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Cluster A Personality Disorders

Personality disorders are ego-syntonic behaviors that begin in childhood or adolescence and are classified into 3 clusters: A, B, and C. They can considerably interfere with a patient’s adherence to medical treatment for a variety of reasons. It is important to rule out organic causes of a mental disorder (e.g., endocrine hormone imbalances, medication adverse effects, alcohol and/or substance use, other mental health co-morbidities) before ascribing a personality disorder to a patient. Cluster A includes paranoid, schizoid, and schizotypal personality disorders, which can be behaviorally described as being distrustful and/or detached from society.

Last updated: Jan 8, 2021

Editorial responsibility: Stanley Oiseth, Lindsay Jones, Evelin Maza

Paranoid Personality Disorder

Key features

  • Strong distrust of others and suspicions that others want to harm or deceive them, even when unfounded
    • E.g., spouse’s infidelity
    • E.g., not sharing personal information even with close relationships out of fear of being exploited or harmed
    • E.g., reads malicious intent or hidden meaning into everyday normal remarks or actions
  • Exaggerated reactions and holding grudges after harmless events

Risk factors

  • Family history Family History Adult Health Maintenance of schizophrenia Schizophrenia Schizophrenia is a chronic mental health disorder characterized by the presence of psychotic symptoms such as delusions or hallucinations. The signs and symptoms of schizophrenia are traditionally separated into 2 groups: positive (delusions, hallucinations, and disorganized speech or behavior) and negative (flat affect, avolition, anhedonia, poor attention, and alogia). Schizophrenia
  • Family history Family History Adult Health Maintenance of delusional disorder Delusional disorder In delusional disorder, the patient suffers from 1 or more delusions for a duration of 1 month or more, without any other psychotic symptoms or behavioral changes and no decline in functioning abilities. Delusional Disorder (persecutory type)
  • Affects men more commonly than women

Management

  • Psychotherapy Psychotherapy Psychotherapy is interpersonal treatment based on the understanding of psychological principles and mechanisms of mental disease. The treatment approach is often individualized, depending on the psychiatric condition(s) or circumstance. Psychotherapy (first line)
  • Pharmacotherapy for symptoms that impair functioning (e.g., anxiety Anxiety Feelings or emotions of dread, apprehension, and impending disaster but not disabling as with anxiety disorders. Generalized Anxiety Disorder, depression, psychosis, mood instability)

Clinical associations

  • Projection Projection A defense mechanism, operating unconsciously, whereby that which is emotionally unacceptable in the self is rejected and attributed (projected) to others. Defense Mechanisms is the predominant defense mechanism Defense mechanism Unconscious process used by an individual or a group of individuals in order to cope with impulses, feelings or ideas which are not acceptable at their conscious level; various types include reaction formation, projection and self reversal. Psychotherapy.
  • Should be differentiated from delusional disorder Delusional disorder In delusional disorder, the patient suffers from 1 or more delusions for a duration of 1 month or more, without any other psychotic symptoms or behavioral changes and no decline in functioning abilities. Delusional Disorder

Schizoid Personality Disorder

Key features

  • No interest in close relationships or intimacy → solitary, lack of close relationships other than parents or siblings
  • Inability to enjoy activities usually seen as pleasurable
  • Appears unemotional and indifferent to the opinion of others

Risk factors

  • Family history Family History Adult Health Maintenance of schizophrenia Schizophrenia Schizophrenia is a chronic mental health disorder characterized by the presence of psychotic symptoms such as delusions or hallucinations. The signs and symptoms of schizophrenia are traditionally separated into 2 groups: positive (delusions, hallucinations, and disorganized speech or behavior) and negative (flat affect, avolition, anhedonia, poor attention, and alogia). Schizophrenia or schizotypal personality disorder
  • Slightly higher prevalence Prevalence The total number of cases of a given disease in a specified population at a designated time. It is differentiated from incidence, which refers to the number of new cases in the population at a given time. Measures of Disease Frequency in men

Management

  • It is unlikely that a physician will encounter a patient with schizoid personality disorder without any other reason for medical treatment, as these patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship avoid interacting with people.
  • Psychotherapy Psychotherapy Psychotherapy is interpersonal treatment based on the understanding of psychological principles and mechanisms of mental disease. The treatment approach is often individualized, depending on the psychiatric condition(s) or circumstance. Psychotherapy (first line)
  • Pharmacotherapy for symptoms that impair functioning (e.g., anxiety Anxiety Feelings or emotions of dread, apprehension, and impending disaster but not disabling as with anxiety disorders. Generalized Anxiety Disorder, depression, psychosis, mood instability)

Clinical associations

  • Isolation of affect Affect The feeling-tone accompaniment of an idea or mental representation. It is the most direct psychic derivative of instinct and the psychic representative of the various bodily changes by means of which instincts manifest themselves. Psychiatric Assessment is the predominant defense mechanism Defense mechanism Unconscious process used by an individual or a group of individuals in order to cope with impulses, feelings or ideas which are not acceptable at their conscious level; various types include reaction formation, projection and self reversal. Psychotherapy.
  • Should be differentiated from:
    • The involuntary social withdrawal associated with avoidant personality disorder Avoidant Personality Disorder Cluster C Personality Disorders (Cluster C)
    • Autism spectrum disorder Autism spectrum disorder Autism spectrum disorder (ASD) is a neurodevelopmental disorder marked by poor social skills, restricted interests/social interactions, and repetitive/stereotyped behaviors. The condition is termed a “spectrum” because of the wide variability in the severity of symptoms exhibited. Autism Spectrum Disorder
    • Agoraphobia Agoraphobia Agoraphobia is fear or anxiety in a situation that would be difficult to leave or to obtain help in the event that one develops panic-like symptoms. Situations include being in public or open spaces, lines, crowds, or public transport. Agoraphobia
    • Antisocial personality disorder Antisocial Personality Disorder A personality disorder whose essential feature is a pervasive pattern of disregard for, and violation of, the rights of others that begins in childhood or early adolescence and continues into adulthood. The individual must be at least age 18 and must have a history of some symptoms of conduct disorder before age 15. Cluster B Personality Disorders (in the colloquial sense of the term; i.e., “He’s just being antisocial”)

Schizotypal Personality Disorder

Key features

  • Social anxiety Anxiety Feelings or emotions of dread, apprehension, and impending disaster but not disabling as with anxiety disorders. Generalized Anxiety Disorder and paranoia →  lack of close relationships
  • Odd beliefs and behavior, including:
    • Eccentric appearance
    • Magical thinking
    • Ideas of reference
    • Striking speech patterns, e.g., very vague or overly detailed

Risk factors

  • Family history Family History Adult Health Maintenance of schizophrenia Schizophrenia Schizophrenia is a chronic mental health disorder characterized by the presence of psychotic symptoms such as delusions or hallucinations. The signs and symptoms of schizophrenia are traditionally separated into 2 groups: positive (delusions, hallucinations, and disorganized speech or behavior) and negative (flat affect, avolition, anhedonia, poor attention, and alogia). Schizophrenia or schizotypal personality disorder
  • Slightly higher prevalence Prevalence The total number of cases of a given disease in a specified population at a designated time. It is differentiated from incidence, which refers to the number of new cases in the population at a given time. Measures of Disease Frequency in men

Management

  • Psychotherapy Psychotherapy Psychotherapy is interpersonal treatment based on the understanding of psychological principles and mechanisms of mental disease. The treatment approach is often individualized, depending on the psychiatric condition(s) or circumstance. Psychotherapy (first line)
  • Pharmacotherapy for symptoms that impair functioning (e.g., anxiety Anxiety Feelings or emotions of dread, apprehension, and impending disaster but not disabling as with anxiety disorders. Generalized Anxiety Disorder, depression, psychosis, mood instability)

Clinical associations

  • Should be differentiated from:
    • Schizophrenia Schizophrenia Schizophrenia is a chronic mental health disorder characterized by the presence of psychotic symptoms such as delusions or hallucinations. The signs and symptoms of schizophrenia are traditionally separated into 2 groups: positive (delusions, hallucinations, and disorganized speech or behavior) and negative (flat affect, avolition, anhedonia, poor attention, and alogia). Schizophrenia
    • Schizoaffective disorder Schizoaffective disorder Schizoaffective disorder is a mental disorder that is marked by 2 components: a psychotic component (hallucinations or delusions) and a mood component (mania or depression). Patients must therefore meet the diagnostic criteria for both major mood disorder and schizophrenia. Schizoaffective Disorder
    • Delusional disorder Delusional disorder In delusional disorder, the patient suffers from 1 or more delusions for a duration of 1 month or more, without any other psychotic symptoms or behavioral changes and no decline in functioning abilities. Delusional Disorder (especially ideas of reference)

Summary

Cluster A disorder Paranoid Schizoid Schizotypal
Key features
  • Suspicious
  • Distrustful
  • Hypervigilant
  • Voluntary social withdrawal
  • Detached
  • Unemotional
  • Eccentric thoughts, perceptions, and behavior
  • Uncomfortable in close relationships
Defense mechanism Defense mechanism Unconscious process used by an individual or a group of individuals in order to cope with impulses, feelings or ideas which are not acceptable at their conscious level; various types include reaction formation, projection and self reversal. Psychotherapy Projection Projection A defense mechanism, operating unconsciously, whereby that which is emotionally unacceptable in the self is rejected and attributed (projected) to others. Defense Mechanisms Isolation of affect Affect The feeling-tone accompaniment of an idea or mental representation. It is the most direct psychic derivative of instinct and the psychic representative of the various bodily changes by means of which instincts manifest themselves. Psychiatric Assessment N/A
Differentials Delusional disorder Delusional disorder In delusional disorder, the patient suffers from 1 or more delusions for a duration of 1 month or more, without any other psychotic symptoms or behavioral changes and no decline in functioning abilities. Delusional Disorder
  • Avoidant personality disorder Avoidant Personality Disorder Cluster C Personality Disorders
  • Autism spectrum disorder Autism spectrum disorder Autism spectrum disorder (ASD) is a neurodevelopmental disorder marked by poor social skills, restricted interests/social interactions, and repetitive/stereotyped behaviors. The condition is termed a “spectrum” because of the wide variability in the severity of symptoms exhibited. Autism Spectrum Disorder
  • Agoraphobia Agoraphobia Agoraphobia is fear or anxiety in a situation that would be difficult to leave or to obtain help in the event that one develops panic-like symptoms. Situations include being in public or open spaces, lines, crowds, or public transport. Agoraphobia
  • Schizophrenia Schizophrenia Schizophrenia is a chronic mental health disorder characterized by the presence of psychotic symptoms such as delusions or hallucinations. The signs and symptoms of schizophrenia are traditionally separated into 2 groups: positive (delusions, hallucinations, and disorganized speech or behavior) and negative (flat affect, avolition, anhedonia, poor attention, and alogia). Schizophrenia
  • Schizoaffective disorder Schizoaffective disorder Schizoaffective disorder is a mental disorder that is marked by 2 components: a psychotic component (hallucinations or delusions) and a mood component (mania or depression). Patients must therefore meet the diagnostic criteria for both major mood disorder and schizophrenia. Schizoaffective Disorder
  • Social anxiety Anxiety Feelings or emotions of dread, apprehension, and impending disaster but not disabling as with anxiety disorders. Generalized Anxiety Disorder disorder
Management Psychotherapy Psychotherapy Psychotherapy is interpersonal treatment based on the understanding of psychological principles and mechanisms of mental disease. The treatment approach is often individualized, depending on the psychiatric condition(s) or circumstance. Psychotherapy (first line) with low-dose pharmacotherapy for applicable symptoms (e.g., anxiolytics, mood stabilizers) Psychotherapy Psychotherapy Psychotherapy is interpersonal treatment based on the understanding of psychological principles and mechanisms of mental disease. The treatment approach is often individualized, depending on the psychiatric condition(s) or circumstance. Psychotherapy (first line) with low-dose pharmacotherapy for applicable symptoms (e.g., anxiolytics, mood stabilizers) Psychotherapy Psychotherapy Psychotherapy is interpersonal treatment based on the understanding of psychological principles and mechanisms of mental disease. The treatment approach is often individualized, depending on the psychiatric condition(s) or circumstance. Psychotherapy (first line) with low-dose pharmacotherapy for applicable symptoms (e.g., anxiolytics, mood stabilizers, second-generation antipsychotics Second-Generation Antipsychotics Second-generation antipsychotics (SGAs) are also called atypical antipsychotics. Medications in this class include aripiprazole, asenapine, brexpiprazole, cariprazine, clozapine, iloperidone, lumateperone, lurasidone, olanzapine, paliperidone, pimavanserin, quetiapine, risperidone, and ziprasidone. Second-Generation Antipsychotics)
Epidemiology ♂>♀ ♂>♀ (slightly) ♂>♀ (slightly)
Example A man believes that his neighbors are sneaking into his house at night and are working together to get him kicked out of the neighborhood. A man lives in a remote village and has no known friends or family. A young man believes that the crystals he sells have magical healing properties and that the spirit gods are helping him find his fortune.

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