Specific personality disorders: clinical guidelines

List of Abbreviations

ICD-10 — International Classification of Diseases (10th Revision)

PD — personality disorder

SPD — specific personality disorder

BPD — borderline personality disorder

BD — bipolar disorder

CBT - cognitive behavioral therapy

RCT — randomized controlled trial

ECT — electroconvulsive therapy

rTMS — repetitive transcranial magnetic stimulation

DLPFC — left dorsolateral prefrontal cortex

Serbsky National Medical Research Centre for Psychiatry and Narcology of the Russian Ministry of Health — Federal State Budgetary Institution «Serbsky National Medical Research Centre for Psychiatry and Narcology» of the Ministry of Health of the Russian Federation

RPS - Russian Society of Psychiatrists

SSRI — selective serotonin reuptake inhibitor (N06AB according to the ATC classification)

LoE – level of evidence

LER — level of evidence and recommendation

Terms and Definitions

Clinical interview (interrogation) is the main research method, allowing the collection of a subjective anamnesis and the identification of clinical facts that determine the mental state.

Anamnesis by proxy is an important stage in the diagnosis of a personality disorder. To obtain objective information, close associates of the patient—relatives, acquaintances, and coworkers—are interviewed. Information can also be obtained from character references from the place of study, work, or residence.

Personality disorders are a range of clinically significant conditions and behavioral patterns that tend to be persistent and are the expression of the individual's characteristic lifestyle, as well as their mode of relating to themselves and others. This is a disharmony of all spheres of the personality with a primary impairment of emotions and volition, and peculiar thinking. Personality anomalies change little over the course of life, and these impairments may alter the individual's social adaptation.

1. Brief information on the disease or condition

1.1 Definition of the disease or condition

In ICD-10, specific personality disorders are understood as a severe disturbance of the characterological constitution and behavioral tendencies of the individual, usually involving several areas of the psyche and accompanied by personal and social disintegration. Disorders originating in childhood or adolescence manifest in maturity and represent significant deviations from the lifestyle typical of an ordinary person, with the associated perceptions, thinking, emotions, and interpersonal relationships characteristic of the given culture.

1.2 Etiology and pathogenesis of the disease or condition (group of diseases or conditions)

Specific personality disorders arise from the interaction of two factors: early acquired biological inferiority of the brain and environmental influences.

The common mechanism of the dynamics of specific personality disorders is the decompensation of the pathological condition with the inclusion of new pathological phenomena (affective, delusional).

1.3 Epidemiology of the Disease or Condition

The average total prevalence rate of all types of specific personality disorders among the population is 5–10%. For each specific type of personality disorder, the rate ranges from 0.5% to 7.8% [4, 9].

1.4 Features of Coding the Disease or Condition

Specific personality disorders (F60):

F60.0 — Paranoid personality disorder

F60.1 — Schizoid personality disorder

F60.2 — Dissocial personality disorder

F60.3 — Emotionally unstable personality disorder

F60.30 — impulsive type

F60.31 — borderline type (BPD)

F60.4 — Histrionic personality disorder

F60.5 — Anankastic personality disorder

F60.6 — Anxious (avoidant) personality disorder

F60.7 — Dependent personality disorder

F60.8 — Other specific personality disorders

F60.9 — Personality disorder, unspecified

Mixed and other personality disorders (F61):

F61.0 — Mixed personality disorders

F61.1 — Troublesome personality changes

To code states of decompensation (reactions) and personality development, the fifth digit should be used (in subcategory F60.3x — the sixth digit):

F60.x1 — compensated state;

F60.x2 — state of decompensation (psychopathic reaction);

F60.x3 — personality development;

F60.x4 — unspecified state.

1.5 Classification of the disease or condition

To date, there is no single, universally accepted classification of specific personality disorders shared by the entire scientific community. The classification of specific personality disorders implemented in ICD-10, despite a number of criticisms, generally corresponds to the traditional domestic approach based on a clinical phenomenological description of the abnormal personality.

Specific personality disorders (F60):

F60.0 — Paranoid personality disorder

F60.1 — Schizoid personality disorder

F60.2 — Dissocial personality disorder

F60.3 — Emotionally unstable personality disorder

F60.30 — impulsive type

F60.31 — borderline type (BPD)

F60.4 — Histrionic personality disorder

F60.5 — Anankastic personality disorder

F60.6 — Anxious (avoidant) personality disorder

F60.7 — Dependent personality disorder

F60.8 — Other specific personality disorders

F60.9 — Personality disorder, unspecified

Mixed and other personality disorders (F61)

This category is intended for personality disorders and anomalies that frequently cause distress but do not manifest with the specific set of symptoms that characterize specific disorders.

1.6 Clinical presentation of the disease or condition

According to ICD-10, paranoid personality disorder is characterized by hostility, suspiciousness, irritability, and unbendable and persistent affect. Pathological jealousy, a critical attitude toward other people, an inability to cooperate, and litigious behavior may be observed. Such individuals may develop unrealistic, fantastic ideas. Overvalued ideas dominate the entire personality and determine the individual's behavior. Affective fluctuations (psychogenic and spontaneous) are revealed. In response to stress, individuals may experience brief psychotic episodes (lasting from a few minutes to a few hours). They frequently develop substance dependence.

In schizoid personality disorder, withdrawal (autism), discomfort in human interactions, preoccupation with internal experiences, and a poverty of emotional ties with others gradually develop from an early age. The basis of the schizoid temperament is a combination of excessive sensitivity (hyperesthesia) and emotional coldness (anesthesia). Disharmony and paradoxes in appearance and behavior are striking. Facial expressions lack liveliness, and the voice is poorly modulated. Hobbies are often peculiar and original.

Dissocial personality disorder is characterized by a gross discrepancy between behavior and social norms, involving behavior that violates social norms and laws. These individuals are impulsive, devoid of a sense of responsibility, and incapable of learning from negative experience. Attention-deficit/hyperactivity disorder, behavioral disturbances, and an oppositional and hostile attitude toward others are frequently noted in childhood. A propensity for substance abuse and a pathological urge to gamble are discovered early.

In emotionally unstable personality disorder, there is impulsivity with a tendency to act without regard for consequences and self-control, alongside mood instability with affective outbursts. Individuals with the impulsive type exhibit pronounced excitability; limitations and prohibitions provoke violent protest reactions accompanied by aggression and motor excitation. Dysphoria alternates with periods of fear, panic, or despair. Prolonged periods of elevated mood may be replaced by dysthymic phases triggered by psychogenic or somatic disorders.

Histrionic personality disorder is characterized by excessive emotionality and behavioral traits aimed exclusively at drawing attention to oneself. Appearance and behavior are eccentric, and such individuals tend to exaggerate their capabilities and abilities, fantasizing about them. A feature of the psyche is the absence of clear boundaries between the imaginary and the real. Individuals with this disorder may attempt suicide in order to draw attention to themselves.

Anankastic personality disorder reveals an excessive preoccupation with order, perfectionism, stubbornness, and rigidity combined with insecurity and extreme caution. Impressionability, vulnerability, and a tendency toward anxious apprehensions are discovered. Attention to rules is so pronounced that the purpose of the activity is lost. Pathological dynamics are observed at involutional age, with increasing anxiety, restriction of personal needs, and pathological miserliness. Obsessive-compulsive symptoms have the character of isolated obsessions, compulsions, and rituals. Obsessions are egosyntonic.

In anxious personality disorder, hypersensitivity in interpersonal relations, restriction of contacts, and indecisiveness can be identified. These individuals are timid and fearful from childhood and cannot remain alone. They feel uncomfortable in a group, choosing those in the reference group with whom they feel secure. Low self-esteem and hypersensitivity to rejection are combined with a limitation of interpersonal contacts. The main problems manifest in the social and occupational spheres of functioning.

Dependent personality disorder reveals passivity, submissiveness, suggestibility, and a constant need for care. In daily life, they are inactive and fatiguing, lacking initiative and the ability to resist the wishes of others, and they lack self-confidence. The need to maintain a significant relationship frequently leads to distorted interpersonal dynamics. Within the family, they occupy the position of "grown-up children".

2. Diagnostics, medical indications and contraindications for diagnostic methods

2.1 Complaints and Anamnesis

Taking complaints and history in psychiatry involves psychodiagnostic interviewing. Its principles include: unambiguous, precise, and accessible formulation of questions;

adequacy; consistency (algorithmic approach); impartiality of the interview; verifiability of the information obtained. It helps to clarify whether the patient has a history of traumatic brain injury, neuroinfections, intoxications, cerebrovascular diseases, or somatic conditions, which is important for both differential diagnosis and the identification of comorbid pathological states.

Taking complaints and history, visual examination, psychopathological assessment, and patient observation help identify signs of transient reactions in the patient's mental status that occur during adaptation to a significant life change or stressful event. They are characterized by the aggravation of core characterological manifestations, behavioral disturbances, the emergence of affective (depressive, hypomanic, mixed/bipolar) and delusional disorders, as well as asthenic, hysterical, obsessive, and somatoform symptom complexes.

An objective history includes:

A) data on a family history of mental disorders; personality traits of close associates;

B) data on characterological traits, developmental features, childhood behavior, changes in personality structure throughout life under the influence of age-related crises; data on family and social status, past exogenous harms, and patterns of response to pathogenic environmental factors.

Information regarding mental disorders, their manifestations, developmental dynamics, and therapeutic history is gathered by reviewing and analyzing medical documentation.

When starting the interview, the patient's attitude toward the conversation should be taken into account. Often, there is wariness toward the psychiatrist and frequently a reluctance to undergo examination. The interview should be conducted by the physician in an atmosphere of trust and ease, minimizing factors that could create a sense of being rushed as much as possible.

The physician must avoid demonstrating their own personal stance and refrain from making evaluative, commentary, or didactic remarks.

Preferred questions are those that encourage the interviewee to tell their story independently, which should be delicately guided in the right direction (the passive interview phase).

Questions should be as simple and understandable to the patient as possible. Their accessibility is determined by the alignment of the physician's vocabulary with the patient's speech patterns, which depends on educational and cultural levels, as well as national and ethnic factors.

Anamnestic information is collected from the patient's past to the present. In personality disorders, it is often possible to establish that even in childhood, the patient exhibited character traits that reached an extreme degree and affected their social adaptation.

The interview outline follows a chronological sequence, including school, family, occupational, sexual, social history, and the history of the present illness.

The interview should identify:

A) mental disorders, taking into account the time of their onset, subsequent complexification or regression, with an assessment of their impact on various aspects of the patient's life;

B) personality traits and characterological changes;

C) features of response to psychic trauma;

D) the impact of past exogenous harms (traumatic brain injury, substance use) on the patient's mental state;

E) the course of critical age periods;

F) treatment efficacy.

During the interview, attention is paid to the patient's appearance, facial expressions, movements, and speech.

During the conversation with the patient, the following are assessed:

A) the degree of orientation in the environment, time, and personal identity;

B) features of thinking, memory, attention, and their impairments;

C) features of the emotional-volitional sphere and mood;

D) mental disorders present at the time of examination.

When describing the mental state, a descriptive method is used. In cases where the examinee uses words and expressions that accurately describe their experiences, these should be quoted as direct speech.

• Clinical examination of all patients with personality disorders should conclude with the systematization of identified phenomena, their psychopathological qualification, and an integrative assessment of impairments across various spheres of mental activity (thinking, emotions, volitional sphere, insight) for holistic analysis, nosological diagnosis, and treatment selection [2].

Level of Evidence - 4, Strength of Recommendation - C.

Comment: When interpreting the data obtained, the psychiatrist must be guided by clinical arguments, progressing sequentially from phenomenological description to nosographic verification and functional diagnosis. Patterns of development and dynamics are crucial for diagnosis. The formation of an abnormal personality structure occurs gradually over years; a high degree of clinical variability that is unrelated to psychogenic influences and accompanied by expanding clinical manifestations along with declining mental productivity and prolonged social maladjustment is uncharacteristic. Differential diagnosis with other mental disorders must be performed: true depressive symptoms must be differentiated from feelings of loneliness, emptiness, boredom, and chronic dysphoria characteristic of individuals with emotionally unstable traits; bipolar and cyclothymic disorders must be distinguished from the emotional instability and irritability typical of borderline personality disorder; anxious and anakastic personality disorders must be differentiated from obsessive-compulsive and generalized anxiety disorders; schizoid personality disorder must be distinguished from schizophrenia-spectrum disorders; paranoid personality disorder must be differentiated from chronic delusional disorders [73, 81].

General diagnostic criteria for personality disorders:

1) marked disharmony in personality attitudes and behavior, typically involving several functional areas, such as affectivity, excitability, impulse control, perceptual and cognitive processes, and the style of relating to others;

2) the chronic nature of the abnormal behavioral style, which has a long-standing onset and is not limited to episodes of mental illness;

3) the abnormal behavioral style is pervasive and clearly maladaptive to a broad range of personal and social situations;

4) these manifestations always appear in childhood or adolescence and continue into adulthood;

5) the disorder leads to significant personal distress;

6) as a rule, the disorder is accompanied by significant impairment in occupational and social productivity.

Diagnostic criteria for paranoid personality disorder (F60.0):

A. The general criteria for personality disorders F60 must be met.

B. At least four of the following features must be present:

1) excessive sensitivity to setbacks and rebuffs;

2) a tendency to bear grudges persistently, i.e., refusal to forgive insults, slights, or disdain;

3) suspiciousness and a general tendency to distort facts by misconstruing the neutral or friendly actions of others as hostile or contemptuous;

4) a combative and tenacious sense of personal rights out of keeping with the actual situation;

5) recurrent unjustified suspicions regarding the sexual fidelity of a spouse or sexual partner;

6) a tendency to experience excessive self-importance, manifested in persistent self-referential attitudes;

7) preoccupation with unsubstantiated "conspiratorial" explanations of events concerning the individual or the world at large.

Diagnostic criteria for schizoid personality disorder (F60.1):

A. The general criteria for personality disorders F60 must be met.

B. At least four of the following features must be present:

1) few, if any, activities afford pleasure;

2) emotional coldness, detachment, or flattened affectivity;

3) incapacity to express warm, tender feelings toward others as well as anger;

4) weak responsiveness to both praise and criticism;

5) little interest in having sexual experiences with another person (taking age into account);

6) excessive preoccupation with fantasy and introspection;

7) almost invariable preference for solitary activities;

8) inadvertent marked disregard for prevailing social norms and conventions;

9) absence of close friends and confiding relationships (or having only one) and a lack of desire to have such relationships.

Diagnostic criteria for dissocial personality disorder (F60.2):

A. The general criteria for personality disorders F60 must be met.

B. At least three of the following features must be present:

1) callous unconcern for the feelings of others;

2) gross and persistent attitude of irresponsibility and disregard for social rules and obligations;

3) incapacity to maintain enduring relationships, notwithstanding no difficulty in establishing them;

4) very low tolerance to frustration and a low threshold for the discharge of aggression, including violence;

5) incapacity to experience guilt and to profit from life experience, particularly punishment;

6) marked proneness to blame others, or to offer plausible rationalizations for the behavior that has brought the individual into conflict with society.

Diagnostic criteria for emotionally unstable personality disorder (F60.3):

F60.30 Impulsive type.

A. The general criteria for personality disorders F60 must be met.

B. At least three of the following features must be present:

1) a marked tendency to act unexpectedly and without consideration of the consequences;

2) a marked tendency to quarrelsome behavior and to conflicts with others, especially when impulsive acts are thwarted or criticized;

3) a liability to outbursts of anger or violence, with an inability to control the resulting behavioral explosions;

4) difficulty in maintaining any course of action that offers no immediate reward;

5) an unstable and capricious mood.

F60.31 Borderline type (BPD).

A. The general criteria for personality disorders F60 must be met.

B. At least three of the symptoms in criterion B for F60.30 above must be present, and in addition, at least two of the following:

1) disturbances in and uncertainty about self-image, aims, and internal preferences (including sexual);

2) a proneness to engage in intense and unstable relationships, often leading to emotional crises;

3) excessive efforts to avoid abandonment;

4) recurrent threats or acts of self-harm;

5) chronic feelings of emptiness.

Diagnostic criteria for histrionic personality disorder (F60.4):

A. The general criteria for personality disorders F60 must be met.

B. At least four of the following features must be present:

1) self-dramatization, theatricality, and an exaggerated expression of emotions;

2) suggestibility (easily influenced by others or circumstances);

3) shallow and labile affectivity;

4) a continual seeking for activities in which the individual is the center of attention;

5) inappropriately seductive in appearance and behavior;

6) an over-concern with physical attractiveness.

Diagnostic criteria for anankastic personality disorder (F60.5):

A. The general criteria for personality disorders F60 must be met.

B. At least four of the following features must be present:

1) excessive doubt and caution;

2) preoccupation with details, rules, lists, order, organization, or schedules;

3) perfectionism that interferes with task completion;

4) excessive conscientiousness, scrupulosity, and undue preoccupation with productivity to the exclusion of pleasure and interpersonal relationships;

5) pedantry and adherence to social conventions;

6) rigidity and stubbornness;

7) unreasonable insistence by the individual that others submit to exactly his or her way of doing things, or unreasonable reluctance to allow others to do things;

8) intrusion of insistent and unwanted thoughts or impulses.

Diagnostic criteria for anxious (avoidant) personality disorder (F60.6):

A. The general criteria for personality disorders F60 must be met.

B. At least four of the following features must be present:

1) persistent and pervasive feelings of tension and apprehension;

2) belief that one is socially inept, personally unappealing, or inferior to others;

3) excessive preoccupation with being criticized or rejected in social situations;

4) unwillingness to get involved with people unless certain of being liked;

5) restriction of lifestyle because of the need to have physical safety;

6) avoidance of social or occupational activities that involve significant interpersonal contact, because of fear of criticism, disapproval, or rejection.

Diagnostic criteria for dependent personality disorder (F60.7):

A. The general criteria for personality disorders F60 must be met.

B. At least four of the following features must be present:

1) allowing or encouraging others to make most of one's important life decisions;

2) subordination of one's own needs to those of others whom one is dependent on, and undue compliance with their wishes;

3) unwillingness to make even reasonable demands on the people one depends on;

4) feeling uncomfortable or helpless when alone because of exaggerated fears of inability to care for oneself;

5) preoccupation with fears of being abandoned to care for oneself;

6) limited capacity to make everyday decisions without an excessive amount of advice and reassurance from others.

2.2 Physical Examination

Physical examination to reveal self-harm scars should be considered as one of the additional methods for verifying anamnestic data. Injection marks and signs of vein sclerosis detected during visual inspection are indicators suggesting the subject's proneness to psychoactive substance use.

2.3 Laboratory Diagnostics

Laboratory diagnostic tests are not used for the diagnosis of personality disorders.

2.4 Instrumental Diagnostics

• If the patient's history indicates organic factors (head trauma, neuroinfections) as well as somatic pathology capable of causing central nervous system damage, consultation with a neurologist and, upon agreement with them, electroencephalography, echoencephalography, and brain magnetic resonance imaging are recommended for the differential diagnosis of personality disorders from organic mental disorders [1,2].

LetSD - 5, LeCR - C.

2.5 Other Procedures

• All patients with personality disorders are recommended to undergo experimental psychological (psychodiagnostic) testing in order to identify structural personality traits and their severity [3,66].

LetSD - 5, LeCR - C.

Comment: experimental psychological tests and methods are used, which make it possible to assess the type of temperament, character traits, and personality qualities. The study aims to examine the mental activity of the individual, provides an opportunity to identify the internal structure of cognitive and emotional-volitional processes, preserved aspects of the personality, and establish individual personality traits. The results of the experimental psychological study cannot predetermine a specific diagnostic conclusion and must be evaluated in conjunction with clinical data.

• To determine the severity of a personality disorder upon initial presentation, all patients are recommended to undergo testing using the Self and Interpersonal Functioning Scale (SIFS) [67,68,69].

LetSD - 3, LeCR - B.

Comment: The Self and Interpersonal Functioning Scale allows for the assessment of personality disorder severity based on personality dysfunction across four domains [70]:

• identity - experience of oneself as unique, with clear boundaries between self and others; stability and accuracy of self-esteem; capacity and ability to regulate a range of emotional experiences;

• self-direction (Self-direction) — the pursuit of clear and meaningful short-term and life goals; the use of constructive and prosocial internal standards of behavior; the ability to reflect productively;

• empathy (Empathy) — understanding and respect for others' feelings and motivations; tolerance for differing viewpoints; understanding how one's own behavior affects others;

• capacity for intimacy (Intimacy) — depth and duration of connections with others; desire and ability for closeness; mutual respect reflected in interpersonal behavior.

• To determine the severity of maladaptive personality traits, all patients with personality disorders (PD) at their initial presentation are recommended to undergo testing with the ICD-11 Five-Factor Personality Inventory (FFiCD) [65,68].

LetSD - 5, LeCR - C.

Comment: Dimensional assessment of PD allows for the description of the full variety of maladaptive behaviors in patients with PD [72]. The ICD-11 Five-Factor Personality Inventory makes it possible to assess the severity of five maladaptive personality traits: detachment, dissociality, disinhibition, anankastia, and negative affectivity. Each of these traits, in turn, includes several subdomains (aspects) and nuances (shades), the assessment of which provides a more differentiated personality profile.

3. Treatment, including drug and non-drug therapies, diet therapy, and pain management

3.1 Psychological Methods and Psychotherapy

The goal of treatment is the relief of anxiety, dysphoria, and depression symptoms, as well as the correction of pathological defense mechanisms and behavioral reactions.

• Among psychological treatment methods, for all patients with PD with the aim of correcting psychopathological symptoms, behavioral disorders, and pathological defense mechanisms, it is recommended to use group, family, and individual psychotherapy, psychodynamic therapy, gestalt therapy, cognitive behavioral therapy, and creative expression therapy, with a duration of 1 to 36 months (a course of 10–40 sessions) and a frequency of at least 1–2 sessions per week [4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,19,22,53,54,55,56,57,58,59,60,61,62,63,64,77,78,79,80].

Level of Reliability of Evidence (LRE) - 1, Level of Credibility of Recommendation (LCR) - A.

Comment. Despite differences in theoretical foundations and approaches, no differences in the efficacy of specialized psychotherapy programs have been identified [77]. Psychotherapy can be carried out in outpatient, inpatient, and day hospital settings [81]. An initial consultation with a psychotherapist should preferably be conducted at earlier stages of treatment initiation, while taking into account the patient's mental state, which allows for establishing a therapeutic alliance. Diagnostics are carried out and a plan for psychotherapeutic work (both individual and group) is determined.

The goal of psychotherapeutic correction is the harmonization of behavior and the achievement of stable social adaptation of the patient. The choice of psychotherapeutic method depends on the type of personality disorder and the pattern of its dynamics. Group psychotherapy involves utilizing the relationships that arise between group members, as well as between the psychotherapist and the group as a whole. Therapy is focused on correcting maladaptive pathcharacterological deviations and abnormal behavior of the patient through the disclosure, awareness, and psychological processing of existing problems mediated by group interaction. As a result of group therapy, inadequate attitudes and cognitive, emotional, and behavioral stereotypes are eliminated. It is particularly important that during such work, patients acquire real experience in constructively overcoming intra- and interpersonal conflicts.

Among specialized psychotherapy methods, particularly for borderline personality disorder (BPD), cognitive behavioral therapy (CBT) and its variants are primarily considered, including dialectical behavior therapy and schema therapy, as well as transference-focused psychotherapy and mentalization-based therapy [58].

In treating patients with personality disorders, a balance must be maintained between support and the development of the patient's responsibility, and the patient must be actively involved in problem-solving. It should be noted that psychotherapy is effective when adequate time and resources are available, while it has limited efficacy in treating comorbid affective and anxiety disorders.

3.2 Pharmacotherapy

There is no specific pathogenetic treatment for PD. Pharmacotherapy is used primarily for treating comorbid mental disorders, or in cases of temporary deterioration (decompensation) of the condition and negative dynamics of PD [73,74,75]. Indications for psychopharmacological agents are determined by clinical symptoms. Therapy utilizes drugs from the main psychopharmacological classes: anxiolytics, antidepressants, and antipsychotics, administered parenterally when necessary [76]. There is practically no evidence of the benefit of long-term treatment for PD. Psychopharmacotherapy is part of a comprehensive treatment plan that includes psychotherapy and social work; when prescribing it, one must take into account the features of the psychopathological manifestation of illness symptoms, their severity, and the results of previously used treatment methods. Psychopharmacotherapy does not affect such manifestations of personality disorders as a chronic feeling of emptiness, avoidance of possible abandonment, identity disturbance, and dissociation [20].

Anxiolytics

• For the relief of restlessness, fear, anxiety, tension, and the correction of sleep disturbances, it is recommended to prescribe diazepam** (5–60 mg/day), lorazepam** (4–6 mg/day), bromdihydrochlorphenylbenzodiazepine** (0.5–10 mg/day), hydroxyzine** (50–100 mg/day), or buspirone (20–30 mg/day) [22,23,24].

LetSD - 5, LeCR - C.

Comment: Due to the high probability of developing dependence on psychoactive substances, benzodiazepine anxiolytics should be prescribed with caution to patients with personality disorders [23,24]. A particularly high risk of developing psychological and physical dependence may be observed in individuals with BPD. The use of benzodiazepine derivatives may combine poorly with psychotherapy. In addition, paradoxical and disinhibiting effects and an increase in suicidal risk cannot be excluded [23].

Antipsychotics

• The use of antipsychotics in individuals with PD is recommended for the relief of psychotic symptoms arising within the dynamics of PD, as well as for the correction of emotional and behavioral disorders, and the control of impulsivity and anger. In cases of acute psychomotor agitation, traditional antipsychotics are recommended as a calming therapy: chlorpromazine** (25–600 mg/day), levomepromazine** (oral form — 200–300 mg/day, parenteral form — 75–250 mg/day), thioridazine** (30–200 mg/day). Subsequently, for course treatment, atypical antipsychotics are recommended for a period of no more than 3 months [1,22,24].

LetSD - 5, LeCR - C.

Comment: Target symptoms must be carefully monitored, and in the absence of clinical improvement, the administration of the antipsychotic must be discontinued.

Periciazine** is a traditional antipsychotic used to correct "nonspecific aggressiveness" of various origins, including "psychopathic aggressiveness" [25].

• For the relief of severe psychomotor agitation with impulsivity and aggressive actions in patients with PD, it is recommended to prescribe periciazine** at a dose of 10–30 mg/day [26,27,28,29,30,31,32,33,34,35].

LetSD - 3, LeCR - B.

Comment: Due to the small number of modern studies (most studies were conducted in the 1960s) confirming the safety of periciazine**, as well as the potential for developing extrapyramidal symptoms, periciazine** cannot be considered a first-line drug in the treatment of patients with PD.

• Among traditional antipsychotics for the correction of anger, hostility, irritability, and impulsive behavior in patients with PD, it is recommended to prescribe haloperidol** in low doses (4–5 mg/day) [36,37].

Level of Reliability of Evidence (LRE) - 1, Level of Credibility of Recommendation (LCR) - A.

Comment: Considering the severity of extrapyramidal side effects and the potential for developing depressive symptoms, which may be associated with poor compliance, haloperidol** cannot be a first-line drug for the treatment of patients with PD [38].

Antidepressants

• In personality disorders accompanied by depressive symptoms with affective imbalance, for the purpose of relieving anger, anxiety, and symptoms of depression, it is recommended to use non-selective monoamine reuptake inhibitors (imipramine** — 50–200 mg/day [outpatient], 50–300 mg/day [inpatient], clomipramine** — 50–250 mg/day), SSRIs (fluvoxamine — 50–300 mg/day, escitalopram — 10–20 mg/day, fluoxetine** — 20–60 mg/day), and other antidepressants (pipofezine** — 50–400 mg/day, trazodone — 75–300 mg/day, pirlindole — 50–400 mg/day, duloxetine — 60–120 mg/day, venlafaxine — 75–375 mg/day, mirtazapine — 30–45 mg/day, agomelatine** — 25–50 mg/day) [1,22,39,40,41,42,43,44,45].

Level of Reliability of Evidence (LRE) - 5, Level of Credibility of Recommendation (LCR) - C.

Comment: It is hypothesized that affective instability and impulsivity in borderline personality disorder (BPD) are associated with impaired serotonin metabolism in the prefrontal cortex, which makes the use of selective serotonin reuptake inhibitors (SSRIs) pathogenetically justified [69].

• Among other SSRI medications, the administration of citalopram (20-60 mg/day) or sertraline** (50-150 mg/day) is recommended to relieve depressive symptoms in patients with personality disorders [46].

Level of Evidence - 2, Grade of Recommendation - A.

• To relieve depressive symptoms in patients with BPD, it is recommended to prescribe amitriptyline** at a daily dose of 100-175 mg/day [47].

Level of Evidence - 2, Grade of Recommendation - A.

Comment: it should be borne in mind that most antidepressants have a delayed onset of action (the effect develops within 2-3 weeks), and their prescription, especially agents with psychoanaleptic effects, sometimes requires (especially in the early stages of treatment) combination with anxiolytics and hypnotics to control anxiety and sleep disturbances [2].

3.3 Other Treatment

Given the insufficient efficacy of pharmacotherapy for personality disorders, numerous attempts have been made to use various other biological treatments, including non-pharmacological ones. These data are disparate and based predominantly on individual clinical case reports. The largest body of data concerns transcranial magnetic stimulation (TMS) and electroconvulsive therapy (ECT). At the same time, when ECT is used to treat comorbid depressive symptoms, remission is achieved in no more than 20% of cases [48].

There is also limited evidence regarding the use of TMS in BPD. Most data relate to individual clinical case reports [49, 50], and there is one small randomized controlled trial (RCT) involving 29 patients with BPD demonstrating equal efficacy of both high-frequency (5 Hz) stimulation of the left dorsolateral prefrontal cortex (DLPFC) and low-frequency (1 Hz) TMS of the right DLPFC, with some advantage of the high-frequency technique regarding emotional sensitivity, negative behavior, and cognitive impulsivity [51].

• In patients with BPD, it is recommended to perform a course of TMS (15 sessions) to correct emotional instability and behavioral impulsivity [49, 50, 51, 52].

Level of Evidence - 4, Strength of Recommendation - C.

Comment: Due to the scarcity of studies, it is currently difficult to fully evaluate and explain the efficacy of TMS in patients with BPD. First of all, attention is drawn to the primary impact on comorbid depressive symptoms, as well as the positive effect of various TMS protocols, which does not rule out a high probability of a placebo effect. Considering that the primary problem in patients with BPD is impulsive behavior—which is apparently controlled by neural networks in the prefrontal cortex interacting with subcortical structures—available research data allow a preliminary conclusion about the positive effect of TMS on self-injurious behavior and the reduction of impulsivity, which may improve the quality of life and level of social functioning of patients, as well as enhance their family and interpersonal relationships. However, the lack of RCTs with an adequate sample of BPD patients necessitates a cautious assessment.

4. Medical Rehabilitation and Sanatorium-Resort Treatment

• Psychosocial therapy and psychosocial rehabilitation are recommended for all patients with personality disorders to correct insufficient motivational and emotional personal resources, skills, knowledge, and abilities to interact, solve problems, and use coping strategies that ensure their integration into society [2, 53].

Level of Evidence - 5, Grade of Recommendation - C.

Comment: Psychosocial therapy and psychosocial rehabilitation, along with pharmacotherapy, represent essential and complementary therapeutic strategies [58]. Psychosocial work with patients can be carried out at any stage of psychiatric care provision. Before starting the intervention, it is recommended to determine the nature and degree of social maladaptation, the need for a particular form of psychosocial intervention, and to formulate the goal of each intervention with a defined time frame within which the specified goal is expected to be achieved [2]. Group work formats are recommended, but if it is impossible to include the patient in a group (for example, in case of refusal, etc.), the work is carried out in an individual format; after the completion of active psychosocial interventions, supportive psychosocial measures are recommended [2].

• Long-term psychotherapy is recommended for all patients with BPD to improve their quality of life [54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64].

Level of Evidence - 1, Grade of Recommendation - A.

Comment. The goal of long-term psychotherapy is to correct defense mechanisms, achieve understanding, and resolve unconscious conflicts, which leads to psychological and behavioral changes, as well as the achievement and maintenance of occupational and social adaptation.

5. Prevention and Dispensary Observation

There is no primary prevention for personality disorders. Secondary prevention consists of conducting long-term psychotherapy with the correction of pathological defense mechanisms and behavioral reactions, and begins at the point when the manifestations of decompensation have significantly decreased and pronounced behavioral disorders have been eliminated.

Dispensary observation (active clinical monitoring) may be established regardless of the consent of the person suffering from a mental disorder or their legal representative. "The issues of the necessity of establishing dispensary observation and its termination are decided by a medical commission of psychiatrists appointed by the head of a medical organization providing outpatient psychiatric care, or by a medical commission of psychiatrists appointed by the executive authority of a constituent entity of the Russian Federation in the field of healthcare" (Law of the Russian Federation No. 3185-1 dated July 2, 1992, "On Psychiatric Care and Guarantees of Citizens' Rights in Its Provision", Part 2, Article 27). Such an examination is possible both upon voluntary seeking of psychiatric care and involuntarily, in the presence of indications for involuntary examination. The basis for establishing psychiatric dispensary observation is the presence of a chronic or protracted mental disorder with severe, persistent, or frequently relapsing morbid manifestations (Part 1, Article 27 of the Law).

In accordance with the current Order of the Russian Ministry of Health No. 453 dated June 30, 2022, 5 groups of dispensary observation are distinguished: D-1 — patients with frequent (more than once a year) and prolonged (more than 120 days over 2 years) hospitalizations; D-2 — patients hospitalized in a medical organization with a frequency of once every 2 years with a duration of hospitalization of less than 120 days over 2 years; D-3 — patients who have not been hospitalized in a medical organization for 3 years or more; D-4 — patients in a state of compensation who have not been hospitalized in a medical organization for 5 years or more; D-5 — patients prone to socially dangerous actions, as well as individuals referred by a court for outpatient compulsory observation and treatment by a psychiatrist, who are subject to active dispensary observation. The establishment of dispensary observation is not lifelong. In cases of recovery or significant and persistent improvement in the patient's mental state, dispensary observation is terminated.

6. Organization of Medical Care

Persons suffering from mental disorders have the right to psychiatric care in the least restrictive conditions [1].

Treatment of patients with personality disorders should predominantly be carried out on an outpatient basis.

Indications for inpatient treatment (no more than 30 days) are states of personality disorder decompensation accompanied by psychomotor agitation, auto- and hetero-aggressive behavior that are not relieved on an outpatient basis, and transient psychotic disorders of various structures.

Indications for emergency hospitalization in a psychiatric hospital are acute psychotic states of various structures arising within the dynamics of personality disorders, accompanied by auto- and/or hetero-aggressive behavior [1].

If the same conditions are not accompanied by pronounced auto- and hetero-aggressive tendencies, treatment in a day hospital is recommended [61, 62].

Stay in a medical organization providing inpatient psychiatric care is possible only for the period necessary to provide psychiatric care in such conditions². The indication for discharging a patient from a psychiatric hospital is the relief of psychotic-level disorders that at the time of hospitalization posed a danger to themselves or others.

[1] Article 5 of the Law "On Psychiatric Care and Guarantees of Citizens' Rights in Its Provision".

7. Additional Information

Information is not available.

Criteria for Evaluating the Quality of Medical Care

Criteria for Evaluating the Quality of Medical Care

References

Appendix A1. Working Group Composition

1. Tkachenko A.A. - Doctor of Medical Sciences, Professor, Head of the Department of Forensic Psychiatric Examination in Criminal Proceedings, V.P. Serbsky National Medical Research Centre for Psychiatry and Narcology of the Russian Ministry of Health, member of the Russian Society of Psychiatrists board.

2. Samylkin D.V. - Candidate of Medical Sciences, Head of the Department of Psychogenics and Personality Disorders, V.P. Serbsky National Medical Research Centre for Psychiatry and Narcology of the Russian Ministry of Health, member of the Russian Society of Psychiatrists;

3. Gadisov T.G. - Candidate of Medical Sciences, Senior Researcher at the Department of Psychogenics and Personality Disorders, V.P. Serbsky National Medical Research Centre for Psychiatry and Narcology of the Russian Ministry of Health, member of the Russian Society of Psychiatrists;

4. Ilyushina E.A. - Candidate of Medical Sciences, Senior Researcher at the Department of Psychogenics and Personality Disorders, V.P. Serbsky National Medical Research Centre for Psychiatry and Narcology of the Russian Ministry of Health, member of the Russian Society of Psychiatrists.

5. Gilenko T.D. - Junior Researcher at the Department of Psychogenics and Personality Disorders, V.P. Serbsky National Medical Research Centre for Psychiatry and Narcology of the Russian Ministry of Health, member of the Russian Society of Psychiatrists.

There is no conflict of interest.

Appendix A2. Methodology for Developing Clinical Guidelines

Target audience for these clinical guidelines:

• Psychiatrists

• Psychotherapists

• Forensic psychiatric expert physicians

• Medical psychologists

Methods used to collect evidence: electronic database search.

Description of methods: the evidence base for the recommendations includes MEDLINE databases, with a search depth of 12 years.

Methods used for assessing the quality and strength of evidence:

Expert consensus;

Grading of significance according to the rating scheme

A) Evidence is convincing: there are strong arguments in favor of the stated proposition;

Б) Relative conclusiveness of evidence: there is sufficient evidence to recommend this proposition.

B) Insufficient evidence: available evidence is insufficient, but recommendations can be made taking into account other circumstances.

Г) Sufficient negative evidence: there is sufficient evidence to recommend against the use of this medicinal product in a specific situation.

Д) Strong negative evidence: there is sufficiently convincing evidence to exclude a medicinal product or method from the recommendations.

Evidence is divided into several levels:

1. Evidence obtained from meta-analysis or systematic review.

2. Evidence obtained from prospective randomized studies.

3. Evidence obtained from large prospective, non-randomized studies.

4. Evidence obtained from retrospective non-randomized studies in a large cohort.

5. Evidence obtained from studies in a limited number of patients

6. Evidence obtained in individual patients.

Evidence tables were completed by the members of the working group.

Methods used to formulate evidence:

Expert consensus.

Good practice indicators - based on the clinical experience of members of the recommendation development group.

Economic analysis: cost analysis was not performed and pharmacoeconomic publications were not analyzed.

Validation method:

External peer review

Internal expert review

Description of the validation method: The recommendations were peer-reviewed by experts; expert comments were systematized and discussed.

Consultation and peer review: Changes to these recommendations were presented for discussion at congresses and conferences. The version was posted for broad discussion on the website of the Russian Ministry of Health.

Table II. 1. Scale for grading levels of evidence (LE)

for diagnostic methods (diagnostic interventions)

Table II.2. Scale for grading levels of evidence (LE) for methods of prevention, treatment, and medical rehabilitation, including those based on the use of natural therapeutic factors (preventive, therapeutic, and rehabilitative interventions)

II. 3. Scale for grading grades of recommendation (GR) for methods of prevention, diagnostics, treatment, and medical rehabilitation, including those based on the use of natural therapeutic factors (preventive, diagnostic, therapeutic, and rehabilitative interventions)

Working group: The recommendations were analyzed by the members of the working group, expert comments and feedback were taken into account, and the risk of errors was minimized.

Procedure for updating clinical guidelines — review once every 3 years.

Appendix A3. Reference Materials

1. Federal Law of the Russian Federation No. 323-FZ dated November 21, 2011, "On the Fundamentals of Health Protection of Citizens in the Russian Federation";

2. Federal Law of the Russian Federation No. 3185-1 dated July 2, 1992, "On Psychiatric Care and Guarantees of Citizens' Rights in Its Provision";

3. Order of the Ministry of Health of the Russian Federation No. 453n dated June 30, 2022, "On Approval of the Procedure for Clinical Dispensary Observation of a Person Suffering from a Chronic and Prolonged Mental Disorder with Severe Persistent or Frequently Relapsing Pathological Manifestations";

4. Order of the Ministry of Health of the Russian Federation No. 668n dated October 14, 2022, "On Approval of the Procedure for Providing Medical Care for Mental Disorders and Behavioral Disorders".

Appendix B. Physician Action Algorithms

Management of a patient with a personality disorder, diagnostics, selection of treatment strategy and methods in each case are carried out individually depending on the type of personality disorder and the prevailing psychopathological syndrome. Diagnostics is performed in accordance with the criteria of the current classification, and treatment efficacy is assessed during the course of therapy. In general terms, the management of a patient with a personality disorder is carried out in accordance with the following algorithm.

Appendix C. Patient Information

Personality disorders are based on a persistent character anomaly that leads to increased vulnerability of such individuals to stress. Under favorable environmental conditions, individuals with personality disorders do not require any therapeutic interventions. In the event that behavioral disorders, depression, or anxiety arise against the background of stress or a subjectively intolerable situation, drug therapy and psychotherapy are required. In the vast majority of cases, with timely initiated treatment, such conditions have a favorable prognosis. Treatment can be provided on an outpatient basis, or, in cases of significant symptom severity, may require hospitalization in a psychiatric inpatient facility. Drug doses, choice of psychotherapy methods, duration of treatment, and frequency of visits are determined by a psychiatrist.

Appendix G. Assessment Scales, Questionnaires, and Other Evaluation Tools

Appendix G1. Personal and Interpersonal Functioning Scale

Original title: The Self and Interpersonal Functioning Scale (SIFS)

Source: Gamache D, et al. A Proposed Classification of ICD-11 Severity Degrees of Personality Pathology Using the Self and Interpersonal Functioning Scale. Front Psychiatry. 2021;12.

Samylkin D, Demidova L, Gadisov T, Nikitskiy I, Tkachenko A. The Self and Interpersonal Functioning Scale - SIFS (Russian version) [Internet]. figshare; 2023 [cited 2023May30]. Available from:

https://figshare.com/articles/journal_contribution/The_Self_and_Interpersonal_Functioning_ Scale_SIFS_Russian_version_/21856983/1

Type (underline):

— scale

- score

— questionnaire

— other (specify):__________________

Purpose: Assessment of the severity of personality disorder

Content (template): Consists of 4 subscales: identity, self-direction, empathy, intimacy.

Interpretation: A severity coefficient from 1.30 to 1.89 indicates mild personality disorder, from 1.90 to 2.49 moderate personality disorder, and greater than 2.5 severe personality disorder.

This questionnaire consists of 24 statements about you and your relationships with other people. Please rate how closely each statement describes you using the following scale

Please answer spontaneously, according to your own impression. There are no right or wrong answers; we would like to know how you see yourself. It is important that you answer all questions and provide only one answer to each question.

Scoring instructions:

Identity: 1(R), 2, 3, 4, 5, 6(R), 7.

Self-direction: 8(R), 9, 10, 11, 12(R).

Empathy: 13, 14, 15, 16, 17(R), 18.

Need for trusting relationships: 19(R), 20, 21, 22, 23, 24(R).

(R) indicates reverse-scored items.

After obtaining the raw scores for each scale, mean values are calculated, based on which two integrative indices are computed (Total Score and Severity Index). The Total Score equals the sum of the mean values (Total Score = Self-awareness/7 + Self-direction/5 + Empathy/6 + Need for trusting relationships/6). The Severity Index is calculated using the formula: "Severity Index = Total Score/4".

Appendix G2. ICD-11 Personality Questionnaire

Original title: The Five-Factor Personality Inventory for ICD-11 (FFiCD)

Source: Oltmanns J.R., Widiger T.A. The Five-Factor Personality Inventory for ICD-11: A Facet-Level Assessment of the ICD-11 Trait Model // Psychol Assess. 2020. Vol. 32. № 1. P. 60.

Samylkin D, Demidova L, Gadisov T, Nikitskiy I, Tkachenko A. The Five-Factor Personality Inventory for ICD-11 - FFiCD (Russian version) [Internet]. figshare; 2023 [cited 2023May30]. Available from: https://figshare.com/articles/journal_contribution/The_Five- Factor_Personality_Inventory_for_ICD- 11_FFiCD_Russian_version_/21856938/1 Type (underline): - scale - index - questionnaire - other (specify):

Purpose: Assessment of the severity of maladaptive personality traits

Content (template): consists of 5 subscales (anankastia, dissociality, disinhibition, detachment, negative affectivity), each of which includes several subdomains and facets.

Interpretation: Assessment of the severity of maladaptive personality traits, subdomains, and facets allows for a differentiated personality profile. Instructions: Below are some statements about your well-being or behavior. Please answer each question in a way that best describes your attitude toward the statement on a scale from 1 to 5, where 1 = strongly disagree, 2 = disagree, 3 = neutral (undecided response), 4 = agree, and 5 = strongly agree. Please read each item carefully and provide your answer that most closely reflects the degree of your agreement or disagreement. There are no right or wrong answers. Describe yourself honestly and express your opinion as accurately as possible.

1. My anxiety often prevents me from doing what I would like to do.

2. I consider myself more reserved than most people.

3. Other people have said that I am very attentive to details, perhaps even overly so.

4. Sometimes I feel very vulnerable.

5. I don't care much about the needs of other people.

6. I get into trouble because I don't think things through thoroughly.

7. My emotions can get out of control.

8. I usually catch myself thinking about work even in the middle of a vacation.

9. I am not upset by the suffering of others.

10. I get very irritated even by the slightest setbacks.

11. I tend to back down when a task gets difficult.

12. I constantly compare myself to others and never feel good enough.

13. My friends would be surprised if I ever jumped for joy.

14. From week to week, my life is pretty much the same, and I like it.

15. I have used physical force against other people.

16. Because of fear of embarrassment, I find it difficult to enjoy interacting with friends.

17. I am poorly organized.

18. When someone does something nice for me, I wonder what they want from me.

19. I am not very decisive in my interactions with others.

20. It is always important to follow the rules, even if I am playing a game by myself.

21. I deserve special treatment.

22. I have often been afraid of losing someone I depended on.

23. I have gotten into trouble because of some of my risky decisions.

24. I tend to be serious around people.

25. I examine all the details of an issue before making a decision.

26. I strongly doubt that I will achieve much in life.

27. I give up on things quite easily.

28. Sometimes, in order to succeed in something, it is necessary to use other people.

29. I tend to jump to conclusions.

30. I fly into a rage when people show disrespect toward me.

31. I do not form strong attachments to people, even my friends.

32. I prefer to play it safe, even if I might miss out on an opportunity.

33. I will threaten people to make them act.

34. I have thought about how to kill myself.

35. I rarely finish tasks without the help of others.

36. When I realize I have failed at something, I feel humiliated.

37. I am a person who plans very carefully, perhaps even too much.

38. I try to dress in a way that gets people to notice me.

39. I often feel nervous when I am around unfamiliar people. Morality means adhering to a strict set of rules and principles.

40. It is easy for me to manipulate others.

41. I do not handle things well under pressure.

42. I find it difficult to do things on my own.

43. The taste of food does not give me much pleasure.

44. My emotions can change rapidly and unpredictably.

45. I am considered a workaholic.

46. I have gotten into trouble due to truancy at work and school.

47. I take pleasure in challenging so-called authorities.

48. I often lose my patience when dealing with other people.

49. My manner of speech is disorganized and poorly thought out.

50. I often have a truly pessimistic outlook on the future.

51. I am somewhat withdrawn.

52. I like to be truly certain of everything before taking action.

53. Some people say that I am too arrogant and self-assured.

54. I feel that I cannot sufficiently control my feelings.

55. I have done many rash things in my life.

56. I firmly believe that one should always play strictly by the rules.

57. I do not feel that I have anything to offer other people.

58. I do not have a great influence on the people around me.

59. Most people are too soft-hearted.

60. I am usually very sensitive to the opinions of others.

61. I wish I could think better before acting.

62. In what people say or do, I often perceive hidden threats or disrespect.

63. If I start something, I work until I see it through to the end.

64. Other people have called me calculating.

65. I am a rather moody person.

66. I find it hard to get myself to do anything.

67. Intense joy or exhilaration are almost unknown to me.

68. My anger sometimes gets the better of me.

69. There can never be an excuse for departing from moral standards.

70. If someone starts a conflict, I have no problem finishing it.

71. I feel a constant weight on my shoulders when I fail to meet the expectations of others.

72. People say I am rather disorganized and messy.

74. I strive for perfection even in what others might call insignificant details.

75. Public failure is actually quite shameful.

76. Before I agree to help someone, I want to know what I will get in return.

77. I spend a lot of time worrying about what might happen.

78. On my own, I find it hard to stick to the task at hand.

79. I wish I didn't worry so much about what others think of me.

80. I prefer to be a follower rather than a group leader.

81. I get so absorbed in my work that I lose track of time allocated for other things.

82. To achieve my own goals, I am willing to use other people.

83. I find it difficult to control my mood.

84. As a rule, I confuse people when I express my thoughts.

85. I am definitely a creature of habit.

86. I am easily irritated.

87. I have been told that I am bossy or mean.

88. Since my teenage years, I have had thoughts of suicide.

89. My initial hasty judgments sometimes get me into trouble.

90. I can barely tolerate people laughing at me.

91. People consider me a rather serious and reserved person.

92. I can be quite demanding when it comes to duty and honor.

93. I lack self-discipline when I work alone.

94. I do not think the rules apply to me to the same extent they apply to others.

95. Sometimes I feel that other people have it in for me.

96. I have had trouble due to failing to fulfill my obligations to others.

97. I have often worried that someone might not want to be with me.

98. I believe that safe and predictable is always preferable to exciting and dangerous.

99. Feeling pity for others is a sign of weakness.

100. I often feel that life is overwhelming me.

101. When I focus on something, nothing can prevent me from seeing it through to the end.

102. I have had problems with superiors.

103. I have very little hope that my situation will improve.

104. I tend to jump straight into action without planning too far ahead.

105. I feel very bad when I am humiliated in front of others.

106. I am not emotionally close to most people.

107. I overthink things over and over again before making a decision.

108. I can easily make others sexually attracted to me.

109. People make me nervous.

110. I tend to make a lot of mistakes.

111. I will deceive a person if I consider it necessary.

112. It is hard to trust my feelings because they can easily change.

113. I am an exceptional person.

114. I have a habit of drawing conclusions before I know all the facts.

115. Sometimes I feel worthless.

116. I believe there are few things that are pleasant to look at.

117. I am fanatical about getting things done on time.

118. I do not stick to any clear organization or order of things.

119. Criticism that I receive sometimes really sets me off.

120. I will try almost anything to get "thrills".

121. I am concerned that society is losing its strong moral compass.

DOMAINS

Anankastia = 3 + 8 + 14 + 20 + 25 + 32 + 37 + 40 + 46 + 53 + 57 + 64 + 70 + 74 + 81 + 85 + 92 + 98 + 101 + 107 + 117 + 121.

Dissociality = 5 + 9 + 15 + 21 + 28 + 33 + 38 + 41 + 48 + 54 + 60 + 65 + 71 + 76 + 82 + 87 + 94 + 99 + 102 + 108 + 111 + 113.

Disinhibition = 6 + 11 + 17 + 23 + 27 + 29 + 35 + 43 + 47 + 50 + 56 + 62 + 67 + 73 + 78 + 84 + 89 + 93 + 96 + 104 + 110 + 114 + 118 + 120.

Detachment = 2 + 13 + 19 + 24 + 31 + 44 + 52 + 59 + 68 + 80 + 91 + 106 + 116.

Negative affectivity = 1 + 4 + 7 + 10 + 12 + 16 + 18 + 22 + 26 + 30 + 34 + 36 + 39 + 42 + 45 + 49 + 51 + 55 + 58 + 61 + 63 + 66 + 69 + 72 + 75 + 77 + 79 + 83 + 86 + 88 + 90 + 95 + 97 + 100 + 103 + 105 + 109 + 112 + 115 + 119.

SUBDOMAINS

Dissociality

Aggression = 15 + 33 + 48 + 71 + 87 + 102.

Lack of empathy = 9 + 28 + 41 + 60 + 65 + 82 + 99 + 111

Egocentricity = 5 + 21 + 38 + 54 + 76 + 94 + 108 + 113.

Negative affectivity

Anger = 10 + 30 + 49 + 69 + 86 + 119.

Anxiousness = 1 + 22 + 39 + 77 + 97 + 109.

Depressivity = 12 + 34 + 51 + 58 + 72 + 88 + 103 + 115.

Emotional lability = 7 + 45 + 55 + 66 + 83 + 112.

Suspiciousness = 18 + 63 + 95.

Feelings of shame = 16 + 36 + 61 + 75 + 90 + 105.

Vulnerability = 4 + 26 + 42 + 79 + 100.

Disinhibition

Irresponsibility = 11 + 27 + 35 + 43 + 47 + 67 + 78 + 93 + 96 + 110.

Impulsivity = 6 + 29 + 62 + 89 + 104 + 114.

Distractibility = 17 + 50 + 73 + 84 + 118.

Risk taking = 23 + 56 + 120.

Detachment

Withdrawal = 13 + 31 + 44 + 68 + 106 + 116.

Intimacy avoidance = 2 + 24 + 52 + 91.

Anhedonia = 19 + 59 + 80.

Anankastia

Rigidity = 14 + 25 + 32 + 40 + 53 + 70 + 85 + 98 + 107 + 121.

Perfectionism = 3 + 20 + 37 + 57 + 74 + 92.

Workaholism = 8 + 46 + 64 + 81 + 101 + 117.

FACETS

Dissociality

Passive aggression = 48 + 102.

Physical aggression = 15 + 71.

Verbal aggression = 33 + 87.

Callousness = 9 + 60 + 99.

Venality = 28 + 82.

Manipulativeness = 41 + 65 + 111.

Arrogance = 54 + 113.

Entitlement = 21 + 94.

Selfishness = 5 + 76.

Vanity = 38 + 108.

Negative affectivity

Irritability = 49 + 86.

Unregulated anger = 10 + 69.

Reactive anger = 30 + 119.

Dependence on external validation = 1 + 77.

Insecure attachment = 22 + 97.

Social anxiety = 39 + 109.

Feelings of inadequacy in interpersonal relationships = 12 + 72.

Pessimism = 51 + 103.

Suicidality = 34 + 88.

Sense of worthlessness = 58 + 115.

Emotional dysregulation = 7 + 55 + 83.

Affective lability = 45 + 66 + 112.

Self-deprecation = 36 + 75 + 105.

Shyness = 16 + 61 + 90.

Fragility = 4 + 42 + 100.

Need for admiration = 26 + 79.

Disinhibition

Disorganization = 17 + 73 + 118.

Disorganized speech = 50 + 84.

Unreliability = 47 + 96.

Distractibility = 35 + 78 + 93.

Low endurance = 11 + 27 + 67.

Incompetence = 43 + 110.

Impulsive behavior = 6 + 62 + 104.

Impulsive thinking = 29 + 89 + 114.

Detachment

Joylessness = 13 + 68.

Physical anhedonia = 44 + 116.

Social anhedonia = 31 + 106.

Indifference = 24 + 91.

Social isolation = 2 + 52.

Anankastia

Dogmatism = 40 + 70 + 121.

Rigidity = 14 + 85.

Risk aversion = 32 + 98.

Rumination = 25 + 53 + 107.

Fastidiousness = 3 + 37 + 74.

Pedantry = 20 + 57 + 92.

Stubbornness = 64 + 101 + 117.

Work diligence = 8 + 46 + 81.