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Overview of Personality Disorders

By Lois Choi-Kain, MD

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Patient Education

Personality disorders in general are pervasive, enduring patterns of perceiving, reacting, and relating that cause significant distress or functional impairment. Personality disorders vary significantly in their manifestations, but all are believed to be caused by a combination of genetic and environmental factors. Many gradually become less severe with age, but certain traits may persist to some degree after the acute symptoms that prompted the diagnosis of a disorder abate. Diagnosis is clinical. Treatment is with psychosocial therapies and sometimes drug therapy.

Personality traits represent patterns of thinking, perceiving, reacting, and relating that are relatively stable over time.

Personality disorders exist when these traits become so pronounced, rigid, and maladaptive that they impair work and/or interpersonal functioning. These social maladaptations can cause significant distress in people with personality disorders and in those around them. For people with personality disorders (unlike many others who seek counseling), the distress caused by the consequences of their socially maladaptive behaviors is usually the reason they seek treatment, rather than any discomfort with their own thoughts and feelings. Thus, clinicians must initially help patients see that their personality traits are the root of the problem.

Personality disorders usually start to become evident during late adolescence or early adulthood, and their traits and symptoms vary considerably in how long they persist; many resolve with time.

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) lists 10 distinct types of personality disorders. Some types (eg, antisocial, borderline) tend to lessen or resolve as people age; others (eg, obsessive-compulsive, schizotypal) are less likely to do so.

About 10% of the general population and up to half of psychiatric patients in hospital units and clinics have a personality disorder. Overall, there are no clear distinctions in terms of sex, socioeconomic class, and race. However, in antisocial personality disorder, men outnumber women 6:1. In borderline personality disorder, women outnumber men 3:1 (but only in clinical settings, not in the general population).

For most personality disorders, levels of heritability are about 50%, which is similar to or higher than that of many other major psychiatric disorders. This degree of heritability argues against the common assumption that personality disorders are character flaws primarily shaped by an adverse environment.

The direct heath care costs and indirect costs of lost productivity associated with personality disorders, particularly borderline and obsessive-compulsive personality disorder, are significantly greater than similar costs associated with major depressive disorder or generalized anxiety disorder.

Types of Personality Disorders

DSM-5 groups the 10 types of personality disorders into 3 clusters (A, B, and C), based on similar characteristics. However, the clinical usefulness of these clusters has not been established.

Cluster A is characterized by appearing odd or eccentric. It includes the following personality disorders with their distinguishing features:

Cluster B is characterized by appearing dramatic, emotional, or erratic. It includes the following personality disorders with their distinguishing features:

  • Antisocial: Social irresponsibility, disregard for others, deceitfulness, and manipulation of others for personal gain

  • Borderline: Intolerance of being alone and emotional dysregulation

  • Histrionic: Attention seeking

  • Narcissistic: Underlying dysregulated, fragile self-esteem and overt grandiosity

Cluster C is characterized by appearing anxious or fearful. It includes the following personality disorders with their distinguishing features:

  • Avoidant: Avoidance of interpersonal contact due to rejection sensitivity

  • Dependent: Submissiveness and a need to be taken care of

  • Obsessive-compulsive: Perfectionism, rigidity, and obstinacy

Symptoms and Signs

According to DSM-5, personality disorders are primarily problems with

  • Self-identity

  • Interpersonal relationships

Self-identity problems may manifest as an unstable self-image (eg, people fluctuate between seeing themselves as kind or cruel) or as inconsistencies in values, goals, and appearance (eg, people are deeply religious while in church but profane and disrespectful elsewhere).

Interpersonal issues typically manifest as failing to develop or sustain close relationships and/or being insensitive to others (eg, unable to empathize).

People with personality disorders often seem inconsistent, confusing, and frustrating to people around them (including clinicians). These people may have difficulty knowing the boundaries between themselves and others. Their self-esteem may be inappropriately high or low. They may have inconsistent, detached, overemotional, abusive, or irresponsible styles of parenting, which can lead to physical and mental problems in their spouse or children.

People with personality disorders may not recognize that they have problems.

Diagnosis

  • Clinical criteria (DSM-5)

Once clinicians suspect a personality disorder, they evaluate cognitive, affective, interpersonal, and behavioral tendencies using specific diagnostic criteria. More sophisticated and empirically rigorous diagnostic tools are available for more specialized and academic clinicians.

Diagnosis of a personality disorder requires the following:

  • A persistent, inflexible, pervasive pattern of maladaptive traits involving ≥ 2 of the following: cognition (ways or perceiving and interpreting self, others, and events), affectivity, interpersonal functioning, and impulse control

  • Significant distress or impaired functioning resulting from the maladaptive pattern

  • Stability and early onset (during adolescence or early adulthood) of the pattern

Also, other possible causes of the symptoms (eg, other mental health disorders, substance use, head trauma) must be excluded.

For a personality disorder to be diagnosed in patients < 18 yr, the pattern must have been present for ≥ 1 yr, except for antisocial personality disorders, which cannot be diagnosed in patients < 18 yr.

Because many patients with a personality disorder lack insight into their condition, clinicians may need to obtain history from clinicians who have treated these patients previously, other practitioners, family members, friends, or others who have contact with them.

Treatment

  • Psychotherapy

The gold standard of treatment for personality disorders is psychotherapy. Both individual and group psychotherapy are effective for many of these disorders if the patient is seeking treatment and is motivated to change.

Typically, personality disorders are not very responsive to drugs, although some drugs can effectively target specific symptoms (eg, depression, anxiety).

Disorders that often coexist with personality disorders (eg, mood, anxiety, substance abuse, somatic symptom, and eating disorders) can make treatment challenging, lengthening time to remission, increasing risk of relapse, and decreasing response to otherwise effective treatment. For treatment recommendations for each disorder, see Table: Treatment of Personality Disorders.

Treatment of Personality Disorders

Diagnosis

Psychotherapy

Drugs

Paranoid

Supportive psychotherapy

Cognitive-behavioral therapy

Antidepressants

Atypical antipsychotics

Schizoid

Supportive psychotherapy

Social skills training

Schizotypal

Supportive psychotherapy

Social skills training

Cognitive-behavioral therapy for anxiety management

Antipsychotics

Antisocial*

Cognitive-behavioral therapy

Contingency management

Antidepressants (SSRIs)

Mood stabilizers (lithium, valproate)

Borderline

General psychiatric management and other structured clinical management approaches

Supportive psychotherapy

Dialectical behavioral therapy

Mentalization-based treatment

Transference focused psychotherapy

Schema-focused therapy

Systems training for emotional predictability and problem solving

Mood stabilizers (lamotrigine, topiramate) for mood symptoms, impulsivity, and anxiety

Atypical antipsychotics for transient psychotic symptoms and anger problems

Antidepressants (not harmful but limited efficacy)

Avoidance of benzodiazepines and stimulants

Histrionic

Psychodynamic psychotherapy

Narcissistic

Psychodynamic psychotherapy

Mentalization-based treatment

Transference-focused psychotherapy

Avoidant

Psychodynamic psychotherapy

Supportive psychotherapy

Cognitive-behavioral therapy

Antidepressants (MAOIs, SSRIs)

Anxiolytics

Dependent

Psychodynamic psychotherapy

Cognitive-behavioral therapy

Antidepressants (MAOIs, SSRIs)

Obsessive-compulsive

Psychodynamic psychotherapy

Cognitive-behavioral therapy

Antidepressants (SSRIs)

*There is controversy about whether antisocial personality disorder is treatable.

General principles of treatment

In general, treatment of personality disorders aims to

  • Reduce subjective distress

  • Enable patients to understand that their problems are internal to themselves

  • Decrease significantly maladaptive and socially undesirable behaviors

  • Modify problematic personality traits

Reducing subjective distress (eg, anxiety, depression) is the first goal. These symptoms often respond to increased psychosocial support, which often includes moving the patient out of highly stressful situations or relationships. Drug therapy may also help relieve stress. Reduced stress makes treating the underlying personality disorder easier.

An effort to enable patients to see that their problems are internal should be made early. Patients need to understand that their problems with work or relationships are caused by their problematic ways of relating to the world (eg, to tasks, to authority, or in intimate relationships). Achieving such understanding requires a substantial amount of time, patience, and commitment on the part of a clinician. Clinicians also need a basic understanding of the patient’s areas of emotional sensitivity and usual ways of coping. Family members and friends can help identify problems of which patients and clinicians would otherwise be unaware.

Maladaptive and undesirable behaviors (eg, recklessness, social isolation, lack of assertiveness, temper outbursts) should be dealt with quickly to minimize ongoing damage to jobs and relationships. Behavioral change is most important for patients with the following personality disorders:

  • Borderline

  • Antisocial

  • Avoidant

Behavior can typically be improved within months by group therapy and behavior modification; limits on behavior must often be established and enforced. Sometimes patients are treated in a day hospital or residential setting. Self-help groups or family therapy can also help change socially undesirable behaviors. Because family members and friends can act in ways that either reinforce or diminish the patient’s problematic behavior or thoughts, their involvement is helpful; with coaching, they can be allies in treatment.

Modifying problematic personality traits (eg, dependency, distrust, arrogance, manipulativeness) takes a long time—typically > 1 yr. The cornerstone for effecting such change is

  • Individual psychotherapy

During therapy, clinicians try to identify interpersonal problems as they occur in the patient's life. Clinicians then help patients understand how these problems are related to their personality traits and provide skills training to develop new, better ways of interacting. Typically, clinicians must repeatedly point out the undesirable behaviors and their consequences before patients become aware of them to help patients change their maladaptive behaviors and mistaken beliefs. Although clinicians should act with sensitivity, they should be aware that kindness and sensible advice by themselves do not change personality disorders.

Key Points

  • Personality disorders involve rigid, maladaptive personality traits that are marked enough to cause significant distress or to impair work and/or interpersonal functioning.

  • Treatments become effective only after patients see that their problems are within themselves, not just externally caused.

  • Psychosocial therapies are the main treatment.

  • Drugs help control specific symptoms only in selected cases—eg, to control significant anxiety, angry outbursts, and depression.

  • Personality disorders are often resistant to change, but many gradually become less severe over time.

Resources In This Article

* This is the Professional Version. *