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, although sometimes signs are apparent earlier (during childhood). Traits and symptoms vary considerably in how long they persist; many resolve with time.
The Diagnostic and Statistical Manual of Mental Disorders, 5th ed, Text Revision (DSM-5-TR) lists 10 types of personality disorders Types of Personality Disorders Personality disorders in general are pervasive, enduring patterns of thinking, perceiving, reacting, and relating that cause significant distress or functional impairment. Personality disorders... read more , although most patients who meet criteria for one type also meet criteria for one or more others. Some types (eg, antisocial Antisocial Personality Disorder (ASPD) Antisocial personality disorder is characterized by a pervasive pattern of disregard for consequences and for the rights of others. Diagnosis is by clinical criteria. Treatment may include cognitive-behavioral... read more , borderline Borderline Personality Disorder (BPD) Borderline personality disorder is characterized by a pervasive pattern of instability and hypersensitivity in interpersonal relationships, instability in self-image, extreme mood fluctuations... read more ) tend to lessen or resolve as people age; others (eg, obsessive-compulsive Obsessive-Compulsive Personality Disorder (OCPD) Obsessive-compulsive personality disorder is characterized by a pervasive preoccupation with orderliness, perfectionism, and control (with no room for flexibility) that ultimately slows or interferes... read more , schizotypal Schizotypal Personality Disorder (STPD) Schizotypal personality disorder is characterized by a pervasive pattern of intense discomfort with and reduced capacity for close relationships, by distorted cognition and perceptions, and... read more ) are less likely to do so.
About 9% of the general population (1 General references Personality disorders in general are pervasive, enduring patterns of thinking, perceiving, reacting, and relating that cause significant distress or functional impairment. Personality disorders... read more ) and up to half of psychiatric patients in hospital units and clinics have a personality disorder (2 General references Personality disorders in general are pervasive, enduring patterns of thinking, perceiving, reacting, and relating that cause significant distress or functional impairment. Personality disorders... read more ). Overall, there are no clear distinctions in terms of sex, socioeconomic class, and race. However, for antisocial personality disorder, males outnumber females 3:1 (3 General references Personality disorders in general are pervasive, enduring patterns of thinking, perceiving, reacting, and relating that cause significant distress or functional impairment. Personality disorders... read more ). In borderline personality disorder, females outnumber males 3:1 (but only in clinical settings, not in the general population) (4 General references Personality disorders in general are pervasive, enduring patterns of thinking, perceiving, reacting, and relating that cause significant distress or functional impairment. Personality disorders... read more ).
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 health 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 Depressive Disorders Depressive disorders are characterized by sadness severe enough or persistent enough to interfere with function and often by decreased interest or pleasure in activities. Exact cause is unknown... read more or generalized anxiety disorder Generalized Anxiety Disorder Generalized anxiety disorder is characterized by excessive anxiety and worry about a number of activities or events that are present more days than not for ≥ 6 months. The cause is unknown,... read more .
Types of Personality Disorders
DSM-5-TR 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 Antisocial Personality Disorder (ASPD) Antisocial personality disorder is characterized by a pervasive pattern of disregard for consequences and for the rights of others. Diagnosis is by clinical criteria. Treatment may include cognitive-behavioral... read more : Social irresponsibility, disregard for others, deceitfulness, and manipulation of others for personal gain
Borderline Borderline Personality Disorder (BPD) Borderline personality disorder is characterized by a pervasive pattern of instability and hypersensitivity in interpersonal relationships, instability in self-image, extreme mood fluctuations... read more : Inner emptiness, unstable relationships, and emotional dysregulation
Histrionic Histrionic Personality Disorder (HPD) Histrionic personality disorder is characterized by a pervasive pattern of excessive emotionality and attention seeking. Diagnosis is by clinical criteria. Treatment is with psychodynamic psychotherapy... read more : Attention seeking and excessive emotionality
Narcissistic Narcissistic Personality Disorder (NPD) Narcissistic personality disorder is characterized by a pervasive pattern of grandiosity, need for adulation, and lack of empathy. Diagnosis is by clinical criteria. Treatment is with psychodynamic... read more : Self-grandiosity, need for admiration, and lack of empathy
Cluster C is characterized by appearing anxious or fearful. It includes the following personality disorders with their distinguishing features:
Avoidant Avoidant Personality Disorder (AVPD) Avoidant personality disorder is characterized by the avoidance of social situations or interactions that involve risk of rejection, criticism, or humiliation. Diagnosis is by clinical criteria... read more : Avoidance of interpersonal contact due to rejection sensitivity
Dependent Dependent Personality Disorder (DPD) Dependent personality disorder is characterized by a pervasive, excessive need to be taken care of, leading to submissiveness and clinging behaviors. Diagnosis is by clinical criteria. Treatment... read more : Submissiveness and a need to be taken care of
Obsessive-compulsive Obsessive-Compulsive Personality Disorder (OCPD) Obsessive-compulsive personality disorder is characterized by a pervasive preoccupation with orderliness, perfectionism, and control (with no room for flexibility) that ultimately slows or interferes... read more : Perfectionism, rigidity, and obstinacy
General references
1. Lenzenweger MF, Lane MC, Loranger AW, et al: DSM-IV personality disorders in the National Comorbidity Survey Replication. Biol Psychiatry 62(6):553-564, 2007. doi: 10.1016/j.biopsych.2006.09.019
2. Zimmerman M, Chelminski I, Young D: The frequency of personality disorders in psychiatric patients. Psychiatr Clin North Am 31(3):405-220, 2008 vi. doi: 10.1016/j.psc.2008.03.015
3. Alegria AA, Blanco C, Petry NM, et al: Sex differences in antisocial personality disorder: Results from the National Epidemiological Survey on Alcohol and Related Conditions. Personal Disord 4(3):214-222, 2013. doi: 10.1037/a0031681
4. Sansone RA, Sansone LA: Gender patterns in borderline personality disorder. Innov Clin Neurosci 8(5):16-20, 2011. PMID: 21686143
Symptoms and Signs of Personality Disorders
According to DSM-5-TR, personality disorders are primarily problems with
Self-identity
Interpersonal functioning
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 functioning problems 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 and/or children.
People with personality disorders often lack insight regarding the impact of their behavior on interpersonal relationships.
Diagnosis of Personality Disorders
Diagnostic and Statistical Manual of Mental Disorders, 5th ed, Text Revision (DSM-5-TR) criteria
Personality disorders are underdiagnosed. When people with personality disorders seek treatment, their chief complaints are often of depression or anxiety rather than of the manifestations of their personality disorder. 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 a persistent, inflexible, pervasive pattern of maladaptive traits involving ≥ 2 of the following (1 Diagnosis reference Personality disorders in general are pervasive, enduring patterns of thinking, perceiving, reacting, and relating that cause significant distress or functional impairment. Personality disorders... read more ) :
Cognition (ie, ways of perceiving and interpreting self, others, and events)
Affectivity (ie, range, intensity, lability, and appropriateness of emotional response)
Interpersonal functioning
Impulse control
The persistent pattern of maladaptive traits must cause significant distress or impaired functioning in social, occupational, and other important areas
The pattern is stable and has an early onset (traced back to at least adolescence or early adulthood)
Also, other possible causes of the symptoms (eg, other mental health disorders, substance use Substance Use Disorders Substance use disorders involve a pathologic pattern of behaviors in which patients continue to use a substance despite experiencing significant problems related to its use. Diagnosis of substance... read more , head trauma Traumatic Brain Injury (TBI) Traumatic brain injury (TBI) is physical injury to brain tissue that temporarily or permanently impairs brain function. Diagnosis is suspected clinically and confirmed by imaging (primarily... read more 
) must be excluded.
For a personality disorder to be diagnosed in patients < 18 years, the pattern must have been present for ≥ 1 year, except for antisocial personality disorder Antisocial Personality Disorder (ASPD) Antisocial personality disorder is characterized by a pervasive pattern of disregard for consequences and for the rights of others. Diagnosis is by clinical criteria. Treatment may include cognitive-behavioral... read more , which cannot be diagnosed in patients < 18 years.
Because many patients with a personality disorder lack insight into their condition, clinicians may need to obtain history from other clinicians who have treated these patients previously, family members, friends, or others who have contact with them.
Diagnosis reference
1. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 5th ed, Text Revision (DSM-5-TR). Washington, DC, American Psychiatric Association, 2022, pp. 733-737.
Treatment of Personality Disorders
Psychotherapy
Sometimes medications for specific symptoms or coexisting psychiatric disorders
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 medications, although some medications can effectively target specific symptoms (eg, depression, anxiety).
Disorders that often coexist with personality disorders (eg, depressive disorders Overview of Mood Disorders Mood disorders are emotional disturbances consisting of prolonged periods of excessive sadness, excessive elevated mood, or both. Mood disorders can occur in adults, adolescents, or children... read more , anxiety Overview of Anxiety Disorders Anxiety disorders are characterized by persistent and excessive fear and anxiety and the dysfunctional behavioral changes a patient may use to mitigate these feelings. Anxiety disorders are... read more , substance-related Substance Use Disorders Substance use disorders involve a pathologic pattern of behaviors in which patients continue to use a substance despite experiencing significant problems related to its use. Diagnosis of substance... read more disorders, somatic symptom Somatic Symptom Disorder Somatic symptom disorder is characterized by multiple persistent physical complaints that are associated with excessive and maladaptive thoughts, feelings, and behaviors related to those symptoms... read more disorders, and eating disorders Introduction to Eating Disorders Eating disorders involve a persistent disturbance of eating or of behavior related to eating that Alters consumption or absorption of food Significantly impairs physical health and/or psychosocial... read more ) can make treatment challenging, lengthening time to remission, increasing risk of relapse, and decreasing response to otherwise effective treatment. For treatments typically used for each disorder, see table .
General principles for 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. Pharmacotherapy may also help relieve stress. Reduced stress makes treating the underlying personality disorder easier.
An effort to enable patients to recognize that their problems are internal should be made early. Patients need to understand that their problems with work or relationships are caused by their maladaptive 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:
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 maladaptive behavior or thoughts, their involvement is helpful; with coaching, they can be allies in treatment.
Modifying maladaptive personality traits (eg, dependency, distrust, arrogance, manipulativeness) typically takes > 1 year. 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. This strategy can 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 therapy is the mainstay of treatment.
Medications help control specific symptoms only in selected cases—eg, to control significant anxiety, angry outbursts, and depression.
Personality disorders are slow to change, and may gradually become less severe over time.
