Personality disorders

Antisocial personality disorder is a pervasive, adult pattern of disregard for and violation of others' rights, with deceitfulness, impulsivity, and lack of remorse, diagnosable only at age 18 or older and only with documented conduct disorder before age 15. Management leads with consistent limit-setting; psychotherapy has limited proven benefit, and pharmacotherapy targets comorbid depression, impulsivity, or substance use disorder rather than the personality disorder itself.

Borderline personality disorder is a cluster B personality disorder defined by 5 or more of 9 DSM-5 criteria spanning instability of relationships, self-image, and affect, marked impulsivity, and recurrent self-injury or suicidality; dialectical behavior therapy is the first-line treatment, with pharmacotherapy reserved as a secondary, symptom-targeted adjunct.

Narcissistic personality disorder is a pervasive, ego-syntonic pattern of grandiosity, need for admiration, and lack of empathy that masks a fragile self-esteem intolerant of criticism, usually present by early adulthood. Diagnosis is clinical, requiring at least 5 of 9 characteristic traits causing functional or relationship impairment; first-line management is psychotherapy that sets firm, consistent boundaries, with an antidepressant such as sertraline reserved for comorbid depressive or anxiety symptoms.

Delusional disorder is a primary psychotic illness defined by one or more non-bizarre, fixed delusions lasting at least 1 month, without meeting criteria for schizophrenia and with functioning preserved outside the delusional theme. Diagnosis is clinical after a substance or medical cause is excluded. Management leads with psychotherapy, since antipsychotics are not effective for the core delusion, reserving a low-dose second-generation antipsychotic such as risperidone for overt psychosis or agitation.

Obsessive-compulsive disorder (OCD) is defined by ego-dystonic obsessions and/or compulsions that are time-consuming or cause significant distress and functional impairment, distinguishing it from the ego-syntonic perfectionism of obsessive-compulsive personality disorder. Diagnosis is clinical. First-line treatment combines cognitive behavioral therapy using exposure and response prevention with a high-dose selective serotonin reuptake inhibitor, with clomipramine as an effective second-line tricyclic and an OCD trial that can take up to 10 weeks to judge full response.

Major depressive disorder is a mood disorder defined by 5 or more of 9 major depressive episode symptoms, including depressed mood or anhedonia, present nearly every day for at least 2 weeks and causing significant functional impairment. Diagnosis is clinical, screened with the Patient Health Questionnaire. First-line treatment is cognitive behavioral therapy, a selective serotonin reuptake inhibitor (SSRI) such as sertraline, or both, escalating to augmentation, esketamine, or electroconvulsive therapy for refractory or acutely suicidal presentations.

Generalized anxiety disorder is excessive, hard-to-control worry about multiple life domains occurring more days than not for at least 6 months, with at least 3 of 6 associated physical symptoms and functional impairment. Screen with the GAD-7 after excluding hyperthyroidism and substance use, then treat first-line with cognitive behavioral therapy and/or an SSRI or SNRI such as escitalopram or venlafaxine extended-release, reserving benzodiazepines for short-term severe symptom control only.

Social anxiety disorder is marked, persistent fear of scrutiny or embarrassment in social or performance situations lasting at least 6 months with significant functional impairment. Generalized social anxiety disorder is treated with cognitive behavioral therapy (CBT) plus an SSRI such as sertraline, while the performance-only subtype is treated with a PRN beta blocker such as propranolol taken before the anticipated situation.

Suicidal ideation ranges from passive thoughts of death to an active plan with intent and access to lethal means, and suicide accounts for about 45,000 deaths a year in the United States. Diagnosis is clinical, built on directly asking about intent, plan, and means. A patient with a plan, intent, and access requires emergent hospitalization, involuntary if needed; a patient without intent and with support can be managed as an outpatient with means restriction, close follow-up, and first-line SSRI antidepressant therapy for the driving disorder.

Bipolar I disorder is a chronic mood disorder defined by at least one manic episode lasting a week or requiring hospitalization, with three or more DIG FAST symptoms causing marked impairment. Diagnosis is clinical after substances and medical mimics are excluded. Acute mania is treated with lithium or valproate, often with an atypical antipsychotic, and most patients need lifelong mood-stabilizer maintenance.

Stimulant use disorder is a pattern of amphetamine-type stimulant use, covering methamphetamine, misused prescription amphetamines, and MDMA, that meets 2 or more of 11 substance use disorder criteria within 12 months. Intoxication produces a sympathomimetic toxidrome with hyperthermia and agitation; management starts with a benzodiazepine and active cooling, since no pharmacotherapy is approved for the use disorder itself and contingency management is the named behavioral treatment.