Personality Disorders

September 21, 2011

The Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV), defines a personality disorder as “… an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment.” The DSM-IV defines these disorders categorically, and requires that a certain number of established “criteria” be met before the diagnosis is made. However, many experts argue that personality traits are dimensional and that these disorders represent maladaptive variations of normal traits. In addition, these categories are not objective disease entities, but are instead hypothetical constructs developed for their utility in describing recurrent observations in clinical practice. Individuals who meet the criteria for a diagnosis of a personality disorder also are often diagnosed with other mental disorders, especially mood disorders, anxiety disorders, and substance abuse or dependence. There are 10 recognized personality disorders in all, which the DSM-IV groups into “clusters.”

Cluster A includes personality disorders characterized by oddness or eccentricity: paranoid, schizoid, and schizotypal. Those who meet the criteria for a diagnosis of paranoid personality disorder are generally distrustful and habitually suspect that others are trying to harm them. As a result, they have difficulty forming and maintaining relationships. Individuals diagnosed with schizoid personality disorder do not desire or enjoy close relationships with others. They are restricted in emotional expression and thus may appear cold or detached. Similarly, those with a diagnosis of schizotypal personality disorder exhibit social detachment. However, they also exhibit odd beliefs (e.g., clairvoyance and telepathy), odd behaviors, and peculiar perceptual experiences.

The Cluster B personality disorders are characterized by dramatic, emotional, or self-centered behavior: antisocial, borderline, histrionic, and narcissistic. Those who exhibit antisocial personality disorder consistently violate the rights of others and often use aggression, dishonesty, and criminal behavior in order to meet their goals. They tend to be impulsive and tend to lack remorse. There is a high prevalence of this disorder in prison populations. Individuals who meet the criteria for borderline personality disorder (BPD) have lives characterized by a pattern of instability of behaviors, emotions, relationships, and self-image. They tend to be impulsive and may repeatedly engage in self-injurious behavior or attempt suicide. Completed suicide occurs in approximately 10% of this population. Individuals diagnosed with histrionic personality disorder are only comfortable when they are the center of attention. They are often dramatic in their emotional expressions, speech, and gestures. Narcissistic personality disorder is characterized by an inflated sense of self-importance, a need for excessive admiration, an expectation of special treatment from others, and a lack of empathy.

Cluster C includes personality disorders characterized by anxiety and fear: avoidant, dependent, and obsessive-compulsive. Individuals who have a diagnosis of avoidant personality disorder shun interactions with others because they see themselves as socially inadequate and fear they will be rejected or criticized. If they do have an intimate relationship, they are emotionally restrained within that relationship for fear of ridicule. There is much overlap in the diagnostic criteria of avoidant personality disorder and that of social phobia. Individuals who meet the criteria for dependent personality disorder have an excessive need for nurturance and support, which leads to passivity and fears of separation from others. They believe they need others to take responsibility for major areas of their lives. Individuals who meet the criteria for obsessive-compulsive personality disorder are fearful of being out of control and thus are very rigid in their thinking and activities. They are preoccupied with orderliness, perfectionism, and control of themselves and their environments.

Estimates of the prevalence of personality disorders are based on limited research. The best available data indicate that the personality disorders have prevalence rates between 0.5% and 3% in the general population. BPD is one of the most common personality disorders among individuals seeking mental health treatment, and is seen in approximately 10% of mental health outpatients and 20-40% of mental health inpatients. Prevalence rates according to race, ethnicity, and culture remain largely undetermined.

Three of the personality disorders are diagnosed more commonly in women than in men: dependent, histrionic, and borderline. Antisocial personality disorder is less common in women than in men. These gender differences in prevalence rates may exist for a number of reasons: (a) Real gender differences in the presence of the disorders. For example, invalidating environments, particularly those characterized by abuse, are hypothesized to be important in the etiology of BPD. Girls are more likely to be victims of child abuse than boys are, and therefore, BPD may actually be more common in women than in men. (b) Gender bias in the development of the criteria. In particular, the criteria for dependent and histrionic personality disorders have been criticized by feminists for including personality characteristics that are stereotypically feminine (e.g., difficulty expressing disagreement with others, easily influenced by others), thus increasing the likelihood that normal women who adhere to traditional female gender roles will be diagnosed with one of these personality disorders. (c) Bias in clinicians diagnosing personality disorders. For example, research has indicated that clinicians are more likely to diagnose histrionic personality disorder if the patient is female than if the patient is male, even when given identical information in written case histories.

The most promising theories regarding the etiology of personality disorders are integrative, acknowledging that personality disorders are most likely determined by multiple factors having reciprocal influences over time. One etiological theory that takes this approach is the biosocial theory of BPD. This theory hypothesizes that

BPD develops because of a lack of “good fit” between the child’s biological vulnerabilities and the environment. According to the theory, individuals with BPD have a biological vulnerability to emotion dysregulation that they either were born with or developed very early in life. The “poor fit” environment for these children is an “invalidating environment,” in which the child’s private experiences (e.g., thoughts, feelings, desires) are chronically and pervasively dismissed as wrong, inappropriate, or otherwise invalid. These factors act in a reciprocal fashion over time, each eliciting and amplifying the other, to create severe emotion dysregulation, which consequently results in dysregulation of behavior, relationships, cognitive processes, and self-image. Continued research in psychology and neurobiology will provide important information about the validity of integrative theories of personality disorders like this one.

The development of effective and proven treatments for personality disorders has lagged behind advances in the treatment of other mental health problems, in part because of a belief that these disorders were untreatable. Currently, pharmacological treatments focus on the management of symptoms that may be associated with a personality disorder, such as cognitive-perceptual disturbances, mood dysregulation, aggression, and impulsivity. However, pharmacological treatments alone are inadequate for the treatment of personality disorders, and therefore psychotherapy is the recommended treatment method. Psychodynamic and cognitive-behavioral psychotherapies are popular treatment approaches, but there is surprisingly little research on their effectiveness. Treatments for BPD are among the most studied. “Dialectical behavior therapy” is the type of outpatient psychotherapy for BPD that currently has the most evidence for its effectiveness. There is also demonstrated efficacy for a psychodynamic treatment of BPD that relies on a partial hospitalization program. Avoidant personality disorder has been shown to respond well to behavioral treatments, including systematic desensitization and social skills training. “Multisystemic therapy” has been demonstrated to be effective for adolescents exhibiting behaviors associated with antisocial personality disorder. A few published studies have suggested that cognitive therapy may be effective in the treatment of several personality disorders, including borderline, antisocial, narcissistic, dependent, and avoidant.

SEE ALSO: Mood disorders, Phobia, Substance use

Suggested Reading

  • American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: American Psychiatric Association.
  • Ballou, M., & Brown, L. S. (Eds.). (2002). Rethinking mental health and disorder: Feminist perspectives. New York: Guilford Press.
  • Henggeler, S. W. (1999). Multisystemic therapy: An overview of clinical procedures, outcomes, and policy implications. Child Psychology and Psychiatry Review, 4, 2-10.
  • Linehan, M. M. (1993). Cognitive behavioral treatment of borderline personality disorder. New York: Guilford Press.
  • Millon, T. (1996). Personality and psychopathology: Building a clinical science. New York: Wiley-Interscience.
  • Young, J. E., & Klosko, J. S. (1993). Reinventing your life: How to break free from negative life patterns. New York: Dutton.

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