Personality Disorder

What is personality?

According to the American Psychology Association, personality refers to the unique thinking, feeling, and behaving patterns that are unique to each one of us. It is developed during our childhood and influenced by a wide range of experiences, environments, and genes.

When is it considered a disorder?

Personality disorders are considered as a group of mental disorder; therefore, they consist of unhealthy and inflexible patterns that apply to ones thinking, functioning and behaving, making it very different for the average person. The unhealthy patterns are long-lasting, causing distress and impact the individuals functioning. These disorders tend to start during teenage years or early adulthood, although the causes are unknown, it is believed that one’s genes and childhood experiences play a significant role. Symptoms can be mild or severe and may vary according to the type of personality disorder that is presented, since each have their own diagnostics criteria. However, in order to be diagnosed with any of them, it has to affect at least two of the following areas:

• The way one thinks about themselves and others
• The way one responds emotionally
• The way one relates with other people
• Capacity to control ones behavior

Types of personality disorder

Personality disorders are divided into groups according to characteristics they share between them, and these are called clusters. There are three main clusters:

• Cluster A -> these personality disorders are characterized by an odd and eccentric type of thinking or behavior
  • Paranoid personality disorder
  • Schizoid personality disorder
  • Schizotypal personality disorder
• Cluster B -> these personality disorders are characterized by a theatrical, exceedingly emotional or unpredictable thinking or behavior
  • Antisocial personality disorder
  • Borderline personality disorder
  • Histrionic personality disorder
  • Narcissistic personality disorder
• Cluster C -> these personality disorders are characterized by anxious and fearful thinking or behavior
  • Avoidant personality disorder
  • Dependent personality disorder
  • Obsessive-compulsive personality disorder

Treatment

The treatment required depends on the particular personality disorder which is present and the severity of the case. Since the patterns associated with each personality disorder are persistent and established, treatment may last months or years. Most of the time, a team approach is required in order to meet the person´s psychological, medical and social needs; such team can include: a care provider such as a primary doctor, a psychiatrist and a psychologist/psychotherapist (in other cases it can involve a psychiatric nurse, a pharmacist and/or a social worker). Regarding the psychologist and psychotherapy, the most common approaches that have demonstrated to be efficient with personality disorders are: psychoanalytic/psychodynamic, dialectic behavior, cognitive behavioral and group therapy – sometimes psychoeducation is used to involve the family and the individual in order to teach them about the disorder, coping mechanisms and possible treatments.

Cluster A

This cluster contains personality disorders characterized by an odd and eccentric type of thinking and behavior, therefore, here we can find the paranoid, schizoid and schizotypal personality disorders.

Paranoid personality disorder. They seem distrustful and suspicious of others and their motives. According to the DSM 5 (American Psychiatric Association, 2013, p.649), 4 or more of the following criteria must be met in order to be diagnosed with this personality disorder:

• Suspicious, without sufficient basis, that others are exploiting, harming, or deceiving.
• 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.
• Reads hidden meaning or threats 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 spouse or sexual partner.

Schizoid personality disorder. Can show little interest on establishing personal relationships or being involved in social interactions. Being detached from social relationships and showing only a restricted range of emotional expressions can generate trouble interpreting social cues. According to the DSM 5 (American Psychiatric Association, 2013, p.652-653), 4 or more of the following criteria must be met in order to be diagnosed with this personality disorder:

• 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 to the praise or criticism of others.
• Shows emotional coldness, detachment, or flattened affectivity.

Schizotypal personality disorder. They can believe that they are able to influence other people or external events through their thoughts. These type of cognitive and perceptual distortions and eccentricities of behavior can lead to social and interpersonal deficits, which include a distinct acute discomfort or inappropriate emotional responses and lead to an avoidance if intimate relationships. According to the DSM 5 (American Psychiatric Association, 2013, p.655-656), 4 or more of the following criteria must be met in order to be diagnosed with this personality disorder:

• Ideas of reference (excluding delusions of reference)
• 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.

Cluster B

This cluster contains personality disorders characterized by a theatrical, exceedingly emotional or unpredictable thinking or behavior; here, we find the antisocial, borderline, histrionic and narcissistic personality disorders.

Antisocial personality disorder. They tend to show a pattern of disregarding or violating the rights of others, through manipulation or threats, without showing remorse for their actions. Moreover, they can engage in dishonest behavior such as lying and stealing, and may not conform to social norms by acting impulsively. According to the DSM 5 (American Psychiatric Association, 2013, p.659), the person must be at least 18 years old, show evidence if conduct disorder before the age of 15 and meet 3 or more of the following criteria in order to be diagnosed with this personality disorder:

• 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, using of aliases, or conning other for personal profit pr pleasure.
• Compulsivity 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 honor financial obligations.
• Lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another.

Borderline personality disorder. They show an unstable pattern in personal relationships, intense emotions, poor self-image and impulsivity. They often have an ongoing feeling of emptiness and abandonment regardless of the actual support they have, therefore, they may go to great lengths to avoid being abandoned (including repeated suicide threats or attempts). According to the DSM 5 (American Psychiatric Association, 2013, p.663), 5 or more of the following criteria must be met in order to be diagnosed with this personality disorder:

• Frantic efforts to avoid real or imagined abandonment.
• A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealizing and devaluation.
• Identity disturbance: 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, or 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 feeling if emptiness.
• Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights).
• Transient, stress-related paranoid ideation or severe dissociative symptoms.

Histrionic personality disorder. They tend to show a pattern of excessive emotion and attention seeking, they are usually uncomfortable when they are not the center of attention and frequently try to gain more attention by being dramatic or provocative. Also, they are sensitive to and easily influenced by criticism and disapproval. According to the DSM 5 (American Psychiatric Association, 2013, p.667), 5 or more of the following criteria must be met in order to be diagnosed with this personality disorder:

• 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 expressions of emotions.
• 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. They have a pattern characterized by the need for admiration and lack of empathy for others. They often believe they are more important than others, showing a grandiose sense of self-importance and entitlement by exaggerating their achievements and bragging. According to the DSM 5 (American Psychiatric Association, 2013, p.669-670), 5 or more of the following criteria must be met in order to be diagnosed with this personality disorder:

• 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., takes advantage of others to achieve his or her own ends).
• Lacks empathy: is unwilling to recognize or identify with the feelings and needs of others.
• Is often envious of others or believes that others are envious of him or her.
• Shows arrogant, haughty behavior or attitudes.

Cluster C

This cluster contains personality disorders characterized by anxious and fearful thinking or behavior; therefore, here we can find the avoidant, dependent and obsessive-compulsive personality disorders.

Avoidant personality disorder. They show extreme shyness, feeling of inadequacy and sensitivity towards criticism. They are unwilling to get involved with people due to feelings of inferiority or unattractiveness, unless they are sure they will be liked; therefore, being criticized or rejected is a source of preoccupation. According to the DSM 5 (American Psychiatric Association, 2013, p.672-673), 4 or more of the following criteria must be met in order to be diagnosed with this personality disorder:

• Avoids occupational activities that involve significant interpersonal contact because of fear 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 feeling of inadequacy.
• Views self as socially inept, personally unappealing, or inferior to others.
• Is usually reluctant to take personal risks or to engage in any new activities because that may prove embarrassing.

Dependent personality disorder. They exclusively depend on other people to satisfy their needs, such as the emotional and physical, and they want to be taken care of and exhibit a submissive and clingy behavior. These attitudes makes it difficult for them to be alone or to take decisions without reassurance from others. According to the DSM 5 (American Psychiatric Association, 2013, p.675), 5 or more of the following criteria must be met in order to be diagnosed with this personality disorder:

• 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 initiating projects and doing things on his or her own (because of a lack of self-confidence in judgement 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. They express a preoccupation and overwhelming need for order, perfection and control, adhering themselves strictly to rules and regulations. It must be pointed out that this personality disorder is not the same as the obsessive-compulsive disorder. According to the DSM 5 (American Psychiatric Association, 2013, p.678-679), 4 or more of the following criteria must be met in order to be diagnosed with this personality disorder:

• 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 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 miserly spending style toward both self and others; money is viewed as something to be hoarded for future catastrophes.
• Shows rigidity and stubbornness.

References:

American Psychiatric Association. (2013). Diagnostic and Statistical Manual of mental Disorders (5th ed.). Arlington, VA: American Psychiatric Association Publishing.

American Psychological Association. (n.d.). Personality. American Psychological Association. Recovered from: https://www.apa.org/topics/personality

Carey, E. (2021). Personality Disorder. Healthline. Recovered from: https://www.healthline.com/health/personality-disorders

Mayo Clinic Staff. (2016). Personality disorders. Mayo Clinic. Recovered from: https://www.mayoclinic.org/diseases-conditions/personality-disorders/symptoms-causes/syc-20354463

MedlinePlus (2016). Personality disorders. Healthline. Recovered from: https://medlineplus.gov/personalitydisorders.html

Mental Health America (n.d.). Personality Disorders. Mental Health America. Recovered from: https://mhanational.org/conditions/personality-disorder

Mind. (n.d.). Personality disorders. Mind. Recovered from: https://www.mind.org.uk/information-support/types-of-mental-health-problems/personality-disorders/types-of-personality-disorder/

National Health Service. (2020). Personality disorders. National Health Service. Recovered from: https://www.nhs.uk/mental-health/conditions/personality-disorder/

Robitz, R. (2018). What are personality disorders?. American Psychiatric Association. Recovered from: https://www.psychiatry.org/patients-families/personality-disorders/what-are-personality-disorders