Personality Disorders

What is personality?

Personality has been defined and revised numerous times over the years. The general consensus is that personality is the combination of one’s stable and predictable emotional, cognitive, and behavioral traits that develop from the bidirectional interaction between nature (i.e. genetics) and nurture (i.e. environment). A person’s core personality traits remain relatively stable throughout adulthood. Personality Disorders represent deeply ingrained, pervasive, and rigid patterns of relating to oneself and others that are maladaptive and cause significant impairment in functioning. It is important to remember that personality traits are not considered pathological unless they cause significant distress or dysfunction in a person’s life.

Individuals with personality disorders often lack insight into their problems. Therefore, their symptoms are considered ego-syntonic. 

There has been ongoing debate and controversy surrounding the idea of discrete disorders of personality given that many people meet criteria for more than one personality disorder. Nonetheless, we organize personality disorders into three “Clusters” (i.e., Cluster A, Cluster B, and Cluster C) with each cluster sharing similar core features. 

  • Cluster A: Schizoid, Schizotypal, and Paranoid.

  • Cluster B: Antisocial, Borderline, Histrionic, and Narcissistic.

  • Cluster C: Avoidant, Dependent, and Obsessive-Compulsive.

General Personality Disorder in DSM-5

A. An enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culutre. This pattern is manifested in two (or more) of the following areas:

  1. Cognition (i.e., ways of perceiving and interpreting self, other people, and events)
  2. Affectivity (i.e., the range, intensity, lability, and appropriateness of emotional response)
  3. Interpersonal Functioning
  4. Impulse control

B. The enduring pattern is inflexible and pervasive across a broad range of personal and social situations

C. The enduring pattern leads to clinically significant distress or impairment in social, occupational, or other important areas of functioning.

D. The pattern is stable and of long duration, and its onset can be traced back at least to adolescence or early adulthood.

E. The enduring pattern is not better explained as a manifestation or consequence of another mental disorder

F. The enduring pattern is not attributable to the physiological effects of a substance (e.g., drug of abuse or medication) or another medical condition (e.g., head trauma). 

Cluster A Personality Disorders

Paranoid Personality Disorder (301.0)Schizoid Personality Disorder (301.20)Schizotypal Personality Disorder (301.22)
A pervasive pattern of distrust and suspiciousness of others such that their motives are interpreted as malevolent. Need 4 out of 7:A pervasive pattern of detachment from social relationships and a restricted range of expression of emotions in interpersonal settings. Need 4 out of 7:A pervasive pattern of social and interpersonal deficits, marked by acute discomfort with, and reduced capacity for close relationships as well as cognitive or perceptual distortions and eccentricities of behavior. Need 5 out of 9:
1. Patient suspects, without sufficient basis, that others are exploiting, harming or deceiving him;1. Patient neither desires nor enjoys close relationships, including being part of a family;1. Ideas of reference (excluding delusions of reference);
2. Patient is preoccupied with unjustified doubts about the loyalty or trustworthiness of friends or associates;2. Patient almost always chooses solitary activities;2. Odd beliefs or magical thinking that influences behavior and is inconsistent with subcultural norms (superstitiousness, belief in clairvoyance, telepathy, or 6th sense);
3. Patient is reluctant to confide in others because of unwarranted fear that the info will be used maliciously against him;3. Patient has little, if any, interest in having sexual experiences with others;3. Unusual perceptual experiences, including bodily illusions;
4. Patient misinterprets benign remarks or events as having hidden, demeaning, or threatening meanings;4. Patient takes pleasure in few, if any, activities;4. Odd thinking and speech (vague, circumstantial, metaphorical, over-elaborate, or stereotyped);
5. Patient persistenly bears grudges, cannot forgive insults/injuries/slights;5. Patient lacks close friends or confidants, other than first degree relatives;5. Suspiciousness or paranoid ideation;
6. Patient mistakenly perceives attacks on his character or reputation that are not apparent to others, and patient is quick to react angrily or counterattack;6. Patient appears indifferent to the praise or criticism of others;6. Inappropriate or constricted affect;
7. Patient has recurrent, unjustified suspicions about the fidelity of a spouse or sexual partner.7. Patient is emotionally cold, detached, or with flattened affectivity.7. Odd, eccentric, peculiar behavior or appearance;
8. Lacks close friends or confidants, other than first degree relatives;
9. Excessive social anxiety that does not diminish with familiarity, and tends to be associated with paranoid fears rather than negative judgments about self.

Cluster B Personality Disorders

Antisocial Personality Disorder (301.7)Borderline Personality Disorder (301.83)Narcissistic Personality Disorder (301.81)Histrionic Personality Disorder (301.50)
A pervasive pattern of disregard for and violation of rights of others occurring since age 15, as indicated by at least 3 of the following:A pervasive pattern of instability of interpersonal relationships, self-image, and affect, and marked impulsivity. Need 5 out of 9:A pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy. Need 5 out of 9:A pervasive pattern of excessive emotionality and attention seeking. 5 out of 8:
1. Patient fails to conform to social norms without regard to lawful behaviors as indicated by repeatedly performing acts that are grounds for arrest;1. Frantic efforts to avoid real or imagined abandonment;1. Grandiose sense of self-importance (exaggerates achievements);1. Patient is uncomfortable when he is not the center of attention;
2. Patient is deceitful, as indicated by repeated lying, use of aliases, or conning others for personal profit or pleasure;2. A pattern of unstable and intense interpersonal relationships characterized by changing between extremes of idealization and devaluation;2. Preoccupied with fantasies of unlimited success, power, brilliance, beauty;2. Interaction with others often characterized by inappropriate sexually seductive/provocative behaviors;
3. Patient is impulsive or fails to plan ahead;3. Identity disturbance: Markedly unstable self image sense of self;3. Believes she is special/unique, and can only be understood by or should only associate with other special or high status people (or institutions);3. Patient displays rapidly shifting and shallow expression of emotions;
4. Patient is irritable/aggressive, has repeated physical fights or assaults;4. Impulsivity in at least two areas that are self damaging (spending, sex, substance abuse, reckless driving, binge eating);4. Requires excessive admiration;4. Patient consistently uses physical appearance to draw attention to self;
5. Patient has reckless disregard for the safety of self and others;5. Recurrent suicidal behavior/gestures/threats; or self-mutilating behavior;5. Has sense of entitlement, expectation of favorable treatment;5. Patient's style of speech is overly impressionistic and lacking in detail;
6. Patient is consistently irresponsible, as indicated by repeated failure to sustain consistent work behavior or honor financial obligations;6. Affective instability due to marked reactivity of mood (intense episodic dysphoria, irritability, or anxiety lasting a few hours);6. Is interpersonally exploitative;6. Shows self-dramatization/theatricality/exaggerated expression of emotion;
7. Patient lacks remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another.7. Chronic feelings of emptiness;7. Lacks empathy, unwilling to recognize feelings/needs of others;7. Patient is suggestible, easily influenced by others or circumstances;
8. Inappropriate, intense anger or difficulty controlling anger;8. Is envious of others and believes others are envious of her;8. Patient considers relationships to be more intimate than they actually are.
9. Transient stress-related paranoid ideation, or severe dissociative symptoms.9. Shows arrogant, haughty behaviors or attitudes.

Cluster C Personality Disorders

Avoidant Personality Disorder (301.82)Dependent Personality Disorder (301.6)Obsessive-Compulsive Personality Disorder (301.4)
A pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation. Need 4 out of 7:A pervasive and excessive need to be taken care of that leads to submissive and clinging behavior and fear of separation. Need 5 out of 8:A pervasive pattern of preoccupation w orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness, and efficiency. 4 out of 8:
1. Avoids work that involves significant interpersonal contact, because of fears of criticism, disapproval, or rejection;1. Difficulty making every day decisions without excessive advice and reassurance from others;1. Preoccupied with details, rules, lists, order, organization, or schedules to the extent that the major point of the activity is lost;
2. Is unwilling to get involved with people unless certain of being liked;2. Needs others to assume responsibility for most major areas of life;2. Shows perfectionism that interferes with task completion;
3. Shows restraint with intimate relationships because of fears of being shamed or ridiculed;3. Has difficulty expressing disagreement because of fear of loss of support or approval;3. Excessively devoted to work and productivity to the exclusion of leisure activities and friendships;
4. Is preoccupied with being criticized or rejected in social situations;4. Has difficulty initiating projects or doing things on her own (because of lack of self confidence rather than lack of motivation);4. Over-conscientious, scrupulous, and inflexible about matters of morality/ethics/values;
5. Is inhibited in new social situations because of feelings of inadequacy;5. Goes to excessive lengths to obtain nurturance/support from others, to the point of volunteering to do unpleasant things;5. Unable to discard worn-out or worthless objects even when they have no sentimental value;
6. Views self as socially inept, personally unappealing, or inferior;6. Feels uncomfortable or helpless when alone because of exaggerated fears that she cannot care for self;6. Reluctant to delegate tasks or to work with others unless they submit exactly to his or her way of doing things;
7. Is reluctant to take personal risks or engage in new activities because they may prove embarrassing.7. Urgently seeks new relationships as a source of care/support when a close relationship ends;7. Adopts miserly spending style towards self and others; money viewed as something to be hoarded for future catastrophes;
8. Is unrealistically preoccupied with fears of being left to care for self.8. Shows rigidity and stubbornness.

Additional Information

In general, each personality disorder has a prevalence of approximately 1%. Personality disorders are very difficult to treat as they require changing ingrained patterns of behavior. 

  • Schizotypal Personality Disorder and Schizoid Personality Disorder: Commonly occurs in families with history of Psychotic disorders.
  • Histrionic Personality Disorder: Most common Defense Mechanism is regression.
  • Borderline Personality Disorder: Most common Defense Mechanisms are Splitting and Projection. Projective Identification is a common interpersonal dynamic. Self harm behaviors are common. Manipulation is often used as a way to get what they need. Often there is sexual trauma or abuse in the patient’s history. Substance abuse is highly prevalent.
  • Antisocial Personality Disorder: Usually begins as Conduct Disorder in childhood. Often times there is history of animal cruelty, fighting, and sexual abuse in childhood. Substance abuse and criminal activity is VERY common. Deceptive tactics and manipulation are often used to get what they want. 
  • Schizoid vs Avoidant Personality Disorder: Schizoid PD patients want to be alone and are content with being alone. Avoidant PD patients want to be alone but this is due to anxiety and fear (they would rather be social!)
  • OCD vs OCPD: In Obsessive Compulsive Disorder, patients recognize their thoughts and behaviors as irrational and disturbing (ego dystonic) whereas in Obsessive Compulsive Personality Disorder (OCPD) patients see their traits as essential to their success (ego syntonic).

Treatment of Personality Disorders

Psychotherapy remains the first line and most effective treatment for personality disorders.

Pharmacological treatment is not first line for personality disorders. Because many personality disorders are comorbid with other psychiatric disorders, pharmacological treatment should focus on these comorbid disorders.

For Cluster A disorders: Cognitive Behavioral Therapy and Group Therapy remain the most commonly used psychotherapy modalities. Antipsychotics may be used for transient psychotic symptoms.

For Cluster B disorders: Dialectical Behavioral Therapy, Contingency-Based Therapies, Cognitive Behavioral Therapy and Group Therapy remain the most commonly used psychotherapy modalities. Of all the personality disorders, borderline personality disorder is the most likely to respond to mood stabilizers (e.g., lamotrigine, lithium, valproate), SSRIs (e.g. Fluoxetine), and atypical antipsychotics (e.g., olanzapine). 

For Cluster C disorders: Cognitive Behavioral Therapy, Assertiveness Training, Group therapy, and Exposure Therapy remain the most commonly used psychotherapy modalities. SSRIs and beta-blockers are often used for comorbid anxiety and depressive disorders.