At the conclusion of this exercise, the learner will be prepared to:
- Review the basic aspects of personality disorders, including epidemiology.
- Identify the American Psychiatric Association's latest guidelines for diagnostic criteria of personality disorders.
- Explore the diagnostic tools available for personality disorders.
- Consider the differential diagnoses for personality disorders.
- Develop a basic understanding of the various treatment modalities for personality disorders.
Personality disorders are a group of mental disorders characterized by rigid and unhealthy patterns of thinking, functioning, and behaving. Someone with a personality disorder has difficulty relating to normal situations and those around them. The disorder can create significant difficulty with relationships, social activities, including school and work. Individuals suffering from a personality disorder are likely unaware of their condition, as their behavior seems natural; blaming others for all issues is a common theme. Most personality disorders will manifest during the teenage years, and some become less apparent as the patient ages (Mayo Clinic, 2016). According to the American Psychiatric Association (APA) (2018), there are ten specific types of personality disorders, which are characterized by long-term patterns of behavior differing significantly from expected behavior. The disorders affect at least two of the following areas:
- How one responds emotionally,
- How one relates to others,
- How one controls their behavior, or
- How one thinks about themselves or others (APA, 2018).
These ten types of personality disorders include antisocial personality disorder, avoidant personality disorder, borderline personality disorder, dependent personality disorder, histrionic personality disorder, narcissistic personality disorder, obsessive-compulsive personality disorder, paranoid personality disorder, schizoid personality disorder, and schizotypal personality disorder. These disorders are clustered into three groups; Cluster A, B, or C. The definitions for each cluster and individual personality disorder are described below (APA, 2018).
Terms and Definitions
Axis I disorders- the highest level of clinical mental health disorders in the DSM-5. These are acute symptoms that need treatment, such as major depressive episodes, schizophrenic episodes, or panic attacks. Included categories are adjustment disorders, anxiety disorders, cognitive disorders, dissociative disorder, eating disorders, factitious disorders, impulse-control disorders (NOS), mood disorders, schizophrenia, and other psychotic disorders, sexual and gender identity disorders, sleep disorders, somatoform disorders, and substance-related disorders. This group does NOT include the ten personality disorders (APA, 2013a).
Axis II disorders- the level of the DSM-5 that focuses on personality disorders and intellectual disabilities (APA, 2013a).
Cluster “A” personality disorders are characterized by odd behavior, which may be considered eccentric in thinking or actions. This category includes paranoid, schizoid, and schizotypal personality disorders (Mayo Clinic, 2016).
Cluster “B” personality disorders are characterized by unpredictable thinking or behaviors, extreme emotions, and behaving in ways that are considered overly dramatic in comparison to expected behaviors. This category includes narcissistic, histrionic, borderline personality, and antisocial personality disorders (Mayo Clinic, 2016).
Cluster “C” personality disorders are characterized by fearful or anxious thinking or behaviors. This category includes dependent, avoidant, and obsessive-compulsive personality disorders (Mayo Clinic, 2016).
Antisocial personality disorder is a disorder with patterns of disregarding or violating other people’s rights. The affected individual does not conform to social norms, acts impulsively, may lie to deceive others, and is considered manipulative in their behavior (APA, 2018; Mayo Clinic, 2016).
Avoidant personality disorder is a disorder with feelings of inadequacy, extreme sensitivity to criticism, and extreme shyness. This person may be unwilling to get involved with others, may be preoccupied with criticism from others or in being rejected by others. They have low self-esteem and do not feel good enough for others (APA, 2018; Mayo Clinic, 2016).
Borderline personality disorder is a disorder characterized by poor self-esteem and self-image, impulsivity, intense emotions, and a history of unstable personal relationships. The affected person may go to great lengths to avoid being abandoned, including suicide attempts, inappropriate and intense anger, or ongoing feelings of emptiness regardless of relationship status or personal resources (APA, 2018; Mayo Clinic, 2016).
Dependent personality disorder is a disorder where the individual has an excessive need to be taken care of. The affected person exhibits submissive, clingy behavior toward those who are closest to them. This person cannot make decisions without reassurance from others, may feel uncomfortable and helpless when alone as they are fearful of the inability to care for themselves (APA, 2018; Mayo Clinic, 2016).
Histrionic personality disorder is a disorder with patterns of excessive emotions and attention-seeking behavior. The affected person may have a deep need to be the center of attention and have exaggerated emotions or emotional lability. They may use their appearance to draw attention (APA, 2018; Mayo Clinic, 2016).
Narcissistic personality disorder is a disorder with patterns of behavior that requires a need for admiration from others but yet lacks empathy for others. They may have a grandiose sense of their own importance, may take advantage of others, and may have a sense of entitlement (APA, 2018; Mayo Clinic, 2016).
Obsessive-compulsive personality disorder, otherwise known as anankastic personality disorder, is a disorder characterized by a pattern of preoccupation with perfection, control, and orderliness that is self-imposed. This person is overly focused on their schedule details, inflexible in their morality and values, and may work excessively without time for friends, family, or leisure. This is separate from and should not be confused with the more pathological obsessive-compulsive disorder, a chronic anxiety disorder characterized by reoccurring and repetitive thoughts (obsessions) and behaviors (compulsions) that interfere with all aspects of life. (APA, 2018; Mayo Clinic, 2016; National Institute of Mental Health, 2019).
Paranoid personality disorder is a disorder characterized by a pattern of suspicion and distrust of others. The affected individual may view others as being mean or spiteful; often assuming that others are out to harm them. They do not confide in others or allow others to get close to them, typically causing trust issues in relationships (APA, 2018; Mayo Clinic, 2016).
Schizoid personality disorder is a disorder in which the individual is detached from social relationships and has very few emotions. This person does not seek close relationships and chooses to be alone, does not care about praise from others, or how others view them (APA, 2018; Mayo Clinic, 2016).
Schizotypal personality disorder is a disorder with odd beliefs, peculiar behavior or speech, excessive social anxiety, and eccentric behaviors. This person is highly uncomfortable in close relationships and may have distorted thinking (APA, 2018; Mayo Clinic, 2016).
Psychoanalytic therapy is a form of talk therapy aimed at bringing unconscious or deeply buried thoughts to the surface so the repressed memories can be examined for the ways in which they affect current behavior, thinking, or relationships (Psychology Today, n.d.c).
Dialectical behavior therapy is a form of therapy that focuses on giving patients new skills to manage unhealthy emotions and decrease conflict in relationships. The four therapeutic skills that this therapy focuses on includes mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness. This therapy helps the individual learn to communicate in ways that are assertive, but maintains self-respect and strengthens relationships (Psychology Today, n.d.b)
Cognitive-behavioral therapy is a psychotherapy that focuses on changing dysfunctional emotions, thoughts, or behaviors through interrogation and discovery of negative or irrational thoughts and beliefs. These dysfunctional thoughts are replaced with reality or solutions to the thoughts (Psychology Today, n.d.a).
Group therapy involves one or more psychologists leading a group of 5 to 15 patients, typically meeting one to two hours each week. The groups will typically focus on a specific problem, such as a type of personality disorder or a symptom such as anxiety. Groups can help the individual recognize others with similar problems, and put their problem into perspective (APA, n.d.b).
Psychoeducation is teaching the patient or their family about their illness, ways of coping, or other forms of treatment (APA, 2018).
Impact of Personality Disorders
The etiology of personality disorders is often debated (nature versus nurture), but there are no known genetic risk factors for personality disorders in any of the three classifications. Psychosocial studies have shown that a lack of socialization, the presence of childhood trauma/abuse, a lack of empathy, poverty, family instability, or community violence are likely related to the development of personality disorders. Family issues such as erratic, neglectful, or abusive parenting; substance abuse; divorce; or poverty seem to influence the development of personality disorders (Gotzsche-Astrup & Moskowitz, 2015).
It is difficult to obtain an accurate prevalence rate for personality disorders in comparison to other mental health disorders, due to the difficulty in obtaining national surveys and self-reporting. However, cross-sectional, community-based surveys completed in the US report the prevalence of personality disorders between 4% and 15% through 2006 across the lifespan. In 2015, there was an international study on the prevalence of personality disorders based on seven countries across five continents which reported a worldwide prevalence of 6.1%; the lowest prevalence was found in Europe and the highest in North and South America. Further data show a fairly equal distribution of personality disorders across sex and ethnicity in the community surveys. The study setting has a minor impact on prevalence, with urban areas being higher than rural areas. The highest prevalence of personality disorders is noted in people within the criminal justice system, particularly those who are incarcerated, with up to 2/3 of all prisoners having personality disorders. The prevalence of personality disorders in clinical healthcare services is higher in women than in men, suggesting that women may seek help more often than men for self-harming behaviors. The prevalence of personality disorders is greater in people that are in contact with healthcare providers than those who are not, with about 25% of patients in primary care and 50% in psychiatric outpatient settings meeting the criteria for one or more of the ten disorders (Tyrer et al., 2015). In a systematic review by Volkert and colleagues (2018) the prevalence rates of personality disorders were at 12.6% for all personality disorders, with obsessive-compulsive personality disorder at the highest (4.32%). The lowest prevalence in the study was dependent personality disorder at 0.78%. This study did note that epidemiological studies in western communities are rare, the prevalence rates are fairly high and vary based on the sampling methods, and that more studies are needed in the future to properly identify the needs of these populations (Volkert et al., 2018).
Personality disorders are the most common disorders treated by psychiatrists and psychotherapists in the US. While there are comorbidities of both mental and physical illnesses among those with personality disorders, the frequency of accessing healthcare intervention is also related to the dysfunctional relationships affecting the individual with a personality disorder and their families (Bertsch & Herpertz, 2018). While the financial impact may be less than other illnesses, the emotional and interpersonal impact of personality disorders is exponential (Volkert et al., 2018). Increased mortality and morbidity rates are associated with personality disorders due to an increased incidence of suicide; homicide; and smoking, alcohol, and drug misuse and abuse (Tyrer et al., 2015).
Diagnosing Personality Disorders
A diagnosis can be determined by combining a physical examination, psychiatric evaluation, and the application of diagnostic criteria found in the DSM-5. During the physical examination, the healthcare provider should ask in-depth questions about the patient's health. Symptoms are often linked to underlying physical health issues rather than mental health issues, and those must be ruled out first. The physical examination may also include lab tests and screenings for substance abuse. The psychiatric evaluation should include questions about thoughts, feelings, and behaviors, and may include a questionnaire or screening tool to help with pinpointing a specific diagnosis. The information from the physical and psychiatric evaluation is compared with the diagnostic criteria in the DSM-5 to formulate a diagnosis.
Diagnosing personality disorders can be challenging as many overlap each other. Specifically, of the ten disorders, four themes recur in all the disorders:
- Rigid, distorted, and extreme thinking patterns (thoughts).
- Problematic patterns of emotional response (feelings).
- Difficulty with impulse control (behaviors).
- Substantial interpersonal relationship problems (behaviors) (APA, 2013b).
The DSM-5 criteria for a personality disorder is an "enduring" pattern of inner experience and behaviors that manifests in two or more of the areas (thoughts, feelings, impulse control, and interpersonal relationships). This pattern of behavior deviates markedly from cultural norms or expectations, is pervasive and inflexible, is stable over time, or leads to distress or impairment for the individual (APA, 2013b). See Table 1 for disorders and their primary characteristics.
Antisocial personality disorder
Avoidant personality disorder
Borderline personality disorder
Dependent personality disorder
Histrionic personality disorder
Narcissistic personality disorder
Obsessive-compulsive personality disorder
Paranoid personality disorder
Schizoid personality disorder
Schizotypal personality disorders
(APA, 2013b; Mayo Clinic, 2016)
Other disorders, including depression, anxiety, or substance abuse, can be present simultaneously with a personality disorder and can complicate defining the diagnosis. Accurate diagnosis is important as treatment options will differ for the various conditions. Tyrer and colleagues (2015) note that due to the complexity of assessing for the accurate diagnosis, there are recurrent diagnoses given of borderline or antisocial personality disorders, or occasionally "not otherwise specified" during hospitalizations. Reasons given for these overused diagnoses are the complexity of the diagnostic system or stereotypical thinking of healthcare providers, where those who harm themselves automatically get a diagnosis of borderline personality disorder, and those who are aggressive toward others or have a history of offensive behavior automatically get a diagnosis of antisocial personality disorder. They further note that caregivers are often able to identify that a personality disorder exists, but the distinctions of each category are more difficult to decipher. This study further recognizes the limitations of quick and reliable tools for assessment and diagnosis. The reasons for a lack of tools is multifaceted. There are 79 highly inferential criteria that can determine the specific disorder among the ten, and development of a tool is complex and time-consuming. The implementation of any tool that can assess at this level of determination could take a minimum of one to two hours for administration, which is limiting to providers. A self-rating instrument, the Personality Inventory for DSM-5, has 220 items. Even with completion, the evaluation of the completed instrument requires clinical knowledge and judgment by the provider to determine an accurate diagnosis (APA, n.d.a). The Personality Inventory for DSM-5 tool requires less provider time but is still considered too long and many patients become frustrated and do not fill it out as accurately or completely as desired due to fatigue. However, if completed and appropriately reviewed by the healthcare provider, this tool is the most accurate in diagnosing personality disorders. The APA (n.d.a) website has three versions of this form, including a brief form, routine form, and informant form for family and friends. The brief form only has 25 questions but offers much less insight into the patient's condition and should be used as a follow-up to track the severity of the individual's function over time rather than as an initial assessment. These questions are below:
1. People would describe me as reckless
2. I feel like I act totally on impulse.
3. Even though I know better, I can’t stop making rash decisions.
4. I often feel like nothing I do really matters.
5. Others see me as irresponsible.
6. I’m not good at planning ahead.
7. My thoughts often don’t make sense to others.
8. I worry about almost everything.
9. I get emotional easily, often for very little reason.
10. I fear to be alone in life more than anything else.
11. I get stuck on one way of doing things, even when it's clear it won't work.
12. I have seen things that weren’t really there.
13. I steer clear of romantic relationships.
14. I’m not interested in making friends.
15. I get irritated easily by all sorts of things.
16. I don’t like to get too close to people.
17. It’s no big deal if I hurt other peoples’ feelings.
18. I rarely get enthusiastic about anything.
19. I crave attention.
20. I often have to deal with people who are less important than me.
21. I often have thoughts that make sense to me, but that other people say are strange.
22. I use people to get what I want.
23. I often “zone out” and then suddenly come to and realize that a lot of time has passed.
24. Things around me often feel unreal or more real than usual.
25. It is easy for me to take advantage of others.
Scoring is based on a numerical grade associated with responses of "very false or often false" as zero; "sometimes or somewhat false" as one; "sometimes or somewhat true" as two; and "very true or often true" as three. The individual question scores are added for a total/partial raw score, and an average applied based on how many questions were answered. Scoring criteria are based on the patient selections and overall score. The score does not indicate which personality disorder is present, but simply the presence of one (APA, n.d.a)
The informant form has 218 questions and allows the family or friend to complete the form based on their perception of the person’s behavior. This can offer insight for the provider to develop an appropriate diagnosis as an adjunct to the individual’s own self-assessment (APA, n.d.a).
Two other tools that were developed to reduce the length of assessment for personality disorders are the Standardized Assessment of Personality-Abbreviated Scale (SAPAS) and the Iowa Personality Disorder Screen (Tyrer et al., 2015). The SAPAS was initially developing in 2003 using eight items taken from a previously used informant-based interview tool, the Standardized Assessment of Personality (SAP). The SAPAS asks the following yes/no questions:
- In general, do you have difficulty making and keeping friends?
- Would you normally describe yourself as a loner?
- In general, do you trust other people?
- Do you normally lose your temper easily?
- Are you normally an impulsive sort of person?
- Are you normally a worrier?
- In general, do you depend on others a lot?
- In general, are you a perfectionist? (Moran et al., 2003)
A self-reported score of three out of eight or more indicates a personality disorder is likely (Moran et al., 2003). Tyrer et al. (2015) noted that while simplistic and quick, this tool is likely to over-diagnose personality disorders. This tool does not diagnose between the specific personality disorders but rather identifies there is likely a disorder with further examination being required (Tyrer et al., 2015).
The Iowa Personality Disorder Screener (IPDS) is an 11-item screening tool that asks the patient to consider their thoughts and feelings in recent weeks or months and how they differed from when they were their "usual self." The following yes/no questions are included:
- a. Some people find their mood frequently changes - as if they spend every day on an emotional roller coaster. For example, they might switch from feeling angry to depressed to anxious many times a day. Does this sound like you? b. If YES, have you been this way most of your life?
- a. Some people prefer to be the center of attention, while others are content to remain on the edge of things. Would you describe yourself as preferring to be the center of attention? b. If YES, does it bother you when someone else is in the spotlight?
- a. Do you frequently insist on having what you want right now, even when waiting a little longer would get you something much better? b. Do you often get in trouble at work or with friends because you act excited at first but then lose interest in projects and don't follow through?
- Do you find that most people will take advantage of you if you let them know too much about you? a. Do you generally feel nervous or anxious around people? b. Do you avoid situations where you have to meet new people?
- a. Do you avoid getting to know people because you're worried they may not like you? b. If YES, has this affected the number of friends that you have?
- a. Do you keep changing the way you present yourself to people because you don't know who you really are? b. Do you often feel like your beliefs change so much that you don't know what you really believe anymore?
- Do you often get angry or irritated because people don't recognize your special talents or achievements as much as they should?
- a. Do you often suspect that people you know may be trying to cheat or take advantage of you?
- b. If YES, do you worry about this a lot?
- Do you tend to hold grudges or give people the silent treatment for days at a time?
- a. Do you get annoyed when friends or family complain about their problems? b. Do people complain that you're not very sympathetic to their problems? (Langbehn et al., 1999).
The IPDS is also found to over-diagnose personality disorders as with the other short-version screening tools. While it is not ideal to over-diagnose, it is important to avoid overlooking personality disorders. It has been recognized that personality disorders often interfere with treatment compliance of other mental health disorders or physical comorbidities; thus, it is vital to recognize the condition to improve patient outcomes overall (Tyrer, 2015).
Personality Disorders Differential Diagnoses
As previously noted, there are often overlapping features among mental health disorders, and this can make a differential diagnosis even more complex. Comorbidities within the Axis I disorders, such as mood disorders or substance abuse, can puzzle the most astute practitioner. A developmental history, pre-condition history, and informant observations and perceptions can help in a differential diagnosis. Axis II disorders can also mimic many of the Axis II signs and symptoms. Examples are the dependency features of major depression, the antisocial behaviors in substance abuse, or the narcissistic behaviors of mania within the bipolar spectrum (Bienenfeld, 2016). The following conditions should be considered in the differential diagnosis of a personality disorder:
- Social phobia (intense anxiety or fear of being judged negatively or rejected in a social situation).
- Schizophrenia (reality is interpreted abnormally).
- Anxiety disorders.
- Bipolar disorder (previously manic depression).
- Substance abuse disorders.
- Pathological gambling.
- Developmental disorders.
- Attention deficit hyperactivity disorder (ADHD).
- Schizoaffective disorder (a chronic condition characterized by hallucinations or delusions and symptoms of a mood disorder).
- Post-traumatic stress disorder (a mental health condition that is triggered by a terrifying event causing nightmares, extreme anxiety, or causing flashbacks).
- Paraphilias (intense sexual arousal to atypical objects, fantasies, or situations) (Bienenfeld, 2016).
Management of Personality Disorders
Treatment is most often focused on psychotherapy. The commonly used psychotherapy types include:
- Cognitive-behavioral therapy.
- Dialectical behavior therapy.
- Psychoanalytic therapy.
- Group therapy.
These therapies can aid the patient in gathering insight into their condition as well as understanding the effects of their behaviors on their life and others around them. The focus is on learning coping skills for the symptoms, thereby reducing the problematic behaviors to improve daily function and relationships. No specific medications are approved to treat personality disorders, yet anxiolytics, antidepressants, or mood-stabilizing medications have shown success with certain symptoms of the various personality disorders. Anxiolytics are not indicated for those with impulsive behaviors such as patients with antisocial or borderline personality disorders, as the behaviors can increase with use. Antidepressants, and SSRIs in particular, are not recommended for patients with narcissistic personality disorder as the grandiose behavior and lack of empathy for others can actually increase with use. Otherwise, these medication groups can be used when psychotherapy is unsuccessful but will require a team approach to care that may include primary care providers, psychiatrists, or psychologists for medication management. See Table 2 for supportive medications for symptomatic treatment (Mayo Clinic, 2016).
Supportive Medications for Symptomatic Treatment of Personality Disorders
(Drugs.com, n.d.; Mayo Clinic, 2016)
Additionally, family participation in treatment is important to success. The patient should be educated on additional self-care methods, including:
- Learn about the disorder.
- Increase activity, develop an exercise plan.
- Avoid alcohol, drugs, or any other illicit substances.
- Get regular check-ups with a healthcare provider to maintain overall health.
- If taking medications, stay on the directed plan of treatment.
- Join a support group.
- Practice reflective journaling.
- Practice stress management such as yoga or meditation.
- Stay connected to family and friends and avoid isolation (Mayo Clinic, 2016).
Managing and coping with a personality disorder can be a challenge to not only the patient but also family and friends. Support and education regarding effective coping mechanisms can benefit all individuals involved It is vital to remember this is not an isolated event, but rather is an ongoing, lifelong treatment process geared toward managing the symptoms, pitfalls, and successes of personality disorders (Mayo Clinic, 2016). In contrast, there have been benefits noted with personality disorders in various studies. Burton (2015) noted that "our strengths and weaknesses are two sides of the same coin" (para. 1). Personality disorders can cause significant impairment in daily functioning with personal and professional relationships, yet they can also lead to extraordinary achievements. For instance, someone with narcissistic personality are more common in high-level executive positions than mentally disordered criminal offenders at a high security mental hospital. The individual with narcissistic personality disorder can be confident, highly motivated, ambitious, and self-motivated, with leadership skills that allows them to utilize people and situations to a maximum advantage. An individual with borderline personality disorder can be charming, witty, and the "life of the party". In a study by Board and Fritzon (2005), executives with personality disorders were defined as "successful psychopaths" and the criminal version of the same disorder as "unsuccessful psychopaths". What is the differentiator between the two pathways? According to Board & Fritzon (2005), successful psychopaths seem to have a conscious where unsuccessful ones do not. Their success comes from being able to control impulses and act more responsibly. Unsuccessful psychopaths ten to be unable to restrain their destructive tendencies and build relationships (Burton, 2015).
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