Personality disorder

Personality disorders
Classification and external resources
Specialty Psychiatry
ICD-10 F60
ICD-9-CM 301.9
DiseasesDB 9889
MedlinePlus 000939
eMedicine article/294307
MeSH D010554

Personality disorders are a class of mental disorders characterized by enduring maladaptive patterns of behavior, cognition, and inner experience, exhibited across many contexts and deviating markedly from those accepted by the individual's culture. These patterns develop early, are inflexible, and are associated with significant distress or disability.[1] The definitions may vary somewhat, according to source.[2][3]

Official criteria for diagnosing personality disorders are listed in the Diagnostic and Statistical Manual of Mental Disorders, published by the American Psychiatric Association, and in the mental and behavioral disorders section of the International Statistical Classification of Diseases and Related Health Problems, published by the World Health Organization. The DSM-5 published in 2013 now lists personality disorders in exactly the same way as other mental disorders, rather than on a separate 'axis' as previously.[4]

Personality, defined psychologically, is the set of enduring behavioral and mental traits that distinguish human beings. Hence, personality disorders are defined by experiences and behaviors that differ from societal norms and expectations. Those diagnosed with a personality disorder may experience difficulties in cognition, emotiveness, interpersonal functioning, or impulse control. In general, personality disorders are diagnosed in 40–60 percent of psychiatric patients, making them the most frequent of all psychiatric diagnoses.[5]

Personality disorders are characterized by an enduring collection of behavioral patterns often associated with considerable personal, social, and occupational disruption. What's more, personality disorders are inflexible and pervasive across many situations, due in large part to the fact that such behavior may be ego-syntonic (i.e. the patterns are consistent with the ego integrity of the individual) and are, therefore, perceived to be appropriate by that individual. This behavior can result in maladaptive coping skills, which may lead to personal problems that induce extreme anxiety, distress, or depression.[6] These patterns of behavior typically are recognized in adolescence and the beginning of adulthood and, in some unusual instances, childhood.[1]

Many issues occur with classifying a personality disorder.[7] There are many categories of definition, some mild and some extreme.[7] Because the theory and diagnosis of personality disorders occur within prevailing cultural expectations, their validity is contested by some experts on the basis of inevitable subjectivity. They argue that the theory and diagnosis of personality disorders are based strictly on social, or even sociopolitical and economic considerations.[8][9][10][11]

Classification

The two major systems of classification, the ICD and DSM, have deliberately merged their diagnoses to some extent, but some differences remain. For example, ICD-10 does not include narcissistic personality disorder as a distinct category, while DSM-5 does not include enduring personality change after catastrophic experience or after psychiatric illness. ICD-10 classifies the DSM-5 schizotypal personality disorder as a form of schizophrenia rather than as a personality disorder. There are accepted diagnostic issues and controversies with regard to distinguishing particular personality disorder categories from each other.[12] ICD classifies transgenderism as a personality disorder;[13] while the DSM-5 declassifies transgender, per se, as a mental illness, and introduces a new and distinct classification (gender dysphoria).[14]

World Health Organization

The ICD-10 section on mental and behavioral disorders includes categories of personality disorder and enduring personality changes. They are defined as ingrained patterns indicated by inflexible and disabling responses that significantly differ from how the average person in the culture perceives, thinks, and feels, particularly in relating to others.[15]

The specific personality disorders are: paranoid, schizoid, dissocial, emotionally unstable (borderline type and impulsive type), histrionic, anankastic, anxious (avoidant), and dependent.[16]

There is also an 'Others' category involving conditions characterized as eccentric, haltlose (derived from German haltlos "drifting, aimless, irresponsible"),[17] immature, narcissistic, passive-aggressive, or psychoneurotic. An additional category is for unspecified personality disorder, including character neurosis and pathological personality.

There is also a category for Mixed and other personality disorders, defined as conditions that are often troublesome but do not demonstrate the specific pattern of symptoms in the named disorders. Finally there is a category of Enduring personality changes, not attributable to brain damage and disease. This is for conditions that seem to arise in adults without a diagnosis of personality disorder, following catastrophic or prolonged stress or other psychiatric illness.

American Psychiatric Association

The Diagnostic and Statistical Manual of Mental Disorders (currently the DSM-5) provides a definition of a General personality disorder that stress such disorders are an enduring and inflexible pattern of long duration that lead to significant distress or impairment and are not due to use of substances or another medical condition. DSM-5 lists ten personality disorders, grouped into three clusters. The DSM-5 also contains three diagnoses for personality patterns that do not match these ten disorders, but nevertheless exhibit characteristics of a personality disorder.[18]

Cluster A (odd or eccentric disorders)

These disorders are often associated with schizophrenia, one in particular being Schizotypal personality disorder in that people with the disorder are often described as having a pattern of acute discomfort in close relationships, cognitive or perceptual distortions, and eccentricities of behavior. However, people diagnosed with an odd-eccentric personality disorder tend to have a greater grasp on reality than those diagnosed with schizophrenia. In general, patients suffering from the disorder can be paranoid, have difficulty being understood by others as they have an odd or eccentric manner of speaking and a lack of close relationships. Though their perceptions may be unusual, it is important to distinguish them from delusions or hallucinations as people suffering from these would be diagnosed with a different disorder entirely. There is significant evidence that suggests that a small proportion of people with Type A personality disorder, specifically schizotypal personality disorder, have the potential to develop schizophrenia or another psychotic disorder. These disorders also have a higher risk to occur among individuals whose first-degree relatives have either schizophrenia or Cluster A personality disorder.[19]

Cluster B (dramatic, emotional or erratic disorders)

Cluster C (anxious or fearful disorders)

Other personality disorders

Other

Some types of personality disorder were in previous versions of the diagnostic manuals but have been deleted. This includes two types that were in the DSM-III-R appendix as "Proposed diagnostic categories needing further study" without specific criteria, namely sadistic personality disorder (a pervasive pattern of cruel, demeaning, and aggressive behavior) and self-defeating personality disorder (masochistic personality disorder) (characterised by behaviour consequently undermining the person's pleasure and goals).[20] The psychologist Theodore Millon and others consider some relegated diagnoses to be equally valid disorders, and may also propose other personality disorders or subtypes, including mixtures of aspects of different categories of the officially accepted diagnoses.[21]

Personality disorder diagnoses in each edition of American Psychiatric Association's Diagnostic Manual[22][23]
DSM-I DSM-II DSM-III DSM-III-R DSM-IV(-TR) DSM-5
Personality
Pattern disturbance:
Inadequate Inadequate
Schizoid Schizoid Schizoid Schizoid Schizoid Schizoid
Cyclothymic Cyclothymic
Paranoid Paranoid Paranoid Paranoid Paranoid Paranoid
Schizotypal Schizotypal Schizotypal Schizotypal*
Personality
Trait disturbance:
Emotionally unstable Hysterical Histrionic Histrionic Histrionic Histrionic
Borderline Borderline Borderline Borderline
Compulsive Obsessive-compulsive Compulsive Obsessive-compulsive Obsessive-compulsive Obsessive-compulsive
Passive-aggressive:
Passive-depressive subtype Dependent Dependent Dependent Dependent
Passive-aggressive subtype Passive-aggressive Passive-aggressive Passive-aggressive
Aggressive subtype
Explosive
Asthenic
Avoidant Avoidant Avoidant Avoidant
Narcissistic Narcissistic Narcissistic Narcissistic
Sociopathic personality
Disturbance:
Antisocial reaction Antisocial Antisocial Antisocial Antisocial Antisocial
Dyssocial reaction
Sexual deviation
Addiction
Appendix: Appendix: Appendix:
Self-defeating Negativistic Dependent
Sadistic Depressive Histrionic
Paranoid
Schizoid
Negativistic
Depressive

* – Also classified as a schizophrenia-spectrum disorder in addition to personality disorder.

Millon's description

Psychologist Theodore Millon, who has written numerous popular works on personality, proposed the following description of personality disorders:

Millon's brief description of personality disorders[24]
Type of personality disorder Description
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. People with paranoid personality disorder experience a pattern of pervasive distrust and suspicion of others that lasts a long time. They are generally difficult to work with and are very hard to form relationships with. They are also known to be somewhat short-tempered.[25]
Schizoid Apathetic, indifferent, remote, solitary, distant, humorless. Neither desire nor need human attachments. Withdrawn from relationships and prefer to be alone. Little interest in others, often seen as a loner. Minimal awareness of the feelings of themselves or others. Few drives or ambitions, if any. Is an uncommon condition in which people avoid social activities and consistently shy away from interaction with others. It affects more males than females. To others, they may appear somewhat dull or humorless. Because they don't tend to show emotion, they may appear as though they don't care about what's going on around them.[26]
Schizotypal Eccentric, self-estranged, bizarre, absent. Exhibit peculiar mannerisms and behaviors. Think they can read thoughts of others. Preoccupied with odd daydreams and beliefs. Blur line between reality and fantasy. Magical thinking and strange beliefs. People with schizotypal personality disorder are often described as odd or eccentric and usually have few, if any, close relationships. They generally don't understand how relationships form or the impact of their behavior on others.[27]
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. They often cross the line and violate these rights.[28]
Borderline Unpredictable, manipulative, 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.[29]
Histrionic Dramatic, seductive, shallow, stimulus-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, but they are often high-functioning.[30]
Narcissistic Egotistical, arrogant, grandiose, insouciant. Preoccupied with fantasies of success, beauty, or achievement. See themselves as admirable and superior, and therefore entitled to special treatment. Is a mental disorder in which 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.[31]
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. They experience long-standing feelings of inadequacy and are very sensitive of what others think about them.[32]
Dependent Helpless, incompetent, submissive, immature. Withdrawn from adult responsibilities. See themselves as weak or fragile. Seek constant reassurance from stronger figures. They have the need to be taken care of by a person. They fear being abandoned or separated from important people in their life.[33]
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. This disorder can lead to aggressive acts and hallucinations.[34]
Passive–aggressive (Negativistic) 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.[35]
Sadistic Explosively hostile, abrasive, cruel, dogmatic. Liable to sudden outbursts of rage. Gain satisfaction through dominating, intimidating and humiliating others. They are opinionated and close-minded. Enjoy performing brutal acts on others. Find pleasure in abusing others. Would likely engage in a sadomasochist relationship, but will not play the role of a masochist.[36]
Self-defeating (Masochistic) Deferential, pleasure-phobic, servile, blameful, self-effacing. Encourage others to take advantage of them. Deliberately defeat own achievements. Seek condemning or mistreatful partners. They are suspect of people who treat them well. Would likely engage in a sadomasochist relationship.[36]

Additional classification factors

In addition to classifying by category and cluster, it is possible to classify personality disorders using such additional factors as severity, impact on social functioning, and attribution.[37]

Severity

This involves both the notion of personality difficulty as a measure of subthreshold scores for personality disorder using standard interviews and the evidence that those with the most severe personality disorders demonstrate a “ripple effect” of personality disturbance across the whole range of mental disorders. In addition to subthreshold (personality difficulty) and single cluster (simple personality disorder), this also derives complex or diffuse personality disorder (two or more clusters of personality disorder present) and can also derive severe personality disorder for those of greatest risk.

Dimensional System of Classifying Personality Disorders[38]
Level of Severity Description Definition by Categorical System
0 No Personality Disorder Does not meet actual or subthreshold criteria for any personality disorder
1 Personality Difficulty Meets sub-threshold criteria for one or several personality disorders
2 Simple Personality Disorder Meets actual criteria for one or more personality disorders within the same cluster
3 Complex (Diffuse) Personality Disorder Meets actual criteria for one or more personality disorders within more than one cluster
4 Severe Personality Disorder Meets criteria for creation of severe disruption to both individual and to many in society

There are several advantages to classifying personality disorder by severity:[37]

Effect on social functioning

Social function is affected by many other aspects of mental functioning apart from that of personality. However, whenever there is persistently impaired social functioning in conditions in which it would normally not be expected, the evidence suggests that this is more likely to be created by personality abnormality than by other clinical variables.[39] The Personality Assessment Schedule[40] gives social function priority in creating a hierarchy in which the personality disorder creating the greater social dysfunction is given primacy over others in a subsequent description of personality disorder.

Attribution

Many who have a personality disorder do not recognize any abnormality and defend valiantly their continued occupancy of their personality role. This group have been termed the Type R, or treatment-resisting personality disorders, as opposed to the Type S or treatment-seeking ones, who are keen on altering their personality disorders and sometimes clamor for treatment.[37] The classification of 68 personality disordered patients on the caseload of an assertive community team using a simple scale showed 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.[41]

Signs and symptoms

In the workplace

Depending on the diagnosis, severity and individual, and the job itself, personality disorders can be associated with difficulty coping with work or the workplace - potentially leading to problems with others by interfering with interpersonal relationships. Indirect effects also play a role; for example, impaired educational progress or complications outside of work, such as substance abuse and co-morbid mental diseases, can plague sufferers. However, personality disorders can also bring about above-average work abilities by increasing competitive drive or causing the sufferer to exploit his or her co-workers.[42][43]

In 2005 and again in 2009, psychologists Belinda Board and Katarina Fritzon at the University of Surrey, UK, interviewed and gave personality tests to high-level British executives and compared their profiles with those of criminal psychiatric patients at Broadmoor Hospital in the UK. They found that three out of eleven personality disorders were actually more common in executives than in the disturbed criminals:

According to leadership academic Manfred F.R. Kets de Vries, it seems almost inevitable that some personality disorders will be present in a senior management team.[45]

Relationship with other mental disorders

The disorders in each of the three clusters may share underlying common vulnerability factors involving cognition, affect and impulse control, and behavioral maintenance or inhibition, respectively, and may have a spectrum relationship to certain syndromal mental disorders:[46]

Diagnosis

Diagnostic criteria

In the most recent edition of the DSM, DSM-V, the diagnostic criteria of a personality disorder have been revised. The general criterion for a personality disorder specifies that an individual's personality must deviate significantly from what is expected within their culture.[47] Also, particular personality features must be evident by early adulthood.

A personality disorder diagnosis must meet these criteria:

The ICD-10 'clinical descriptions and diagnostic guidelines' introduces its specific personality disorder diagnoses with some general guideline criteria that are similar. To quote:[49]

The ICD adds: "For different cultures it may be necessary to develop specific sets of criteria with regard to social norms, rules and obligations."

In clinical practice, individuals are generally diagnosed by an interview with a psychiatrist based on a mental status examination, which may take into account observations by relatives and others. One tool of diagnosing personality disorders is a process involving interviews with scoring systems. The patient is asked to answer questions, and depending on their answers, the trained interviewer tries to code what their responses were. This process is fairly time consuming.

Normal personality

The issue of the relationship between normal personality and personality disorders is one of the important issues in personality and clinical psychology. The personality disorders classification (DSM IV TR and ICD-10) follows a categorical approach that views personality disorders as discrete entities that are distinct from each other and from normal personality. In contrast, the dimensional approach is an alternative approach that personality disorders represent maladaptive extensions of the same traits that describe normal personality. Thomas Widiger[50] and his collaborators have contributed to this debate significantly. He discussed the constraints of the categorical approach and argued for the dimensional approach to the personality disorders. Specifically, he proposed the Five Factor Model of personality as an alternative to the classification of personality disorders. For example, this view specifies that Borderline Personality Disorder can be understood as a combination of emotional lability (i.e., high neuroticism), impulsivity (i.e., low conscientiousness), and hostility (i.e., low agreeableness). Many studies across cultures have explored the relationship between personality disorders and the Five Factor Model.[51] This research has demonstrated that personality disorders largely correlate in expected ways with measures of the Five Factor Model[52] and has set the stage for including the Five Factor Model within the upcoming DSM-5.[53]

DSM-IV-TR Personality Disorders from the Perspective of the Five-Factor Model of General Personality Functioning[46]
Factors PPD SzPD StPD ASPD BPD HPD NPD AvPD DPD OCPD PAPD DpPD
Neuroticism (vs. emotional stability)
Anxiousness (vs. unconcerned) n/a n/a High Low High n/a n/a High High High n/a n/a
Angry hostility (vs. dispassionate) High n/a n/a High High n/a High n/a n/a n/a High n/a
Depressiveness (vs. optimistic) n/a n/a n/a n/a High n/a n/a n/a n/a n/a n/a High
Self-consciousness (vs. shameless) n/a n/a High Low n/a Low Low High High n/a n/a High
Impulsivity (vs. restrained) n/a n/a n/a High High High n/a Low n/a Low n/a n/a
Vulnerability (vs. fearless) n/a n/a n/a Low High n/a n/a High High n/a n/a n/a
Extraversion (vs. introversion)
Warmth (vs. coldness) Low Low Low n/a n/a n/a Low n/a High n/a Low Low
Gregariousness (vs. withdrawal) Low Low Low n/a n/a High n/a Low n/a n/a n/a Low
Assertiveness (vs. submissiveness) n/a n/a n/a High n/a n/a High Low Low n/a Low n/a
Activity (vs. passivity) n/a Low n/a High n/a High n/a n/a n/a n/a Low n/a
Excitement seeking (vs. lifeless) n/a Low n/a High n/a High High Low n/a Low n/a Low
Positive emotionality (vs. anhedonia) n/a Low Low n/a n/a High n/a Low n/a n/a n/a n/a
Openness (vs. closedness)
Fantasy (vs. concrete) n/a n/a High n/a n/a High n/a n/a n/a n/a n/a n/a
Aesthetics (vs. disinterest) n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a
Feelings (vs. alexithymia) n/a Low n/a n/a High High Low n/a n/a Low n/a n/a
Actions (vs. predictable) Low Low n/a High High High High Low n/a Low Low n/a
Ideas (vs. closed-minded) Low n/a High n/a n/a n/a n/a n/a n/a Low Low Low
Values (vs. dogmatic) Low n/a n/a n/a n/a n/a n/a n/a n/a Low n/a n/a
Agreeableness (vs. antagonism)
Trust (vs. mistrust) Low n/a n/a Low n/a High Low n/a High n/a n/a Low
Straightforwardness (vs. deception) Low n/a n/a Low n/a n/a Low n/a n/a n/a Low n/a
Altruism (vs. exploitative) Low n/a n/a Low n/a n/a Low n/a High n/a n/a n/a
Compliance (vs. aggression) Low n/a n/a Low n/a n/a Low n/a High n/a Low n/a
Modesty (vs. arrogance) n/a n/a n/a Low n/a n/a Low High High n/a n/a High
Tender-mindedness (vs. tough-minded) Low n/a n/a Low n/a n/a Low n/a High n/a n/a n/a
Conscientiousness (vs. disinhibition)
Competence (vs. laxness) n/a n/a n/a n/a n/a n/a n/a n/a n/a High Low n/a
Order (vs. disorderly) n/a n/a Low n/a n/a n/a n/a n/a n/a n/a High Low
Dutifulness (vs. irresponsibility) n/a n/a n/a Low n/a n/a n/a n/a n/a High Low High
Achievement striving (vs. lackadaisical) n/a n/a n/a n/a n/a n/a n/a n/a n/a High n/a n/a
Self-discipline (vs. negligence) n/a n/a n/a Low n/a Low n/a n/a n/a High Low n/a
Deliberation (vs. rashness) n/a n/a n/a Low Low Low n/a n/a n/a High n/a High

Abbreviations used: PPD – Paranoid Personality Disorder, SzPD – Schizoid Personality Disorder, StPD – Schizotypal Personality Disorder, ASPD – Antisocial Personality Disorder, BPD – Borderline Personality Disorder, HPD – Histrionic Personality Disorder, NPD – Narcissistic Personality Disorder, AvPD – Avoidant Personality Disorder, DPD – Dependent Personality Disorder, OCPD – Obsessive-Compulsive Personality Disorder, PAPD – Passive-Aggressive Personality Disorder, DpPD – Depressive Personality Disorder, n/a – not available.

Causes

There are numerous possible causes of mental disorders, and they may vary depending on the disorder, the individual, and the circumstances. There may be genetic dispositions as well as particular life experiences, which may or may not include particular incidents of trauma or abuse.

A study of almost 600 male college students, averaging almost 30 years of age and who were not drawn from a clinical sample, examined the relationship between childhood experiences of sexual and physical abuse and currently reported personality disorder symptoms. Childhood abuse histories were found to be definitively associated with greater levels of symptomatology. Severity of abuse was found to be statistically significant, but clinically negligible, in symptomatology variance spread over Cluster A, B and C scales.[54]

Child abuse and neglect consistently evidence themselves as antecedent risks to the development of personality disorders in adulthood.[55] In the following study, efforts were taken to match retrospective reports of abuse with a clinical population that had demonstrated psychopathology from childhood to adulthood who were later found to have experienced abuse and neglect. In a study of 793 mothers and children, researchers asked mothers if they had screamed at their children, and told them that they did not love them or threatened to send them away. Children who had experienced such verbal abuse were 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.[56] The sexually abused group demonstrated the most consistently elevated patterns of psychopathology. Officially verified physical abuse showed an extremely strong correlation with the development of antisocial and impulsive behavior. On the other hand, cases of abuse of the neglectful type that created childhood pathology were found to be subject to partial remission in adulthood.[55]

Epidemiology

The prevalence of personality disorder in the general community was largely unknown until surveys starting from the 1990s. In 2008 the median rate of diagnosable PD was estimated at 10.6%, based on six major studies across three nations. This rate of around one in ten, especially as associated with high use of services, is described as a major public health concern requiring attention by researchers and clinicians.[57]

The prevalence of individual personality disorders ranges from about 2% to 3% for the more common varieties, such as schizotypal, antisocial, borderline, and histrionic, to 0.5–1% for the least common, such as narcissistic and avoidant.[46]

A screening survey across 13 countries by the World Health Organization using DSM-IV criteria, reported in 2009 a prevalence estimate of around 6% for personality disorders. The rate sometimes varied with demographic and socioeconomic factors, and functional impairment was partly explained by co-occurring mental disorders.[58] In the US, screening data from the National Comorbidity Survey Replication between 2001 and 2003, combined with interviews of a subset of respondents, indicated a population prevalence of around 9% for personality disorders in total. Functional disability associated with the diagnoses appeared to be largely due to co-occurring mental disorders (Axis I in the DSM).[59]

A UK national epidemiological study (based on DSM-IV screening criteria), reclassified into levels of severity rather than just diagnosis, reported in 2010 that the majority of people show some personality difficulties in one way or another (short of threshold for diagnosis), while the prevalence of the most complex and severe cases (including meeting criteria for multiple diagnoses in different clusters) was estimated at 1.3%. Even low levels of personality symptoms were associated with functional problems, but the most severely in need of services was a much smaller group.[60]

There are also some sex differences in the frequency of personality disorders. They are shown in the table below.

Sex differences in the frequency of personality disorders[46]
Type of personality disorder Predominant sex
Paranoid personality disorder Male
Schizoid personality disorder Male
Schizotypal personality disorder Male
Antisocial personality disorder Male
Borderline personality disorder Female
Histrionic personality disorder Female
Narcissistic personality disorder Male
Avoidant personality disorder Equal
Dependent personality disorder Female
Obsessive–compulsive personality disorder Male

Comorbidity

There is a considerable personality disorder diagnostic co-occurrence. Patients who meet the DSM-IV-TR diagnostic criteria for one personality disorder are likely to meet the diagnostic criteria for another.[46] Diagnostic categories provide clear, vivid descriptions of discrete personality types but the personality structure of actual patients might be more accurately described by a constellation of maladaptive personality traits.

DSM-III-R personality disorder diagnostic co-occurrence aggregated across six research sites[46]
Type of Personality Disorder PPD SzPD StPD ASPD BPD HPD NPD AvPD DPD OCPD PAPD
Paranoid (PPD) 8 19 15 41 28 26 44 23 21 30
Schizoid (SzPD) 38 39 8 22 8 22 55 11 20 9
Schizotypal (StPD) 43 32 19 4 17 26 68 34 19 18
Antisocial (ASPD) 30 8 15 59 39 40 25 19 9 29
Borderline (BPD) 31 6 16 23 30 19 39 36 12 21
Histrionic (HPD) 29 2 7 17 41 40 21 28 13 25
Narcissistic (NPD) 41 12 18 25 38 60 32 24 21 38
Avoidant (AvPD) 33 15 22 11 39 16 15 43 16 19
Dependent (DPD) 26 3 16 16 48 24 14 57 15 22
Obsessive-Compulsive (OCPD) 31 10 11 4 25 21 19 37 27 23
Passive-Aggressive (PAPD) 39 6 12 25 44 36 39 41 34 23

Sites used DSM-III-R criterion sets. Data obtained for purposes of informing the development of the DSM-IV-TR personality disorder diagnostic criteria.

Abbreviations used: PPD – Paranoid Personality Disorder, SzPD – Schizoid Personality Disorder, StPD – Schizotypal Personality Disorder, ASPD – Antisocial Personality Disorder, BPD – Borderline Personality Disorder, HPD – Histrionic Personality Disorder, NPD – Narcissistic Personality Disorder, AvPD – Avoidant Personality Disorder, DPD – Dependent Personality Disorder, OCPD – Obsessive-Compulsive Personality Disorder, PAPD – Passive-Aggressive Personality Disorder.

Management

Specific approaches

There are many different forms (modalities) of treatment used for personality disorders:[61]

There are different specific theories or schools of therapy within many of these modalities. They may, for example, emphasize psychodynamic techniques, or cognitive or behavioral techniques. In clinical practice, many therapists use an 'eclectic' approach, taking elements of different schools as and when they seem to fit to an individual client. There is also often a focus on common themes that seem to be beneficial regardless of techniques, including attributes of the therapist (e.g. trustworthiness, competence, caring), processes afforded to the client (e.g. ability to express and confide difficulties and emotions), and the match between the two (e.g. aiming for mutual respect, trust and boundaries).

Response of Patients with Personality Disorders to Biological and Psychosocial Treatments[46]
Cluster Evidence for Brain Dysfunction Response to Biological Treatments Response to Psychosocial Treatments
A Evidence for relationship of schizotypal personality to schizophrenia; otherwise none known Schizotypal patients may improve on antipsychotic medication; otherwise not indicated Poor. Supportive psychotherapy may help
B Evidence suggestive for antisocial and borderline personalities; otherwise none known Antidepressants, antipsychotics, or mood stabilizers may help for borderline personality; otherwise not indicated Poor in antisocial personality. Variable in borderline, narcissistic, and histrionic personalities
C None known No direct response. Medications may help with comorbid anxiety and depression Most common treatment for these disorders. Response variable

Challenges

The management and treatment of personality disorders can be a challenging and controversial area, for by definition the difficulties have been enduring and affect multiple areas of functioning. This often involves interpersonal issues, and there can be difficulties in seeking and obtaining help from organizations in the first place, as well as with establishing and maintaining a specific therapeutic relationship. On the one hand, an individual may not consider themselves to have a mental health problem, while on the other, community mental health services may view individuals with personality disorders as too complex or difficult, and may directly or indirectly exclude individuals with such diagnoses or associated behaviors.[62] The disruptiveness that people with personality disorders can create in an organisation makes these, arguably, the most challenging conditions to manage.

Apart from all these issues, an individual may not consider their personality to be disordered or the cause of problems. This perspective may be caused by the patient's ignorance or lack of insight into their own condition, an ego-syntonic perception of the problems with their personality that prevents them from experiencing it as being in conflict with their goals and self-image, or by the simple fact that there is no distinct or objective boundary between 'normal' and 'abnormal' personalities. Unfortunately, there is substantial social stigma and discrimination related to the diagnosis.

The term 'personality disorder' encompasses a wide range of issues, each with different a level of severity or disability; thus, personality disorders can require fundamentally different approaches and understandings. To illustrate the scope of the matter, consider that while some disorders or individuals are characterized by continual social withdrawal and the shunning of relationships, others may cause fluctuations in forwardness. The extremes are worse still: at one extreme lie self-harm and self-neglect, while at another extreme some individuals may commit violence and crime. There can be other factors such as problematic substance use or dependency or behavioral addictions. A person may meet the criteria for multiple personality disorder diagnoses and/or other mental disorders, either at particular times or continually, thus making coordinated input from multiple services a potential requirement.

Therapists in this area can become disheartened by lack of initial progress, or by apparent progress that then leads to setbacks. Clients may be perceived as negative, rejecting, demanding, aggressive or manipulative. This has been looked at in terms of both therapist and client; in terms of social skills, coping efforts, defense mechanisms, or deliberate strategies; and in terms of moral judgments or the need to consider underlying motivations for specific behaviors or conflicts. The vulnerabilities of a client, and indeed a therapist, may become lost behind actual or apparent strength and resilience. It is commonly stated that there is always a need to maintain appropriate professional personal boundaries, while allowing for emotional expression and therapeutic relationships. However, there can be difficulty acknowledging the different worlds and views that both the client and therapist may live with. A therapist may assume that the kinds of relationships and ways of interacting that make them feel safe and comfortable have the same effect on clients. As an example of one extreme, people who may have been exposed to hostility, deceptiveness, rejection, aggression or abuse in their lives, may in some cases be made confused, intimidated or suspicious by presentations of warmth, intimacy or positivity. On the other hand, reassurance, openness and clear communication are usually helpful and needed. It can take several months of sessions, and perhaps several stops and starts, to begin to develop a trusting relationship that can meaningfully address a client's issues.[63]

History

Personality disorder is a term with a distinctly modern meaning, owing in part to its clinical usage and the institutional character of modern psychiatry. The currently accepted meaning must be understood in the context of historical changing classification systems such as DSM-IV and its predecessors. Although highly anachronistic, and ignoring radical differences in the character of subjectivity and social relations, some have suggested similarities to other concepts going back to at least the ancient Greeks.[3] For example, the Greek philosopher Theophrastus described 29 'character' types that he saw as deviations from the norm, and similar views have been found in Asian, Arabic and Celtic cultures. A long-standing influence in the Western world was Galen's concept of personality types, which he linked to the four humours proposed by Hippocrates.

Such views lasted into the 18th century, when experiments began to question the supposed biologically based humours and 'temperaments'. Psychological concepts of character and 'self' became widespread. In the 19th century, 'personality' referred to a person's conscious awareness of their behavior, a disorder of which could be linked to altered states such as dissociation. This sense of the term has been compared to the use of the term 'multiple personality disorder' in the first versions of the DSM.[64]

Physicians in the early 19th century started to diagnose forms of insanity that involved disturbed emotions and behaviors but seemingly without significant intellectual impairment or delusions or hallucinations. Philippe Pinel referred to this as 'manie sans délire' – mania without delusions – and described a number of cases mainly involving excessive or inexplicable anger or rage. James Cowles Prichard advanced a similar concept he called moral insanity, which would be used to diagnose patients for some decades. 'Moral' in this sense referred to affect (emotion or mood) rather than ethics, but it was arguably based in part on religious, social and moral beliefs, with a pessimism about medical intervention so that social control should take precedence.[65] These categories were much different and broader than later definitions of personality disorder, while also being developed by some into a more specific meaning of moral degeneracy akin to later ideas about 'psychopaths'. Separately, Richard von Krafft-Ebing popularized the terms sadism and masochism, as well as homosexuality, as psychiatric issues.

The German psychiatrist Koch sought to make the moral insanity concept more scientific, and in 1891 suggested the phrase 'psychopathic inferiority', theorized to be a congenital disorder. This referred to continual and rigid patterns of misconduct or dysfunction in the absence of apparent mental retardation or illness, supposedly without a moral judgment. Described as deeply rooted in his Christian faith, his work has been described as a fundamental text on personality disorders that is still of use today.[66]

20th century

In the early 20th century, another German psychiatrist, Emil Kraepelin, included a chapter on psychopathic inferiority in his influential work on clinical psychiatry for students and physicians. He suggested six types – excitable, unstable, eccentric, liar, swindler and quarrelsome. The categories were essentially defined by the most disordered criminal offenders observed, distinguished between criminals by impulse, professional criminals, and morbid vagabonds who wandered through life. Kraepelin also described three paranoid (meaning then delusional) disorders, resembling later concepts of schizophrenia, delusional disorder and paranoid personality disorder. A diagnostic term for the latter concept would be included in the DSM from 1952, and from 1980 the DSM would also include schizoid and schizotypal personality disorders; interpretations of earlier (1921) theories of Ernst Kretschmer led to a distinction between these and another type later included in the DSM, avoidant personality disorder.

In 1933 Russian psychiatrist Pyotr Borisovich Gannushkin published his book Manifestations of psychopathies: statics, dynamics, systematic aspects, which was one of the first attempts to develop a detailed typology of psychopathies. Regarding maladaptation, ubiquity, and stability as the three main symptoms of behavioral pathology, he distinguished 9 clusters of psychopaths: cycloids (including constitutionally depressive, constitutionally excitable, cyclothymics, and emotionally labile), asthenics (including psychasthenics), schizoids (including dreamers), paranoiacs (including fanatics), epileptoids, hysterical personalities (including pathological liars), unstable psychopaths, antisocial psychopaths, and constitutionally stupid.[67] Some elements of Gannushkin's typology were later incorporated into the theory developed by a Russian adolescent psychiatrist, Andrey Yevgenyevich Lichko, who was also interested in psychopathies along with their milder forms, the so-called accentuations of character.[68]

In 1939, psychiatrist David Henderson published a theory of 'psychopathic states' that contributed to popularly linking the term to anti-social behavior. Hervey M. Cleckley’s 1941 text, The Mask of Sanity, based on his personal categorization of similarities he noted in some prisoners, marked the start of the modern clinical conception of psychopathy and its popularist usage.[69]

Towards the mid 20th century, psychoanalytic theories were coming to the fore based on work from the turn of the century being popularized by Sigmund Freud and others. This included the concept of character disorders, which were seen as enduring problems linked not to specific symptoms but to pervasive internal conflicts or derailments of normal childhood development. These were typically understood as weaknesses of character or willful deviance, and were distinguished from neurosis or psychosis. The term 'borderline' stems from a belief that some individuals were functioning on the edge of those two categories, and a number of the other personality disorder categories were also heavily influenced by this approach, including dependent, obsessive-compulsive and histrionic,[70] the latter starting off as a conversion symptom of hysteria particularly associated with women, then a hysterical personality, then renamed histrionic personality disorder in later versions of the DSM. A passive aggressive style was defined clinically by Colonel William Menninger during World War II in the context of men's reactions to military compliance, which would later be referenced as a personality disorder in the DSM.[71] Otto Kernberg was influential with regard to the concepts of borderline and narcissistic personalities later incorporated in 1980 as disorders into the DSM.

Meanwhile, a more general personality psychology had been developing in academia and to some extent clinically. Gordon Allport published theories of personality traits from the 1920s—and Henry Murray advanced a theory called personology, which influenced a later key advocate of personality disorders, Theodore Millon. Tests were developing or being applied for personality evaluation, including projective tests such as the Rorshach, as well as questionnaires such as the Minnesota Multiphasic Personality Inventory. Around mid-century, Hans Eysenck was analysing traits and personality types, and psychiatrist Kurt Schneider was popularising a clinical use in place of the previously more usual terms 'character', 'temperament' or 'constitution'.

American psychiatrists officially recognised concepts of enduring personality disturbances in the first Diagnostic and Statistical Manual of Mental Disorders in the 1950s, which relied heavily on psychoanalytic concepts. Somewhat more neutral language was employed in the DSM-II in 1968, though the terms and descriptions had only a slight resemblance to current definitions. The DSM-III published in 1980 made some major changes, notably putting all personality disorders onto a second separate 'axis' along with mental retardation, intended to signify more enduring patterns, distinct from what were considered axis one mental disorders. 'Inadequate' and 'asthenic' personality disorder' categories were deleted, and others were expanded into more types, or changed from being personality disorders to regular disorders. Sociopathic personality disorder, which had been the term for psychopathy, was renamed Antisocial Personality Disorder. Most categories were given more specific 'operationalized' definitions, with standard criteria that psychiatrists could agree on in order to conduct research and diagnose patients.[72] In the DSM-III revision, self-defeating personality disorder and sadistic personality disorder were included as provisional diagnoses requiring further study. They were dropped in the DSM-IV, though a proposed 'depressive personality disorder' was added; in addition, the official diagnosis of passive-aggressive personality disorder was dropped, tentatively renamed 'negativistic personality disorder.'[73]

International differences have been noted in how attitudes have developed towards the diagnosis of personality disorder. Kurt Schneider had argued that they were simply 'abnormal varieties of psychic life' and therefore not necessarily the domain of psychiatry, a view said to still have influence in Germany today. British psychiatrists have also been reluctant to address such disorders or consider them on par with other mental disorders, which has been attributed partly to resource pressures within the National Health Service, as well as to negative medical attitudes towards behaviors associated with personality disorders. In the US, the prevailing healthcare system and psychanalytic tradition has been said to provide a rationale for private therapists to diagnose some personality disorders more broadly and provide ongoing treatment for them.[74]

Children

Early stages and preliminary forms of personality disorders need a multi-dimensional and early treatment approach. Personality development disorder is considered to be a childhood risk factor or early stage of a later personality disorder in adulthood.[75] In addition, in Robert F. Krueger's review of their research indicates that some children and adolescents do suffer from clinically significant syndromes that resemble adult personality disorders, and that these syndromes have meaningful correlates and are consequential. Much of this research has been framed by the adult personality disorder constructs from Axis II of the Diagnostic and Statistical Manual. Hence, they are less likely to encounter the first risk they described at the outset of their review: clinicians and researchers are not simply avoiding use of the PD construct in youth. However, they may encounter the second risk they described: under-appreciation of the developmental context in which these syndromes occur. That is, although PD constructs show continuity over time, they are probabilistic predictors; not all youths who exhibit PD symptomatology become adult PD cases.[75]

Five Factor Model

As of 2002, there were over fifty published studies relating the Five Factor Model (FFM) to personality disorders.[76] Since that time, quite a number of additional studies have expanded on this research base and provided further empirical support for understanding the DSM personality disorders in terms of the FFM domains.[77]

In her seminal review of the personality disorder literature published in 2007, Dr. Lee Anna Clark asserted that "the five-factor model of personality is widely accepted as representing the higher-order structure of both normal and abnormal personality traits".[78]

The Five Factor Model has been shown to significantly predict all 10 personality disorder symptoms and outperform the Minnesota Multiphasic Personality Inventory (MMPI) in the prediction of borderline, avoidant, and dependent personality disorder symptoms.[79]

Research results examining the relationships between the FFM and each of the ten DSM personality disorder diagnostic categories are widely available. For example, in a study published in 2003 titled "The five-factor model and personality disorder empirical literature: A meta-analytic review",[80] the authors analyzed data from 15 other studies to determine how personality disorders are different and similar, respectively, with regard to underlying personality traits. In terms of how personality disorders differ, the results showed that each disorder displays a FFM profile that is meaningful and predictable given its unique diagnostic criteria. With regard to their similarities, the findings revealed that the most prominent and consistent personality dimensions underlying a large number of the personality disorders are positive associations with neuroticism and negative associations with agreeableness.

Openness to experience

At least three aspects of openness to experience are relevant to understanding personality disorders: cognitive distortions, lack of insight and impulsivity. Problems related to high openness that can cause problems with social or professional functioning are excessive fantasising, peculiar thinking, diffuse identity, unstable goals and nonconformity with the demands of the society.[81]

High openness is characteristic to schizotypal personality disorder (odd and fragmented thinking), narcissistic personality disorder (excessive self-valuation) and paranoid personality disorder (sensitivity to external hostility). Lack of insight (shows low openness) is characteristic to all personality disorders and could explain the persistence of maladaptive behavioral patterns.[82]

The problems associated with low openness are difficulties adapting to change, low tolerance for different worldviews or lifestyles, emotional flattening, alexithymia and a narrow range of interests.[81] Rigidity is the most obvious aspect of (low) openness among personality disorders and that shows lack of knowledge of one's emotional experiences. It is most characteristic of obsessive-compulsive personality disorder; the opposite of it known as impulsivity (here: an aspect of openness that shows a tendency to behave unusually or autistically) is characteristic of schizotypal and borderline personality disorders.[82]

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