self-efficacy; and schedule primary care visits at regular, pre-established times (such as monthly) rather than as unscheduled visits prompted by the emergence of new symptom complaints.

There is insufficient evidence to recommend any pharmacotherapy for dependent personality disorder.

Plus – psychotherapy

Back

Plus –

psychotherapy

Treatment recommended for ALL patients in selected patient group

Social skills training results in most improvement at follow-up.[84]

There are conflictual results regarding the relative efficacy of other treatments. However cognitive behavioural therapy (CBT) and psychodynamic approaches have also been found to be effective.[84]

Consider – substance use disorder treatment programme referral

Back

Consider –

substance use disorder treatment programme referral

Additional treatment recommended for SOME patients in selected patient group

For promotion of abstinence from substances, pharmacotherapy may be employed.

Where access to specialty substance use disorder treatment is limited, primary care physicians can utilise behavioural counselling interventions and indicated pharmacotherapies.[68][115]

obsessive-compulsive

1st line – patient communication and relationship management strategies

Back

1st line –

patient communication and relationship management strategies

Establishment of a stable, supportive physician-patient relationship lies at the core of the approach to managing personality-disordered patients.

Physicians should provide information about conditions/treatments without extended discussion; power struggles should be avoided.

Limited information-seeking on the internet and through other resources while reinforcing other interests (those that support functional, non-illness-related behaviours) could be encouraged.

There is insufficient evidence to recommend any pharmacotherapy for obsessive-compulsive personality disorder.

Plus – psychotherapy

Back

Plus –

psychotherapy

Treatment recommended for ALL patients in selected patient group

Social skills training results in most improvement at follow-up.[84]

There are conflictual results regarding the relative efficacy of other treatments. However, cognitive behavioural therapy (CBT) and psychodynamic approaches have also been found to be effective.[84]

Consider – substance use disorder treatment programme referral

Back

Consider –

substance use disorder treatment programme referral

Additional treatment recommended for SOME patients in selected patient group

For promotion of abstinence from substances, pharmacotherapy may be employed.

Where access to specialty substance use disorder treatment is limited, primary care physicians can utilise behavioural counselling interventions and indicated pharmacotherapies.[68][115]

multiple features of different personality disorders: non-life-threatening

1st line – complex pharmacotherapy + psychiatric referral

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1st line –

complex pharmacotherapy + psychiatric referral

Patients with mixtures of significant symptoms (cognitive-perceptual, affective-dysregulation, impulse-dyscontrol, and substance abuse) are commonly encountered.

Complex pharmacological interventions may be necessary to address these symptoms. Many patients with personality disorders present with problems related to self-harm and suicidality, which makes prescribing problematic, and the side effects can be substantial. These are important factors when pharmacotherapy is being considered.

Consultation with a psychiatrist is recommended if benzodiazepines, stimulants, opioids, or psychotropic drugs with lethal overdose potential (tricyclic and monoamine oxidase inhibitor [MAOI] antidepressants, lithium) are being prescribed or considered for use.

Psychiatric consultation may also be prudent for patients with poor symptom response to initial medication interventions, those whose psychiatric symptoms are escalating in severity, and those who are on a complicated regimen incorporating multiple psychotropic agents.

Consider – substance use disorder treatment programme referral

Back

Consider –

substance use disorder treatment programme referral

Additional treatment recommended for SOME patients in selected patient group

For promotion of abstinence from substances, pharmacotherapy may be employed.

Where access to specialty substance use disorder treatment is limited, primary care physicians can utilise behavioural counselling interventions and indicated pharmacotherapies.[68][115]

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Personality disorders

Treatment algorithm

at risk for harming self or others, or unable to attend to basic self-needs

partial hospitalisation or inpatient hospitalisation referral

referral for assessment

cluster A (odd/eccentric): non-life-threatening

patient communication and relationship management strategies

low-dose antipsychotics

Primary options

antidepressants

Primary options

substance use disorder treatment programme referral

cluster B (dramatic): non-life-threatening

patient communication and relationship management strategies

psychotherapy

mood stabilisers or anticonvulsants

Primary options

Secondary options

substance use disorder treatment programme referral

patient communication and relationship management strategies

substance use disorder treatment programme referral

patient communication and relationship management strategies

substance use disorder treatment programme referral

patient communication and relationship management strategies

psychotherapy

substance use disorder treatment programme referral

cluster C (anxious): non-life-threatening

patient communication and relationship management strategies

psychotherapy

pharmacotherapy

Primary options

Secondary options

Tertiary options

substance use disorder treatment programme referral

patient communication and relationship management strategies

psychotherapy

substance use disorder treatment programme referral

patient communication and relationship management strategies

psychotherapy

substance use disorder treatment programme referral

multiple features of different personality disorders: non-life-threatening

complex pharmacotherapy + psychiatric referral

substance use disorder treatment programme referral