Personality disorders are identified as being enduring patterns of behavior that are pervasive and inflexible.1 These disorders are a part of a person’s genetic make-up and, therefore, are likely to be permanent. There are more than a dozen diagnosable personality disorders. Individuals with personality disorders have significant impairment in relationships, thinking processes, ego esteem, and occupational functioning.
The effects of personality disorders, as with any psychological disorder, are diagnosable when they inhibit a person’s ability to function in everyday life. Treatments may include dialectical behavior therapy, long-term psychotherapy and medication.2 There is evidence that people with personality disorders can improve and become more able to manage their symptoms with the proper treatment.
There is no clear cause of personality disorders, but it is widely accepted that both genetic inheritance as well as early attachment issues are likely to blame.3 Other environmental factors beyond attachment may also be at work, but this is unclear.
Types of Personality Disorders
There are thirteen diagnosable personality disorders in the DSM-5. They are organized into three categories or “clusters” of disorders sharing similar symptoms in individuals suffering from personality disorders.
Cluster A includes paranoid personality disorder, schizoid personality disorder and schizotypal personality disorder. Cluster B includes antisocial personality disorder, borderline personality disorder, histrionic personality disorder, and narcissistic personality disorder. Cluster C includes avoidant personality disorder, dependent personality disorder, and obsessive-compulsive disorder.
Also included in the DSM-5 for personality disorders are personality disorders due to another medical condition, other personality disorder specified, and other personality disorder unspecified.
Paranoid Personality Disorder
Identified by a “pervasive and unwarranted” mistrust of others, sensitivity to criticism, aggressiveness, rigidity, hypervigilance, and excessive need for autonomy.”4 Fear that others are plotting to cause the patient harm is a distinguishing characteristic with paranoid personality disorder.
Schizoid Personality Disorder
Schizoid personality disorder is characterized by three factors: Social detachment, withdrawal from the business of life, and restricted affect.5 Lacking the ability to experience pleasure, known as anhedonia, is included here as well.
Some have argued that this disorder should not have been included in the DSM-5 because of problems with consistency in the diagnostic process.5 However, these calls were not heeded and, for now, it is included in the current DSM.
Schizotypal Personality Disorder
As opposed to schizoid personality disorder where individuals are “detached” in their relationships, schizotypal individuals exhibit eccentric behaviors and display distortions and discomfort in their social relationships.6 These patients are seen as peculiar by others and their odd language, eccentric habits, and peculiar rituals are quite noticeable to friends, co-workers, and family.
Antisocial Personality Disorder
Most people who are mentally ill are not dangerous, but some can be. Perhaps among the most potentially dangerous people with personality disorders are those with antisocial personality disorder. Characterized by a “repetitive irresponsible, delinquent, and criminal behavior,”7 people with this diagnosis are “users.” They use others for their own gain and have no concern for the rights of other people.
In the process of using others, they may use up other people’s time, steal their money, impede their happiness, and even take the lives of others for their own pleasure. Individuals with this diagnosis might be lazy, taking advantage of free rent from friends, cut-throat business persons or politicians, or rapists and serial killers.8
Not all people with personality disorders are violent, but violence is a common symptom in this condition.9 Substance abuse is also common among those with antisocial personality disorder. In earlier days in mental health before the DSM-5, individuals with this disorder were sometimes referred to as psychopaths or sociopaths.
Borderline Personality Disorder
Borderline personality disorder is characterized by unstable relationships, self-image issues, and impulsive behaviors. This disorder nearly always brings with it a host of other problems. Among those problems are eating disorders, mood disorders, suicidal ideation, self-harm, substance abuse, impulsivity, and aggression. Up to 75% of these patients attempt suicide and approximately 10% succeed.10 In these patients, relationships at home, work, and in social arenas are marked by intense emotional distress.
Histrionic Personality Disorder
Histrionic personality disorder is sometimes called dramatic personality disorder because these individuals’ lives are characterized by drama. As is true with narcissism, individuals with histrionic personality disorder have an intense need to be the center of attention, but with this condition, they are not particular about how they get that attention.
Also unique to this disorder are emotionality, being sexually tempting, and sexually provocative behavior.11 Histrionic personality disorder is more often diagnosed in women than in men,12 although it is argued that this data is possibly caused by measurement issues rather than an actual gender difference.
Narcissistic Personality Disorder
Characterized by grandiose self-thoughts and high need for admiration, narcissistic personality disorder is named after the Greek mythological character Narcissus. This character admired his own reflection in a pool of water so much that he fell in and drowned. These individuals are seen across the social spectrum—introverts, extroverts, loners, social butterflies, model citizens, and anti-social individuals.2 They are entitled, lack empathy, and are sensitive to any suggestion that they are not extraordinary. As with all personality disorders, other issues are often seen in these persons: Depression, anxiety, substance abuse, suicide, and self-injury.2
Avoidant Personality Disorder
As with schizotypal personality disorders, those with avoidant personality disorder have challenges in social relationships. Individuals are inhibited when it comes to social functioning and, like other personality disorders, experience feelings of inadequacy and, consequently, can be hypersensitive to criticism.13 These patients are more likely to appear quiet and shy than those with schizotypal personality disorder.
Dependent Personality Disorder
Dependent personality disorder is noted by a high need to be taken care of, an inability to be alone, submissiveness, fear of rejection, and clinginess.1 Persons with this disorder are easily wounded by criticism and will go to great lengths to please others indiscriminately.
Personality Disorder Due to Another Medical Condition
This category addresses social, interpersonal, and/or occupational impairment due to personality issues that have a medical condition as the clear source.
Even though it is generally accepted that personality disorders have, at least in part, a genetic base, changes in personality are not uncommon among individuals with brain trauma, stroke, or head injury. This is sometimes referred to as acquired brain injury. This is especially true if damage occurs to the frontal or temporal lobes.16
The well-known case of Phineas Gage provides an example of this. Gage, a railroad worker in the 1848, suffered a brain injury when an accidental explosion sent a tamping iron through his skull. Surprisingly, the severe damage to his frontal lobe didn’t kill Phineas Gage, but it left him with a personality change that persisted for the rest of his life.17 This case marked the beginning of understanding the effects of brain injury on personality.
Other Specified Personality Disorder and Unspecified Personality Disorder
Many mental health classifications have a “not otherwise specified” (NOS) diagnosis. NOS diagnoses exist for situations in which a patient’s symptoms appear to be consistent with a general diagnosis (e.g. anxiety), but do not meet the specific criteria for that disorder. In other words, in the opinion of the clinician, there was sufficient evidence for the existence of the general disorder, but not enough for a specific disorder within that category.
These final two classifications are for situations in which the clinician has identified a personality disorder, but the criteria are not met for any specific personality disorder. These two options differ only in the identification of why the symptoms don’t meet any specific disorder (in the case of specified personality disorder), or no reason is given in the case of unspecified personality disorders.
Personality Disorder Symptoms
The symptoms of personality disorders vary, but the general indicator is a marked impairment in interpersonal relationships. Personality disorders are identified by one of three general groups of behavioral symptoms called “clusters.” In Cluster A, the disorders are characterized by odd or eccentric behaviors. Cluster B is characterized by dramatic, emotional, and erratic behavior, and Cluster C is characterized by anxiousness and fearfulness.1
Because personality disorders may have a genetic link, symptoms are likely present even in early childhood. However, is it difficult to distinguish between symptoms of a personality disorder from the normal developmental behaviors of childhood. It is not unusual for normal children to be dramatic or emotional, for example. Therefore, clear symptoms typically begin to distinguish themselves in adolescence.18 By adulthood, these patterns of behavior have nearly always resulted in problems with family, friends, social groups, and work.
Persons with personality disorder will exhibit problems in:
- Thinking processes
- Interpersonal Relationships
- Impulse control19
Challenges in these areas are not uncommon in the normal population as well as in other psychological disorders. For individuals with personality disorders, however, these problems are intrusive and cause significant impairment in the ability to conduct the business of life.
There is a strong relationship between personality disorders and other psychiatric disorders. This is called “comorbidity,” and common comorbid diagnoses include depression, anxiety, and substance abuse, to name a few.20
Many people with personality disorders exhibit problems with:
- Self harm
- Suicidal thinking
- Suicidal threats and behaviors
- Eating disorders
- Substance abuse
- Mood disorders
- Anxiety disorders
In order to be treated correctly, the disorder has to be properly diagnosed. It has been noted that because of the multiple problems these patients often have, personality disorders might be overlooked and treatments for tangential issues might be ineffective or even harmful.21 This means that while a person may show symptoms of depression, therapeutically addressing depression alone would be ineffective if the underlying cause is a personality disorder. Attention to both may be needed.
Instruments that measure personality, like the MMPI-2, have been found to be useful in identifying personality disorders, but most general practitioners do not, or cannot, use these instruments.22 This leaves proper diagnosis in the hands of an experienced clinician with expertise in differential diagnostics.
Treatments for Personality Disorders
There is little argument among mental health practitioners that personality disorders of all types are difficult to diagnose and treat. While “persistent disorder” or “genetic in cause” sounds ominous, there is evidence that patients with personality disorders can improve. In fact, it has been demonstrated that these patients can improve even more than subjects with mood disorders.23
While there are many different approaches to treatment of personality disorders, there are few empirical studies that supported one therapy over another.24 Treatment options also vary depending on which disorder is diagnosed.
Generally, treatments for personality disorders include the following:
- Psychodynamic therapy
- Cognitive Behavioral Therapy
- Behavioral Training
- Behavioral activation
- Dialectical Behavior Therapy
Effective treatment of personality disorders may require more than one professional intervention (e.g. a therapist and a physician to prescribe medication), but professionals who may be qualified to treat personality disorders include:
- General practitioners
- Professional counselors
- Licensed clinical social workers
The costs of treating personality disorders is higher than other common disorders such as depression or generalized anxiety disorder. Between direct patient care costs (e.g. therapy) and indirect costs (lost wages), one study in Great Britain indicated costs per patient to be around $15,000 per year.25 That study was conducted over ten years ago, so with inflation one can expect the costs are even higher today.
There is a difference between being “cured” and making progress or improvements. Personality disorders can be managed and progress can be made, but by definition “full recovery” has not been clearly demonstrated.
When to Seek Professional Help
Many people go through life with symptoms from a variety of disorders— depression, anxiety, phobias, or even personality disorders. Seeking help is necessary when the symptoms of any disorder impairs one’s ability to function.
Intervention may be needed if one has difficulty or an inability to:
- Get out of bed
- Go to school or work
- Manage and complete tasks while at school or work
- Manage stress
- Engage in healthy social and intimate relationships
- Pay one’s bills/manage money
- Find pleasure in life
Personality Disorder Statistics
Personality disorders are quite common. While numbers vary, it is widely believed that between 4-7% of the general population suffer from personality disorders.26 Some studies show those percentages even higher, hovering just under 10%.27
Among specific populations the numbers are staggering. Studies have shown that among incarcerated individuals, over half have been diagnosed with a personality disorder.28 In fact, “personality disorders are the most common form of psychopathology in forensic settings [50-90%].”28
In hospitalized patients the prevalence of personality disorders has been shown at 30%, and among those in primary care, personality disorders appear in about 25% of the population.29
Of the different types of personality disorders, OCPD, narcissistic, and borderline disorders appear most often at about 7-9% in frequency,27 while histrionic personality disorder and dependent personality disorders are the least common at about 1.8% and .5% of the population, respectively.30
Personality Traits vs Personality Disorders
Personality traits are observable traits people are born with. Some traits are quite normal, like introversion or extroversion. Unlike normal characteristics, personality disorders are marked by behaviors and attitudes that cause significant problems in one’s relationships and occupational functioning.18
Because these disorders are believed to be linked to genetics, at least in many cases, personality disorders, like personality traits (introversion and extroversion), are things a person can’t change. However, one can learn to manage personality traits, such as introversion, even though the trait can’t be “cured.” For example, an introvert can learn to be an effective public speaker, but she is still an introvert.
The same can be said of people with personality disorders. If it is indeed genetic, the trait may exist throughout the person’s life, but there are interventions, like therapy and medication, that can help manage its effects.
History of Personality Disorders
Observations of what we call personality have been around for centuries. As early as the first millennium, Greek philosophers noted different types of “character.” It wasn’t until the 18th century, however, that personality and its abnormalities were studied in an organized way. By the late 19th and early 20th century, researchers were beginning to systematically identify and study abnormal personalities.31
Inclusion of personality disorders appeared for the first time in the DSM II in 1968. In the current version of the DSM, the DSM-5, there are thirteen specific personality disorders that can be identified, and the DSM organizes them into three global categories called clusters.
Therefore, the majority of what is known about personality disorders is quite recent, and the diagnosis and treatment of these disorders is still in its infancy. A lot is known, but there are just as many questions about personality disorders as there are answers.
Future Directions on Personality Disorders
Research in the arena of personality disorders must focus on the causes of the disorder. Genetics, abuse or neglect in early childhood, bonding issues, and brain injury are all areas that have been demonstrated as possible causes of personality disorders. But there is no clear single cause and it is unknown which, if any, of these causes are most common. As is true with any young area of science, there are likely even other causes for personality disorders that are as yet unidentified.
Future research must also focus on the effectiveness of therapeutic treatments for those with personality disorders. Current opinions on treatment range from those who believe the disorder can only be managed to those who believe it can be completely cured. Evidence exists for both ends of the continuum. Which treatments are most effective for which disorder also needs further study.
Research must investigate the role of brain chemistry, hormones and neurotransmitters, and the role of chemicals in personality disorders. If these disorders are caused by brain chemistry, medication will most likely be a central focus in treatment plans for persons with personality disorders.