Personality Disorders: MCCQE1 Preparation Guide

Introduction

Personality Disorders (PDs) represent a significant portion of psychiatric practice and are a high-yield topic for the MCCQE1. According to the DSM-5-TR, a personality disorder is an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture.

For the Canadian medical graduate, understanding PDs is crucial not only for the psychiatry rotation but for family medicine and emergency medicine, where these patients frequently present. The CanMEDS roles of Communicator and Professional are heavily tested here, specifically regarding maintaining boundaries and managing counter-transference.

General Diagnostic Criteria (The “3 Ps”)

To diagnose a personality disorder, the pattern must be:

1. Pervasive (occurring across a broad range of personal and social situations).
2. Persistent (stable and of long duration, onset in adolescence or early adulthood).
3. Pathological (leads to clinically significant distress or impairment).

Classification: The Three Clusters

The DSM-5 groups the 10 specific personality disorders into three clusters based on descriptive similarities.

Detailed Clinical Features and Management

Cluster A: Odd/Eccentric

Paranoid Personality Disorder

• Core Feature: Pervasive distrust and suspiciousness of others.
• Key Symptoms: Suspects others are exploiting them, doubts loyalty of friends, reads hidden demeaning meanings into benign remarks.
• MCCQE1 Tip: Differentiate from Paranoid Schizophrenia (Schizophrenia has fixed delusions and hallucinations; PD does not).

Schizoid Personality Disorder

• Core Feature: Detachment from social relationships and a restricted range of expression of emotions.
• Key Symptoms: Neither desires nor enjoys close relationships, chooses solitary activities, little interest in sexual experiences, emotional coldness.
• Mnemonic: DISTANT (Detached, Indifferent to praise/criticism, Sexual drive low, Tasks done alone, Absence of close friends, No emotion, Takes pleasure in few activities).

Schizotypal Personality Disorder

• Core Feature: Social deficits and cognitive or perceptual distortions/eccentricities.
• Key Symptoms: Ideas of reference (excluding delusions), odd beliefs/magical thinking, odd thinking and speech, suspiciousness.
• Clinical Pearl: These patients may have “micro-psychotic” episodes under stress.

Cluster B: Dramatic/Emotional

Borderline Personality Disorder (BPD)

• Core Feature: Pervasive instability of interpersonal relationships, self-image, and affects, and marked impulsivity.
• Diagnostic Criteria (5 of 9 required):
  1. Frantic efforts to avoid abandonment.
  2. Unstable/intense relationships (alternating between idealization and devaluation - Splitting).
  3. Identity disturbance.
  4. Impulsivity in two areas (spending, sex, substance abuse, reckless driving).
  5. Recurrent suicidal behavior or self-mutilation.
  6. Affective instability.
  7. Chronic feelings of emptiness.
  8. Inappropriate, intense anger.
  9. Transient, stress-related paranoid ideation or dissociation.
• Management: Dialectical Behavior Therapy (DBT) is the gold standard.

Antisocial Personality Disorder (ASPD)

• Core Feature: Disregard for and violation of the rights of others.
• Requirements: Must be at least 18 years old, with evidence of Conduct Disorder before age 15.
• Key Symptoms: Failure to conform to social norms (lawful behaviors), deceitfulness, impulsivity, irritability/aggressiveness, lack of remorse.

Histrionic Personality Disorder

• Core Feature: Excessive emotionality and attention-seeking.
• Key Symptoms: Uncomfortable when not center of attention, inappropriate sexually seductive behavior, rapidly shifting/shallow emotions, uses physical appearance to draw attention.

Narcissistic Personality Disorder

• Core Feature: Grandiosity, need for admiration, lack of empathy.
• Key Symptoms: Grandiose sense of self-importance, preoccupied with fantasies of unlimited success, believes they are “special,” requires excessive admiration, sense of entitlement.

Cluster C: Anxious/Fearful

Avoidant Personality Disorder

• Core Feature: Social inhibition, feelings of inadequacy, hypersensitivity to negative evaluation.
• Differentiation: Unlike Schizoid (who prefer isolation), Avoidant patients desire relationships but fear rejection.

Dependent Personality Disorder

• Core Feature: Excessive need to be taken care of leading to submissive/clinging behavior.
• Key Symptoms: Difficulty making everyday decisions without reassurance, needs others to assume responsibility, difficulty expressing disagreement.

Obsessive-Compulsive Personality Disorder (OCPD)

• Core Feature: Preoccupation with orderliness, perfectionism, and mental/interpersonal control.
• Differentiation: Unlike OCD (anxiety disorder), OCPD is ego-syntonic (the patient believes their way is the “right” way and does not wish to change it). OCPD generally lacks true obsessions/compulsions.

Comparison Table: Common Differential Diagnoses

Management Strategies

Management of personality disorders is challenging and requires a long-term approach.

Canadian Guidelines and Context

Trauma-Informed Care

Canadian medical education emphasizes Trauma-Informed Care, recognizing that many patients with PDs (especially BPD) have histories of significant childhood trauma or abuse. This is particularly relevant when working with Indigenous populations in Canada who may suffer from intergenerational trauma.

Medical Assistance in Dying (MAID)

As of the current legislation (March 2024 update), individuals whose sole underlying medical condition is a mental illness (including severe Personality Disorders) are not yet eligible for MAID. The eligibility date has been delayed to March 2027 to allow provinces to prepare. This is a rapidly evolving ethical and legal area relevant to the MCCQE1 “ELOM” (Ethical, Legal, and Organizational Medicine) objectives.

Key Points to Remember for MCCQE1

• Ego-Syntonic: PD symptoms are usually acceptable to the ego (the patient doesn’t think they have a problem); they blame the world. This contrasts with Ego-Dystonic (e.g., Depression, OCD).
• Age Criteria: You generally do not diagnose a PD before age 18. Conduct Disorder is the precursor to Antisocial PD.
• Splitting: A defense mechanism common in BPD where people are viewed as “all good” or “all bad.”
• Projection: Common in Paranoid PD (attributing one’s own unacceptable impulses to others).
• Counter-transference: Be aware of your own feelings. If a patient makes you feel angry or manipulated, consider Cluster B. If you feel bored or ignored, consider Cluster A.

// High Yield Abbreviations
const abbreviations = {
  BPD: "Borderline Personality Disorder",
  ASPD: "Antisocial Personality Disorder",
  OCPD: "Obsessive-Compulsive Personality Disorder",
  DBT: "Dialectical Behavior Therapy",
  CBT: "Cognitive Behavioral Therapy"
};

Sample Question

Scenario

A 24-year-old female presents to the emergency department in Toronto with superficial cuts on her left forearm. She states she did this after her boyfriend of 3 weeks did not reply to her text message immediately, leading her to believe he was abandoning her. She reports feeling “empty” inside and has a history of multiple short-lived, intense relationships. On examination, she is tearful but cooperative. Her toxicology screen is negative. She has no acute intent to end her life but admits to cutting to “relieve the pain.”

Question

Which one of the following is the most appropriate long-term management strategy for this patient?

• A. Admission to the inpatient psychiatric unit for safety monitoring
• B. Initiation of Quetiapine 50mg PO at bedtime
• C. Referral for Dialectical Behavior Therapy (DBT)
• D. Referral for psychoanalysis
• E. Initiation of Lithium Carbonate

Explanation

The correct answer is:

• C. Referral for Dialectical Behavior Therapy (DBT)

Detailed Explanation: The clinical presentation is classic for Borderline Personality Disorder (BPD). Key features include fear of abandonment, self-harm behavior (cutting), chronic feelings of emptiness, and unstable relationships.

• Option C (Correct): DBT is the evidence-based, gold-standard psychotherapeutic treatment for BPD. It has been proven to reduce self-harm behaviors, hospitalizations, and improve emotional regulation.
• Option A (Incorrect): Hospitalization is generally avoided for chronic self-harm in BPD unless there is an imminent, lethal suicide risk. Hospitalization can sometimes regress patients and reinforce maladaptive behaviors. The goal is to manage distress in the community.
• Option B (Incorrect): While low-dose antipsychotics are sometimes used adjunctively for symptom control, pharmacotherapy is not the primary treatment for the personality disorder itself. Psychotherapy is first-line.
• Option D (Incorrect): Traditional psychoanalysis is generally not indicated for BPD and can sometimes be destabilizing.
• Option E (Incorrect): Mood stabilizers may be used adjunctively, but DBT is the definitive management.

References

1. American Psychiatric Association. (2022). Diagnostic and Statistical Manual of Mental Disorders (5th ed., text rev.).
2. Medical Council of Canada. (n.d.). MCCQE Part I Clinical Decision-Making and Multiple-Choice Question Objectives. Retrieved from mcc.ca 
3. Public Health Agency of Canada. (2023). Mood and Anxiety Disorders in Canada.
4. Choi-Kain, L. W., et al. (2017). What works in the treatment of borderline personality disorder. Current Behavioral Neuroscience Reports.
5. Government of Canada. (2024). Medical Assistance in Dying (MAID): Mental illness as a sole underlying medical condition.