Personality disorder

Personality disorders
SpecialtyPsychiatry; clinical psychology
Frequency9–15%[1]

Personality disorders (PD) are a class of mental disorders characterized by enduring maladaptive patterns of behavior, cognition, and inner experience, exhibited across many contexts and deviating from those accepted by the individual's culture. These patterns develop early, are inflexible, and are associated with significant distress or disability. The definitions may vary somewhat, according to source.[2][3][4] Official criteria for diagnosing personality disorders are listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM) and the fifth chapter of the International Classification of Diseases (ICD).

Personality, defined psychologically, is the set of enduring behavioral and mental traits that distinguish individual humans. Hence, personality disorders are defined by experiences and behaviors that differ from social 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% of psychiatric patients, making them the most frequent of psychiatric diagnoses.[5]

Personality disorders are characterized by an enduring collection of behavioral patterns often associated with considerable personal, social, and occupational disruption. Personality disorders are also inflexible and pervasive across many situations, largely due 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 and may lead to personal problems that induce extreme anxiety, distress, or depression. These behaviour patterns are typically recognized in adolescence, the beginning of adulthood or sometimes even childhood and often have a pervasive negative impact on the quality of life.[2][6][7]

Many issues occur with classifying a personality disorder. 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]

Classification

The two relevant major systems of classification are

Both 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.[9]

General criteria

Both diagnostic systems provide a definition and six criteria for a general personality disorder. These criteria should be met by all personality disorder cases before a more specific diagnosis can be made.

The ICD-10 lists these general guideline criteria:[10]

  • Markedly disharmonious attitudes and behavior, generally involving several areas of functioning; e.g. affectivity, arousal, impulse control, ways of perceiving and thinking, and style of relating to others;
  • The abnormal behavior pattern is enduring, of long standing, and not limited to episodes of mental illness;
  • The abnormal behavior pattern is pervasive and clearly maladaptive to a broad range of personal and social situations;
  • The above manifestations always appear during childhood or adolescence and continue into adulthood;
  • The disorder leads to considerable personal distress but this may only become apparent late in its course;
  • The disorder is usually, but not invariably, associated with significant problems in occupational and social performance.

The ICD adds: "For different cultures it may be necessary to develop specific sets of criteria with regard to social norms, rules and obligations."[10]

In DSM-5, any personality disorder diagnosis must meet the following criteria:[11]

  • An enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture. This pattern is manifested in two (or more) of the following areas:
  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.
  • The enduring pattern is inflexible and pervasive across a broad range of personal and social situations.
  • The enduring pattern leads to clinically significant distress or impairment in social, occupational, or other important areas of functioning.
  • The pattern is stable and of long duration, and its onset can be traced back at least to adolescence or early adulthood.
  • The enduring pattern is not better explained as a manifestation or consequence of another mental disorder.
  • The enduring pattern is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., head trauma).

In ICD-10

Chapter V in the ICD-10 contains the mental and behavioral disorders and 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.[12]

The specific personality disorders are: paranoid, schizoid, dissocial, emotionally unstable (borderline type and impulsive type), histrionic, anankastic, anxious (avoidant) and dependent.[13]

Besides the ten specific PD, there are the following categories:

  • Other specific personality disorders (involves PD characterized as eccentric, haltlose, immature, narcissistic, passive–aggressive, or psychoneurotic.)
  • Personality disorder, unspecified (includes "character neurosis" and "pathological personality").
  • 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).
  • 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).

In ICD-11

In the proposed revision of ICD-11, all discrete personality disorder diagnoses will be removed and replaced by the single diagnosis "personality disorder". Instead, there will be specifiers called "prominent personality traits" and the possibility to classify degrees of severity ranging from "mild", "moderate", and "severe" based on the dysfunction in interpersonal relationships and everyday life of the patient.[14][15]

In DSM-5

The most recent fifth edition of the Diagnostic and Statistical Manual of Mental Disorders stresses a personality disorder is an enduring and inflexible pattern of long duration leading to significant distress or impairment and is not due to use of substances or another medical condition. The DSM-5 lists personality disorders in the same way as other mental disorders, rather than on a separate 'axis', as previously.[16]

DSM-5 lists ten specific personality disorders: paranoid, schizoid, schizotypal, antisocial, borderline, histrionic, narcissistic, avoidant, dependent and obsessive-compulsive personality disorder.

The DSM-5 also contains three diagnoses for personality patterns not matching these ten disorders, but nevertheless exhibit characteristics of a personality disorder:[11]

  • Personality change due to another medical condition – personality disturbance due to the direct effects of a medical condition.
  • Other specified personality disorder – general criteria for a personality disorder are met but fails to meet the criteria for a specific disorder, with the reason given.
  • Unspecified personality disorder – general criteria for a personality disorder are met but the personality disorder is not included in the DSM-5 classification.

Personality clusters

The specific personality disorders are grouped into the following three clusters based on descriptive similarities:

Cluster A (odd or eccentric disorders)

Cluster A personality disorders are often associated with schizophrenia: in particular, schizotypal personality disorder shares some of its hallmark symptoms, e.g., acute discomfort in close relationships, cognitive or perceptual distortions, and eccentricities of behavior, with schizophrenia. However, people diagnosed with odd-eccentric personality disorders tend to have a greater grasp on reality than those diagnosed with schizophrenia. Patients suffering from these disorders can be paranoid and have difficulty being understood by others, as they often have odd or eccentric modes of speaking and an unwillingness and inability to form and maintain close relationships. Though their perceptions may be unusual, these anomalies are distinguished from delusions or hallucinations as people suffering from these would be diagnosed with other conditions. Significant evidence suggests a small proportion of people with Cluster A personality disorders, especially schizotypal personality disorder, have the potential to develop schizophrenia and other psychotic disorders. These disorders also have a higher probability of occurring among individuals whose first-degree relatives have either schizophrenia or a Cluster A personality disorder.[17]

Cluster B (dramatic, emotional or erratic disorders)

Cluster C (anxious or fearful disorders)

Other personality types

Some types of personality disorder were in previous versions of the diagnostic manuals but have been deleted. Examples include sadistic personality disorder (pervasive pattern of cruel, demeaning, and aggressive behavior) and self-defeating personality disorder or masochistic personality disorder (characterised by behaviour consequently undermining the person's pleasure and goals). They were listed in the DSM-III-R appendix as "Proposed diagnostic categories needing further study" without specific criteria.[19] 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.[20]

Personality disorder diagnoses in each edition of the Diagnostic and Statistical Manual[11][21]:17
DSM-I DSM-II DSM-III DSM-III-R DSM-IV(-TR) DSM-5
Inadequate[a] Inadequate Deleted[21]:19
Schizoid[a] Schizoid Schizoid Schizoid Schizoid Schizoid
Cyclothymic[a] Cyclothymic Reclassified[21]:16, 19
Paranoid[a] Paranoid Paranoid Paranoid Paranoid Paranoid
Schizotypal Schizotypal Schizotypal Schizotypal[b]
Emotionally unstable[c] Hysterical[21]:18 Histrionic Histrionic Histrionic Histrionic
Borderline[21]:19 Borderline Borderline Borderline
Compulsive[c] Obsessive-compulsive Compulsive Obsessive-compulsive Obsessive-compulsive Obsessive-compulsive
Passive-aggressive,
Passive-depressive subtype[c]
Deleted[21]:18 Dependent[21]:19 Dependent Dependent Dependent
Passive-aggressive,
Passive-aggressive subtype[c]
Passive-aggressive Passive-aggressive Passive-aggressive Negativistic[21]:21
Passive-aggressive,
Aggressive subtype[c]
Explosive[21]:18 Deleted[21]:19
Asthenic[21]:18 Deleted[21]:19
Avoidant[21]:19 Avoidant Avoidant Avoidant
Narcissistic[21]:19 Narcissistic Narcissistic Narcissistic
Antisocial reaction[d] Antisocial Antisocial Antisocial Antisocial Antisocial
Dyssocial reaction[d]
Sexual deviation[d] Reclassified[21]:16, 18
Addiction[d] Reclassified[21]:16, 18
Appendix
Self-defeating Negativistic Dependent
Sadistic Depressive Histrionic
Paranoid
Schizoid
Negativistic
Depressive
  1. ^ a b c d DSM-I Personality Pattern disturbance subsection.[21]:16
  2. ^ Also classified as a schizophrenia-spectrum disorder in addition to personality disorder.
  3. ^ a b c d e DSM-I Personality Trait disturbance subsection.[21]:16
  4. ^ a b c d DSM-I Sociopathic personality disturbance subsection.[21]:16

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[20]:4
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. 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.[22][unreliable medical source?]
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.[23]
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.[24]
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.[25][unreliable medical source?]
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.[26][unreliable medical source?]
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.[27][unreliable medical source?]
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.
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.[28][unreliable medical source?]
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.[29][unreliable medical source?]
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.[30][unreliable medical source?]
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.[31][unreliable medical source?]
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.[32][unreliable medical source?]
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 suspicious of people who treat them well. Would likely engage in a sadomasochist relationship.[32][unreliable medical source?]

Additional factors

In addition to classifying by category and cluster, it is possible to classify personality disorders using additional factors such as severity, impact on social functioning, and attribution.[33]

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[34]
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:[33]

  • It not only allows for but also takes advantage of the tendency for personality disorders to be comorbid with each other.
  • It represents the influence of personality disorder on clinical outcome more satisfactorily than the simple dichotomous system of no personality disorder versus personality disorder.
  • This system accommodates the new diagnosis of severe personality disorder, particularly "dangerous and severe personality disorder" (DSPD).

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.[35] The Personality Assessment Schedule[36] 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.[33] 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.[37]

Other Languages
беларуская (тарашкевіца)‎: Разлад асобы
한국어: 인격장애
Кыргызча: Психопатия
مازِرونی: اختلال شخصيت
Simple English: Personality disorder
slovenčina: Porucha osobnosti
slovenščina: Osebnostna motnja
Soomaaliga: Khalkhal
Tiếng Việt: Rối loạn nhân cách
中文: 人格障礙