Personality disorders (PD) are a class of mental disorders characterized by maladaptive patterns of behavior, cognition, and inner experience, exhibited across many situations and deviating from those accepted by the individual’s culture.
The term personality refers to a relatively stable set of tendencies in behavior, cognition, and emotional patterns, which together comprise a persons unique character.
People generally recognize the characteristics that they exhibit, how they affect their personalities on others and how the environment shapes who they are.
The awareness of one’s behavior/personality helps make decisions and manage relationships.
In some, behaviors, cognition, and emotional patterns are extreme and maladaptive with problems in self-regulation and formation of unstable relationships, with a compromised ability to perform at work and school.
Such patients are felt to have a personality disorder.
PD patterns of behavior develop early, and are inflexible.
PD behaviors are associated with significant distress or disability.
Frequency is 9-11% of population.
Personality disorders are defined by experiences and behaviors that deviate from social norms and expectations.
Individuals with a personality disorder may experience difficulties in cognition, emotion, interpersonal functioning, or impulse control.
Among psychiatric patients, the prevalence of personality disorders is estimated between 40 and 60%.
PD behavior patterns typically are recognized by adolescence, the beginning of adulthood.
Sometimes it is apparent in childhood.
PD often has a pervasive negative impact on the quality of life.
Treatment for personality disorders is primarily psychotherapeutic:
cognitive behavioral therapy, and dialectical behavior therapy especially for borderline personality disorder, and a variety of psychoanalytic approaches are also used.
The two latest editions of the major systems of classification are
The International Classification of Diseases published by the World Health Organization, and the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition, DSM-5) by the American Psychiatric Association.
DSM-5 lists ten specific personality disorders: paranoid, schizoid, schizotypal, antisocial, borderline, histrionic, narcissistic, avoidant, dependent and obsessive–compulsive personality disorder.
Personality change may be due to the direct effects of a medical condition.
Cluster A-odd or eccentric disorders
Cluster A personality disorders are often associated with schizophrenia.
Schizotypal personality disorder shares some of its hallmark symptoms with schizophrenia: acute discomfort in close relationships, cognitive or perceptual distortions, and eccentricities of behavior.
People diagnosed with odd-eccentric personality disorders tend to have a greater grasp on reality than those with schizophrenia.
People with these disorders can be paranoid and have difficulty being understood by others.
People with PD often have odd or eccentric modes of speaking and an unwillingness and inability to form and maintain close relationships.
A small proportion of people with Cluster A personality disorders, especially schizotypal personality disorder, have the potential to develop schizophrenia and other psychotic disorders.
These disorders also have a higher probability of occurring among individuals whose first-degree relatives have either schizophrenia or a Cluster A personality disorder.
Paranoid personality disorder: characterized by a pattern of irrational suspicion and mistrust of others, interpreting motivations as malevolent.
Schizoid personality disorder: lack of interest and detachment from social relationships, apathy, and restricted emotional expression.
Schizotypal personality disorder: pattern of extreme discomfort interacting socially, and distorted cognition and perceptions.
Cluster B personality disorders are characterized by impulsive, self-destructive, emotional behavior and sometimes incomprehensible interactions with others.
Antisocial personality disorder: pervasive pattern of disregard for and violation of the rights of others, lack of empathy, bloated self-image, manipulative and impulsive behavior.
Borderline personality disorder: pervasive pattern of abrupt emotional outbursts, altered empathy, instability in relationships, self-image, identity, behavior and affect, often leading to self-harm and impulsivity.
Histrionic personality disorder: pervasive pattern of attention-seeking behavior, excessive emotions, and egocentrism.
Narcissistic personality disorder: pervasive pattern of superior grandiosity, need for admiration, and a perceived or real lack of empathy: a more severe expression of narcissistic personality disorder may show evidence of paranoia, aggression, psychopathy, and sadistic personality disorder, which is known as malignant narcissism.
Cluster C-anxious or fearful disorders
Avoidant personality disorder: pervasive feelings of social inhibition and inadequacy, extreme sensitivity to negative evaluation.
Dependent personality disorder: pervasive psychological need to be cared for by other people.
Obsessive–compulsive personality disorder: characterized by rigid conformity to rules, perfectionism, and control to the point of satisfaction and exclusion of leisurely activities and friendships: this is distinct from obsessive–compulsive disorder.
Personality disorder diagnosis must meet the following criteria:
An enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture.
This pattern is manifested in two, or more, of the following areas:
Cognition
Affectivity, suggesting the range, intensity, lability, and appropriateness of emotional response.
Interpersonal functioning.
Impulse control.
The enduring pattern is
pervasive across a broad range of personal and social situations, and leads to clinically significant distress or impairment in social, occupational, or other important areas of functioning.
The personality disorder is stable and of long duration.
PD onset can be traced back at least to adolescence or early adulthood.
The enduring pattern of behavior is not explained by another mental disorder,
the physiological effects of a substance
or another medical condition.
Personality disorders can be coded as Mild, Moderate, Severe, or severity unspecified.
The category called Personality difficulty
describes personality traits that are problematic, but do not meet the diagnostic criteria for a PD.
Personality disorder traits or patterns:
The ICD-11 uses five trait domains:
Negative affectivity
Detachment
Dissociality
Disinhibition
Anankastia (obsessive-compulsive)
ICD-11, PD must meet all of the following criteria:
An enduring disturbance with problems in functioning of : identity, self-worth, accuracy of self-view, self-direction, and/or interpersonal dysfunction, with inability to develop and maintain close and mutually satisfying relationships, and inability to understand others’ perspectives and to manage conflict in relationships.
The disturbance is persistent over an extended period of time, lasting 2 years or more.
The disturbed behavior is manifested in patterns of cognition, emotional expressions, and maladaptive behavior that is inflexible or poorly regulated.
Such disturbance are manifest across a range of personal and social situations,
though it may be evoked by particular types of circumstances and not others.
PD symptoms are not due to the direct effects of a medication or substance, and are not accounted for by another mental disorder, or another medical condition.
PD disturbances are associated with distress or significant impairment in personal, family, social, educational, occupational or other important areas of functioning.
Impaired behavior, generally involves several areas of functioning:
affectivity, arousal, impulse control, ways of perceiving and thinking, and style of relating to others
The abnormal behavior pattern is enduring, of long standing.
The abnormal behavior pattern is pervasive and clearly maladaptive to a broad range of personal and social situations.
PD manifestations always appear during childhood or adolescence and continue into adulthood.
PD is usually associated with significant problems in occupational and social performance.
Personality disorder and enduring personality changes are defined as ingrained patterns of inflexible and disabling responses that differ from how the average person.
The specific personality disorders are: paranoid, schizoid, schizotypal, dissocial, emotionally unstable (borderline type and impulsive type), histrionic, narcissistic, anankastic, anxious (avoidant) and dependent.
Paranoid:
Guarded, defensive, distrustful and suspicious.
Hypervigilant to the motives of others to undermine or do harm.
Always seeking confirmatory evidence of hidden schemes.
Feel righteous, but persecuted.
Experience a pattern of pervasive distrust and suspicion of others that lasts a long time.
Difficult to work with and are very hard to form relationships with.
Short-tempered.
Schizoid:
Apathetic, indifferent, remote, solitary, distant, humorless, contempt, odd fantasies.
Neither desire nor need human attachments.
Withdrawn from relationships and prefer to be alone.
Little interest in others.
Seen as a loner.
Minimal awareness of the feelings of themselves or others.
Few ambitions, if any.
Avoid social activities and consistently shy away from interaction with others.
Schizoid PD affects more males than females.
Seem appear somewhat dull or humorless, slow to show emotion.
Schizotypal PD
Eccentric, self-estranged, bizarre, absent.
Exhibit peculiar mannerisms and behaviors.
Think they can read thoughts of others.
Preoccupied with odd daydreams and beliefs.
Magical thinking and strange beliefs.
Odd or eccentric and usually have few, if any, close relationships.
They think others think negatively of them.
Antisocial, Impulsive, irresponsible, deviant, unruly.
Act without due consideration.
Meet social obligations only when self-serving.
Disrespect societal customs, rules, and standards.
See themselves as free and independent.
People with antisocial personality disorder depict a long pattern of disregard for other people’s rights.
Borderline
Unpredictable, egocentric, emotionally unstable.
Frantically fears abandonment and isolation.
Experience rapidly fluctuating moods.
Shift rapidly between loving and hating.
See themselves and others alternatively as all-good and all-bad.
Unstable and frequently changing moods.
People with borderline personality disorder have a pervasive pattern of instability in interpersonal relationships.
Histrionic
Hysteria, dramatic, seductive, shallow, egocentric, attention-seeking, vain.
Overreact to minor events.
Exhibitionistic as a means of securing attention and favors.
See themselves as attractive and charming.
Constantly seeking others’ attention.
Disorder is characterized by constant attention-seeking, emotional overreaction, and suggestibility.
Their tendency to over-dramatize may impair relationships and lead to depression.
Often high-functioning.
Narcissistic
Egotistical, arrogant, grandiose, insouciant.
Preoccupied with fantasies of success, beauty, or achievement.
Find themselves admirable and superior, and therefore entitled to special treatment.
Such people have an inflated sense of their own importance and a deep need for admiration.
Those with narcissistic personality disorder believe that they’re superior to others and have little regard for other people’s feelings.
Avoidant
Hesitant, self-conscious, embarrassed, anxious.
Tense in social situations due to fear of rejection.
Plagued by constant performance anxiety.
See themselves as inept, inferior, or unappealing.
Long-standing feelings of inadequacy and are very sensitive of what others think about them.
Dependent ant
Helpless, incompetent, submissive, immature.
Withdrawn from adult responsibilities.
See themselves as weak or fragile.
Seek constant reassurance from stronger figures.
Need to be cared for.
They fear being abandoned or separated from important people in their life.
Obsessive–compulsive
Restrained, conscientious, respectful, rigid.
Maintain a rule-bound lifestyle.
Adhere closely to social conventions.
See the world in terms of regulations and hierarchies.
See themselves as devoted, reliable, efficient, and productive.
Depressive
Somber, discouraged, pessimistic, brooding, fatalistic.
Present themselves as vulnerable and abandoned.
Feel valueless, guilty, and impotent.
Judge themselves as worthy only of criticism and contempt.
Hopeless, suicidal, restless.
Can lead to aggressive acts and hallucinations.
Passive–aggressive
Resentful, contrary, skeptical, discontented.
Resist fulfilling others’ expectations.
Deliberately inefficient.
Vent anger indirectly by undermining others’ goals.
Alternately moody and irritable, then sullen and withdrawn.
Withhold emotions.
Will not communicate when there is something problematic to discuss.
Sadistic
Explosively hostile, abrasive, cruel, dogmatic.
Liable to sudden outbursts of rage.
They gain satisfaction through dominating, intimidating and humiliating others.
They are opinionated and closed-minded.
They enjoy performing brutal acts on others.
They find pleasure in abusing others.
They would likely engage in a sadomasochist relationship, but will not play the role of a masochist.
Self-defeating (Masochistic)
Deferential, pleasure-phobic, servile, blameful, self-effacing.
Encourage others to take advantage of them.
Deliberately defeat own achievements.
Seek condemning or maltreating partners.
Suspicious of people who treat them well.
It is also possible to classify personality disorders by: severity, impact on social functioning, and attribution.
Many patients with a personality disorder do not recognize their abnormality.
This group have been termed the Type R: or treatment-resisting personality disorders.
Type S or treatment-seeking patients ones, want to altering their personality disorders.
There is a 3 to 1 ratio between Type R and Type S personality disorders with Cluster C personality disorders being significantly more likely to be Type S, and paranoid and schizoid (Cluster A) personality disorders significantly more likely to be Type R than others.
There is a considerable personality disorder diagnostic co-occurrence.
While diagnostic categories provide clear descriptions of discrete personality types, the personality structure of actual patients are more accurately described by a constellation of maladaptive personality traits.
Disorders in the three clusters may share with each other underlying common vulnerability factors involving cognition, affect and impulse control, and behavioral maintenance or inhibition.
Paranoid, schizoid or schizotypal personality disorders may be observed to be premorbid antecedents of delusional disorders or schizophrenia.
Borderline personality disorder is seen in association with mood and anxiety disorders, with impulse-control disorders, eating disorders, ADHD, or a substance use disorder.
Avoidant personality disorder is seen with social anxiety disorders.
Higher levels of disability and lower QoL are seen with avoidant, dependent, schizoid, paranoid, schizotypal, borderline and antisocial personality disorders.
Obsessive–compulsive PD and narcissistic PD are not associated with a reduced QoL or increased impairment, otherwise all PD are associated with significant impairment 15 years.
Schizotypal, antisocial, borderline and dependent PD, schizoid PD have the lowest scores regarding some aspects of life success in status, wealth and successful intimate relationships.
Paranoid, histrionic and avoidant PD were average in these aspects, while narcissistic and obsessive–compulsive PD, however, had high functioning and appeared to contribute rather positively to these aspects of life success.
For additional personality disorder criterion that a person meets there is an even further reduction in quality of life.
Personality disorders can be associated with difficulty coping with work or the workplace, interfering with interpersonal relationships, impairing educational progress or complications outside of work, such as substance abuse and co-morbid mental disorders, can be problematic.
In some cases PD can enhance work abilities by increasing competitive drive or causing the individual with the condition to exploit his or her co-workers.
Studies have found that personality disorders are more common in executives than in the disturbed criminals: increased competitive drive and exploitation of coworkers.
PD associated with enhanced work abilities include:
Histrionic personality disorder: including superficial charm, insincerity, egocentricity and manipulation
Narcissistic personality disorder: including grandiosity, self-focused lack of empathy for others, exploitativeness and independence.
Obsessive–compulsive personality disorder: including perfectionism, excessive devotion to work, rigidity, stubbornness and dictatorial tendencies.
Personality disorder is considered to be a childhood risk factor or early stage of a later personality disorder in adulthood.
Some children and adolescents experience clinically significant syndromes that resemble adult personality disorders, and that these syndromes have meaningful correlates and are consequential.
Not all youths who exhibit PD symptomatology become adult PD cases.
Borderline Personality Disorder (BPD) can be understood as a combination of emotional lability, impulsivity and hostility.
The five factor model significantly predicts all 10 personality disorder symptoms and outperform the Minnesota Multiphasic Personality Inventory (MMPI) in the prediction of borderline, avoidant, and dependent personality disorder symptoms.
Then most prominent and consistent personality dimensions underlying a large number of the personality disorders are positive associations with neuroticism and negative associations with agreeableness.
At least three aspects are relevant to understanding personality disorders: cognitive distortions, lack of insight, and impulsivity.
PD problems can cause problems with social or professional functioning include: excessive fantasizing, peculiar thinking, diffuse identity, unstable goals and nonconformity with the demands of the society.
High openness is characteristic to schizotypal personality disorder with odd and fragmented thinking, narcissistic personality disorder, excessive self-valuation and paranoid personality disorder and sensitivity to external hostility.
Lack of insight with low openness is characteristic to all personality disorders and could help explain the persistence of maladaptive behavioral patterns.
Low openness is associated with difficulties adapting to change, low tolerance for different worldviews or lifestyles, emotional flattening, alexithymia and a narrow range of interests.
Rigidity has the most obvious low openness among personality disorders and that shows lack of knowledge of one’s emotional experiences.
Rigidity is most characteristic of obsessive–compulsive personality disorder.
The opposite of rigidity is impulsivity.
Genetic disposition and life experiences, such as trauma and abuse, play a key role in the development of personality disorders.
Child abuse and neglect consistently are risk factors to the development of personality disorders in adulthood.
Children that experience verbal abuse are three times as likely as other children, who did not experience such verbal abuse, to have borderline, narcissistic, obsessive–compulsive or paranoid personality disorders in adulthood.
Sexually abused children demonstrate the most consistently elevated patterns of psychopathology, with the development of antisocial and impulsive behavior.
There is a strong association with low parental/neighborhood socioeconomic status and personality disorder symptoms.
Children from higher socioeconomic backgrounds are more altruistic, less risk seeking, and have overall higher IQs, and correlate with a low risk of developing personality disorders later on in life.
Evidence shows personality disorders may begin with parental personality issues, causing the child to have their own difficulties in adulthood, such as difficulties reaching higher education, obtaining jobs, and securing dependable relationships: children can pick up these traits.
Poor parenting appears has symptom elevating effects on personality disorders.
The lack of maternal bonding has also been correlated with personality disorders.
In a study comparing 100 healthy individuals to 100 borderline personality disorder patients, analysis showed that BPD patients were significantly more likely not to have been breastfed as a baby (42.4% in BPD vs. 9.2% in healthy controls).
Breast feeding may be essential in fostering maternal relationships.
Personality disorders show a negative correlation with two attachment variables: maternal availability and dependability.