Personality Disorders

According to the American Psychiatric Association, a personality disorder is a way of thinking, feeling, and behaving that deviates from the expectations of the culture, causes distress or problems functioning, and lasts over time.  There are 10 specific types of personality disorders.

Personality disorders affect at least two of these areas:

• Way of thinking about oneself and others
• Way of responding emotionally
• Way of relating to other people
• Way of controlling one’s behavior

Personality disorders occur in 10 to 20 percent of the general population, and they can last for decades. A personality disorder is also a predisposing factor for other psychiatric disorders, such as substance abuse, suicide, affective disorders, impulse-control disorders, eating disorders, and anxiety disorders. Individuals with personality disorders are far more likely to refuse psychiatric help and to deny their problems than persons with other mental health conditions. That’s because they are not concerned about their maladaptive behavior.

Personality disorders are generally divided into three subtypes (or clusters) and include the following:

Cluster A – Odd/Eccentric

• Paranoid Personality Disorder
• Schizoid Personality Disorder
• Schizotypal Personality Disorder

Cluster B – Dramatic/Erratic

• Borderline personality disorder
• Antisocial personality disorder
• Narcissistic personality disorder
• Histrionic personality disorder

Cluster C – Anxious/Inhibited

• Dependent Personality Disorder
• Avoidant Personality Disorder
• Obsessive-compulsive Personality Disorder

There is evidence that genetics plays a role in personality disorders and associated mental health problems. For example, an antisocial personality disorder is associated with alcohol abuse. Depression is common in the family background of individuals with a borderline personality disorder. People with an avoidant personality disorder often have high anxiety levels.

A diagnosis of “general personality disorder” is given to an individual with an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the person’s culture. The disorder is demonstrated in two or more of the following areas:

• Cognition (i.e., ways of perceiving and interpreting self, other people, and events)
• Affectivity (i.e., the range, intensity, range, and appropriateness of emotional response).
• Interpersonal functioning.
• Impulse control.

The longstanding pattern can be traced back at least to adolescence or early adulthood. The enduring pattern is inflexible and pervasive across a broad range of personal and social situations. The pattern leads to significant distress or impairment in social, occupational, or other important areas of functioning. The disorder is not related to another mental disorder and is not attributable to the physiological effects of a substance (e.g., a drug of abuse or medication) or another medical condition (e.g., head trauma).

“Paranoid personality disorder” is a pervasive distrust and suspiciousness of others such that their motives are interpreted as malevolent. The disorder begins by early adulthood with four or more of the following:

• Suspects, without sufficient basis, that others are exploiting, harming, or deceiving him or her.
• Is preoccupied with unjustified doubts about the loyalty or trustworthiness of friends or associates.
• Is reluctant to confide in others because of unwarranted fear that the information will be used maliciously against him or her.
• Reads hidden demeaning or threatening meanings into benign remarks or events.
• Persistently bears grudges (i.e., is unforgiving of insults, injuries, or slights).
• Perceives attacks on his or her character or reputation that are not apparent to others and is quick to react angrily or to counterattack.
• Has recurrent suspicions, without justification, regarding fidelity of their spouse or sexual partner.
  
  

The pattern does not occur exclusively during the course of schizophrenia, a bipolar disorder or depressive disorder with psychotic features, or another psychotic disorder. The disorder is not attributable to the physiological effects of another medical condition.

“Schizoid personality disorder” is a pervasive pattern of detachment from social relationships and a restricted range of expression of emotions in interpersonal settings. The disorder begins by early adulthood and is demonstrated by four or more of the following:

• Neither desires nor enjoys close relationships, including being part of a family.
• Almost always chooses solitary activities.
• Has little, if any, interest in having sexual experiences with another person.
• Takes pleasure in few, if any, activities.
• Lacks close friends or confidants other than first-degree relatives.
• Appears indifferent tothe praise or criticism of others.
• Shows emotional coldness, detachment, or flattened affectivity.

The symptoms do not occur exclusively during the course of schizophrenia, a bipolar disorder or depressive disorder with psychotic features, another psychotic disorder, or autism spectrum disorder. The disorder is not attributable to the physiological effects of another medical condition.

“Schizoid personality disorder” is a pervasive pattern of social and interpersonal deficits marked by acute discomfort with, and reduced capacity for, close relationships as well as by cognitive or perceptual distortions and eccentricities of behavior. The disorder begins by early adulthood and is indicated by five or more of the following:

• Ideas of reference (delusions that irrelevant occurrences in the world relate directly to oneself).
• Odd beliefs or magical thinking that influences behavior and is inconsistent with subcultural norms (e.g., superstitiousness, belief in clairvoyance, telepathy or “sixth sense”; in children and adolescents, bizarre fantasies or preoccupations.
• Unusual perceptual experiences, including bodily illusions.
• Odd thinking and speech (e.g., vague, circumstantial, metaphorical, overelaborate, or stereotyped).
• Suspiciousness or paranoid ideation.
• Inappropriate or constricted affect.
• Behavior or appearance that is odd, eccentric, or peculiar.
• Lack of close friends or confidants other than first-degree relatives.
• Excessive social anxiety does not diminish with familiarity and tends to be associated with paranoid fears rather than negative judgments about self.

The symptoms do not occur exclusively during the course of schizophrenia, a bipolar disorder or depressive disorder with psychotic features, another psychotic disorder, or autism spectrum disorder.

“Antisocial personality disorder” is a pervasive pattern of disregard for and violation of the rights of others, occurring since the age of 15, as indicated by three or more of the following:

• Failure to conform to social norms with respect to lawful behaviors, as indicated by repeatedly performing acts that are grounds for arrest.
• Deceitfulness, as indicated by repeated lying, use of aliases, or conning others for personal profit or pleasure.
• Impulsivity or failure to plan ahead.
• Irritability and aggressiveness, as indicated by repeated physical fights or assaults.
• Reckless disregard for safety of self or others.
• Consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or to honor financial obligations.
• Lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another.

A diagnosis of an antisocial personality disorder requires that the individual is at least 18 years of age and has no evidence of a conduct disorder before the age of 15. The occurrence of antisocial behavior is not exclusively during the course of schizophrenia or bipolar disorder.

“Borderline personality disorder” is a pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity. The disorder begins by early adulthood and is indicated by five or more of the following:

• Frantic efforts to avoid real or imagined abandonment.
• A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and evaluation.
• Markedly and persistently unstable self-image or sense of self.
• Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating).
• Recurrent suicidal behavior, gestures, threats, or self-mutilating behavior.
• Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days).
• Chronic feelings of emptiness
• Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights).
• Transient, stress-related paranoia or severe dissociative symptoms.

“Histrionic personality disorder” is a pervasive pattern of excessive emotionality and attention-seeking, beginning by early adulthood. It is indicated by five or more of the following:

• Is uncomfortable in situations in which he or she is not the center of attention.
• Interaction with others is often characterized by inappropriate sexually seductive or provocative behavior.
• Displays rapidly shifting and shallow expression of emotions.
• Consistently uses physical appearance to draw attention to self.
• Has a style of speech that is excessively impressionistic and lacking in detail.
• Shows self-dramatization, theatricality, and exaggerated expression of emotion.
• Is suggestible (i.e., easily influenced by others or circumstances).
• Considers relationships to be more intimate than they actually are.

“Narcissistic personality disorder” is a pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy. The disorder begins by early adulthood and is indicated by five or more of the following:

• Has a grandiose sense of self-importance (e.g., exaggerates achievements and talents, expects to be recognized as superior without commensurate achievements).
• Is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love.
• Believes that he or she is “special” and unique and can only be understood by, or should associate with, other special or high-status people (or institutions).
• Requires excessive admiration.
• Has a sense of entitlement (i.e., unreasonable expectations of especially favorable treatment or automatic compliance with his or her expectations).
• Is interpersonally exploitative (i.e., unreasonable expectations of especially favorable treatment or automatic compliance with his or her expectations).
• Lacks empathy: is unwilling to recognize or identify with the feelings and needs of others.
• If often envious of others or believes that others are envious of him or her.
• Shows arrogant, haughty behaviors or attitudes.

“Avoidant personality disorder” is a pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation, beginning by early adulthood. The patterns is indicated by four or more of the following:

• Avoids occupational activities that involve significant interpersonal contact because of fears of criticism, disapproval, or rejection.
• Is unwilling to get involved with people unless certain of being liked.
• Shows restraint within intimate relationships because of the fear of being shamed or ridiculed.
• Is preoccupied with being criticized or rejected in social situations.
• Is inhibited in new interpersonal situations because of feelings of inadequacy.
• Views self as socially inept, personally unappealing, or inferior to others.
• Is unusually reluctant to take personal risks or to engage in any new activities because they may prove embarrassing.

“Dependent personality disorder” is a pervasive and excessive need to be taken care of that leads to submissive and clinging behavior and fears of separation. The disorder begins by early adulthood and is indicated by five or more of the following:

• Has difficulty making everyday decisions without an excessive amount of advice and reassurance from others. Needs others to assume responsibility for most major areas of his or her life.
• Has difficulty expressing disagreement with others because of fear of loss of support or approval.
• Has difficulty initiating projects or doing things on his or her own (because of a lack of self-confidence in judgment or abilities rather than a lack of motivation or energy).
• Goes to excessive lengths to obtain nurturance and support from others to the point of volunteering to do things that are unpleasant.
• Feels uncomfortable or helpless when alone because of exaggerated fears of being unable to care for himself or herself.
• Urgently seeks another relationship as a source of care and support when a close relationship ends.
• Is unrealistically preoccupied with fears of being left to take care of himself or herself.

“Obsessive-compulsive personality disorder” is a pervasive pattern of preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness and efficiency. The disorder begins by early adulthood and is indicated by four or more of the following:

• Is preoccupied with details, rules, lists, order, organization, or schedules to the extent that the major point of the activity is lost.
• Shows perfectionism that interferes with task completion (e.g., is unable to complete a project because his or her own overly strict standards are not met).
• Is excessively devoted to work and productivity to the exclusion of leisure activities and friendships (not accounted for by obvious economic necessity).
• Is overconscientious, scrupulous, and inflexible about matters of morality, ethics, or values (not accounted for by cultural or religious identification).
• Is unable to discard worn-out or worthless objects even when they have no sentimental value.
• Is reluctant to delegate tasks or to work with others unless they submit to exactly his or her way of doing things.
• Adopts a miserly spending style toward both self and others; money is viewed as something to be hoarded for future catastrophes.
• Shows rigidity and stubbornness.

Yes. In fact, there is a diagnosis for “personality change due to another medical condition.” This diagnosis is based on a persistent personality disturbance that represents a change from the individual’s previous characteristic personality. There must be evidence from the history, physical examination, or laboratory findings that the disturbance is the direct consequence of another medical condition. The change in personality is not better explained by another mental disorder, and it does not occur exclusively during the course of a delirium. The diagnosis also requires that the disturbance causes significant distress or impairment in social, occupational, or other important areas of functioning.

Yes, a person can receive a diagnosis for a personality disorder that falls into the category of “other specified personality disorder” or “unspecified personality disorder.” Either one of these categories applies when an individual has symptoms characteristic of a personality disorder that cause significant distress or impairment in daily life but the symptoms do not meet the full criteria for any specific personality disorder diagnosis. The “other specified” personality disorder diagnosis may be given when there are mixed personality features from different categories. The “unspecified” diagnosis may be given when there is insufficient information to make a more specific diagnosis.

Specific treatment for each personality disorder is based on each individual’s age, overall health, and medical history. Personality disorders are often challenging to treat. They may need long-term attention to change the inappropriate behavior and thought patterns. Treatment will often involve psychotherapy (talk therapy) and include family involvement. Medication is often useful in dealing with anxiety, depression, mood swings, rage, hostility, and brief psychotic episodes.