Personality disorders

The personality disorders (American Psychiatric Association, 1994) are defined as an enduring pattern of inner experience and behaviour that is pervasive across a wide range of personal and social situations and deviate markedly from the expectations of the individual's culture. The personality disorders that are most frequently encountered in dermatology include Borderline, Narcissistic and Histrionic personality disorders which all fall in the 'Cluster B' (American Psychiatric Association, 1994) category in the DSM-IV and Obsessive-compulsive personality disorder (which is categorised in 'Cluster C'). Borderline personality disorder is associated with a pattern of instability in interpersonal relationships, affects and self-image, and impulsive behaviours. Such patients are often 'difficult' as their instability in interpersonal relationships and self-image are also manifested in their relationship with their dermatologists and other health care providers. Such patients often try to 'split' or play one professional against the other, and at times may be very unreasonable, manipulative and demanding. The borderline patient is also prone to impulsive self-harm such as cutting of the skin. Narcissistic personality disorder presents with a pattern of grandiosity, need for admiration and often a lack of empathy for others. Some such patients may place an inordinate importance on their appearance and the approval of others, and face a psychiatric crisis including suicidal ideation, when faced with a cosmetically disfiguring skin disorder or the normal changes of aging. The patient with a Histrionic personality disorder presents with excessive emotionality and are attention seeking. Some such patients, who have very immature coping mechanisms, may self-induce skin lesions to get attention. This can be the case in dermatitis artefacta or some patients with acne excoriee des jeunes filles. In Obsessive-compulsive personality disorder there is a pattern of preoccupation with orderliness, perfectionism and control. This may be a feature in patients with compulsive behaviours such as compulsive washing and picking of the skin, or patients with excessive body image concerns where the patient is bothered by a minor or nonexistent 'imperfection' in their skin.

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