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Personality Disorders Nursing CE Course

1.5 ANCC Contact Hours

About this course:

This learning activity aims to provide a comprehensive overview of personality disorders, including the terminology, characteristics, diagnostic criteria, differential diagnoses, and treatment modalities.

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Personality Disorders

Disclosure Statement

This learning activity aims to provide a comprehensive overview of personality disorders, including the terminology, characteristics, diagnostic criteria, differential diagnoses, and treatment modalities.

Upon completion of this module, learners will be able to:

  • differentiate between the cluster types of personality disorders
  • describe the various personality disorders and their distinguishing features
  • summarize the clinical manifestations and diagnostic criteria for each personality disorder
  • explain the diagnostic tools available for personality disorder screening
  • recognize the differential diagnoses for each personality disorder
  • understand the various treatment modalities for personality disorders

Personality disorders are a group of psychiatric conditions characterized by rigid, pervasive, and persistent patterns of thinking, perceiving, functioning, and behaving. Individuals diagnosed with a personality disorder experience difficulty relating to everyday situations and the individuals around them. Personality disorders can create significant difficulty with maintaining relationships, engaging in social activities, and succeeding at school or work. Individuals with 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 manifest during late adolescence or early adulthood, but some individuals may exhibit signs during childhood. Personality disorders vary in persistence as the patient ages, with some, such as antisocial and borderline personality disorders, becoming less severe and even resolving as the patient ages (American Psychiatric Association [APA], 2022a; Zimmerman, 2022). There are 10 distinct personality disorders, which are characterized by long-term patterns of behavior differing significantly from expected behavior, including:

  • 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 disorder (APA, 2022a)

Commonly, when an individual meets the criteria for one personality disorder, they also meet the criteria for one or more other personality disorders (APA, 2022a; Zimmerman, 2022).

Personality disorders are grouped into three clusters based on similar clinical features. These clusters are labeled A, B, or C. Cluster A personality disorders are characterized by odd or eccentric thinking or behavior. This category includes paranoid, schizoid, and schizotypal personality disorders. Cluster B personality disorders are characterized by unpredictable thinking or behaviors, extreme emotions, and behaving in ways that are considered overly dramatic, emotional, or erratic compared to expected behaviors. This category includes narcissistic, histrionic, borderline, and antisocial personality disorders. Cluster C personality disorders are characterized by fearful or anxious thinking or behaviors. This category comprises dependent, avoidant, and obsessive-compulsive personality disorders (APA, 2022a; Zimmerman, 2022). Table 1 outlines the different personality disorders within each cluster.

Table 1 

Personality Disorder Definitions 

Personality Disorder


Cluster A

Paranoid personality disorder

  • characterized by a pattern of suspicion and distrust of others
  • the individual:
    • may view others as being mean or spiteful; often assuming that others are out to harm them
    • does not confide in others or allow others to get close to them, typically causing trust issues in relationships

Schizoid personality disorder

  • the individual:
    • is detached from social relationships and has very few emotions
    • does not seek close relationships and chooses to be alone; demonstrates disinterest in others
    • does not care about praise from others or how others view them

Schizotypal personality disorder

  • characterized by the presence of odd beliefs, peculiar speech (i.e., using words unusually, being vague, or using metaphorical speech), excessive social anxiety, and eccentric behaviors
  • the individual is highly uncomfortable in close relationships and may have distorted thinking

Cluster B

Antisocial personality disorder

  • characterized by patterns of disregarding or violating other people’s rights
  • the individual:
    • does not conform to social norms, acts impulsively, and is socially irresponsible
    • may lie to deceive others
    • demonstrates manipulative behavior for personal gain

Borderline personality disorder

  • characterized by poor self-esteem and self-image, impulsivity, intense emotions, and a history of unstable personal relationships
  • the individual:
    • may go to great lengths to avoid being abandoned, including suicide attempts
    • may exhibit inappropriate and intense anger or ongoing feelings of emptiness regardless of relationship status or personal resources

Histrionic personality disorder

  • characterized by patterns of excessive emotions and attention-seeking behavior
  • the individual may:
    • have a deep need to be the center of attention and have exaggerated emotions or emotional lability
    • use their appearance to gain attention from others

Narcissistic personality disorder

  • characterized by patterns of behavior due to a need for admiration from others but yet lacking empathy for others
  • the individual may:
    • have a grandiose sense of their importance
    • take advantage of others
    • have a sense of entitlement

Cluster C

Avoidant personality disorder

  • characterized by feelings of inadequacy, extreme sensitivity to criticism, and extreme shyness
  • the individual may:
    • be unwilling to get involved with others
    • be preoccupied with criticism from others or being rejected by others
    • have low self-esteem and may not feel good enough for others

Dependent personality disorder

  • characterized by an excessive need to be taken care of
  • the individual:
    • exhibits submissive, clingy behavior toward those who are closest to them
    • cannot make decisions without reassurance from others
    • may feel uncomfortable and helpless when alone as they are fe

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      arful of the inability to care for themselves

Obsessive-compulsive personality disorder

  • also known as anankastic personality disorder
  • characterized by a pattern of preoccupation with perfection, control, and orderliness that is self-imposed
  • the individual 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, 2022a, 2022b)


Impact of Personality Disorders

Personality disorders are considered a global mental health priority. Personality disorders are the most common disorders treated by psychiatrists and psychotherapists in the US. The prevalence of personality disorders in the US is approximately 10%, and the median prevalence varies between the three clusters. The median prevalence of cluster B disorders is highest at 4.5%, followed by cluster A (3.6%) and cluster C (2.8%). Personality disorders account for approximately 50% of all inpatient psychiatric admissions (APA, 2022a; Zimmerman, 2022).

Individuals with personality disorders frequently utilize healthcare services, likely due to the severity of impairment experienced by these patients. The number of comorbidities experienced by these patients also increases their need for healthcare services outside of psychiatric care. These disorders also affect the individual's ability to function in a workplace setting, leading to decreased productivity. Due to the need for healthcare services and the inability to maintain employment, a personal financial burden is associated with a personality disorder diagnosis (Bertsch & Herpertz, 2018; Zimmerman, 2022).

Being diagnosed with a personality disorder makes it three times more likely that the individual will commit a crime than the general population. The most common being crimes involving property and violence. Of all the personality disorders, borderline personality disorder and antisocial personality disorder have the highest imprisonment rate. It is estimated that borderline personality disorder affects 25% to 55% of incarcerated individuals. These individuals also have an increased rate of infractions, disciplinary action, and violence while incarcerated (Mundt & Baranyi, 2020; Yasmeen et al., 2022).

Risk Factors 

The etiology of personality disorders is often debated (nature versus nurture). It has been shown that there is a genetic influence on the development of personality disorders which contradicts the common belief that the characteristics of personality disorders result from negative environmental influences. The heritability of personality disorders is approximately 50%, similar to other psychiatric disorders. Psychosocial studies have shown that experiencing a lack of socialization, childhood trauma or abuse, or community violence is likely related to the development of personality disorders. Family issues such as erratic, neglectful, or abusive parenting; substance abuse; divorce; instability; or poverty seem to influence the development of personality disorders. Individuals likely have a genetic predisposition to a personality disorder influenced by environmental factors. As an example, those with a first-degree relative diagnosed with borderline personality disorder are five times more likely to be diagnosed themselves when compared to the general population; however, there are also environmental risk factors such as experiencing sexual abuse as a child, childhood emotional or physical abuse, or substance abuse (Perugula et al., 2017; Solmi et al., 2021; Zimmerman, 2022).

Overall, there is no increased risk of developing a personality disorder due to gender, socioeconomic class, or race; however, certain personality disorders are more prevalent in men than women or vice versa. Among individuals diagnosed with a personality disorder, the number of men diagnosed with antisocial personality disorder is six times higher than women, and women are three times more likely to be diagnosed with borderline personality disorder (Zimmerman, 2022).


Diagnosing Personality Disorders

A diagnosis can be determined by combining a physical examination, psychiatric evaluation, and applying diagnostic criteria found in the DSM-5-TR. The healthcare provider (HCP) should ask in-depth questions about the patient's health during the physical examination. Symptoms are often linked to underlying physical health issues rather than mental health issues, which must be ruled out first. The physical examination may also include lab tests and screenings for substance abuse. The psychiatric evaluation should consist of questions about thoughts, feelings, and behaviors and may include a questionnaire or screening tool to help pinpoint a specific diagnosis. The information from the physical and psychiatric evaluation is compared with the diagnostic criteria in the DSM-5-TR to formulate a diagnosis. Diagnosing personality disorders can be challenging as many overlap each other (APA, 2022a). Specifically, of the 10 disorders, four themes recur in them all:

  • rigid, distorted, and extreme thinking patterns (thoughts)
  • problematic patterns of emotional response (feelings)
  • difficulty with impulse control (behaviors)
  • substantial interpersonal relationship problems (behaviors; APA, 2022a)

The DSM-5-TR criteria for a personality disorder is an "enduring" pattern of inner experience and behaviors that manifests in two or more 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, 2022a). See Table 2 for disorders and their primary characteristics.

Table 2

Personality Disorders Diagnostic Criteria 



Antisocial personality disorder

A consistent ignorance and abuse of surrounding people’s rights that began at age 15 (or earlier) as evidenced by at least three of the following:

  • dishonesty in the form of defrauding, deceiving, or misleading others for individual gain
  • an agitated and sometimes hostile nature with a history of numerous altercations
  • a lack of personal accountability as evidenced by a failure to fulfill financial responsibilities or deliver professionally when promised
  • lack of concern regarding social norms or laws, with repeated arrests or undetected breaches of the law
  • quick decision-making without consideration of consequences or preparation
  • lack of concern about the well-being or security of others or oneself
  • an inability to feel guilty or personally responsible following the harm, deception, or abuse of another person

The symptoms must be present outside of and notwithstanding a diagnosis of bipolar disorder, schizophrenia, or some other psychotic disorder.

A prior history of conduct disorder must have been diagnosed or retrospectively evident before age 15.

Antisocial personality disorder is not to be confirmed in an individual under 18.

Avoidant personality disorder

A consistent finding of feelings of deficiency, highly touchy when presented with constructive feedback, and shyness or self-consciousness

This personality disorder typically presents by the patient’s '20s and is evidenced by at least four of the following:

  • resistance to interacting with others unless acceptance is guaranteed prior
  • consistent distraction by the prospect or threat of being disparaged or excluded
  • a self-image that includes being substandard, socially awkward, and unlikable
  • avoids functions or get-togethers that include interacting with others out of concern for reproach or censure
  • is hesitant in romantic or close friendships due to concern about being judged or mocked
  • is reserved early on in relationships due to a sense of deficiency
  • is highly resistant to trying new things or taking risks due to a fear of humiliation

Borderline personality disorder

A consistent fluctuation in self-regard, social connections, and displays of emotion, along with quick decision-making without consideration of consequences or preparation

This personality disorder typically presents by the patient's '20s and is evidenced by at least five of the following:

  • fluctuations and extremes in social connections with others, bouncing between intense like and dislike
  • quick decision-making without consideration of consequences or preparation in 2 or more environments that risk harm (e.g., illicit substances, unsafe driving, sexual risk-taking, etc.)
  • fluctuations in displays of emotion secondary to considerable responsiveness in emotion (e.g., extreme euphoria, agitation, sadness, or nervousness, etc.) typically lasting several hours to several days
  • fits of rage that are challenging to regulate
  • desperate attempts to prevent actual or perceived rejection or desertion by others
  • a self-regard or inner knowing that is uncalibrated and inconsistent
  • repeated discussions, attempts, or contemplations of suicide or intentional self-harm
  • consistent reports of feeling unfulfilled, hollow, or meaningless
  • short-term thoughts of persecution/victimhood or severe derealization or depersonalization

Dependent personality disorder

A consistent and extreme desire to be cared for, resulting in actions that are passive, docile, and insecure and concerns of estrangement

This personality disorder typically presents by the patient's '20s and is evidenced by at least five of the following:

  • the patient requires people to manage the most significant portions of their life
  • challenges starting tasks due to a lack of self-assurance in skill or decision-making
  • dislikes being by themselves secondary to a lack of self-confidence in their ability to care for themselves
  • consistently distracted by concerns of abandonment to care for themselves
  • challenged by daily choices unless provided with external guidance and encouragement
  • challenges discussing a difference of opinion with others due to concern that they will lose their confidence in them or disapprove
  • extraordinary measures are taken to acquire other's care and encouragement
  • immediately moves on to another personal connection when one ends to replace the encouragement and attention

Histrionic personality disorder

A consistent finding of emotional lability and pursuing notice and attention from others

This personality disorder typically presents by the patient's '20s and is evidenced by at least five of the following:

  • when socializing, the patient is often overly sensual or erotic
  • dresses and grooms themselves to attract attention
  • displays of emotion are vivid, melodramatic, and dynamic
  • perceives interpersonal connections to be closer and more intense than they are in reality
  • is not comfortable when they are in the background and others are in the spotlight
  • emotional communication is superficial and changes quickly
  • communication is exceptionally imprecise and vague
  • is impressionable or pliable

Narcissistic personality disorder

A consistent desire for veneration or respect from others, grandness, and lack of understanding and compassion for the feelings of others

This personality disorder typically presents by the patient's '20s and is evidenced by at least five of the following:

  • is myopically focused on daydreams regarding intelligence, magnificence, achievement, true love, and authority/control
  • craves constant veneration from others
  • will use others to accomplish their goals
  • is somewhat preoccupied with jealousy and envy of others or suspicion of others directed at them
  • an inflated self-regard, with a false belief that they are more crucial than they are, giving the impression that they are more successful and expert than their past accomplishments would suggest
  • an impression that they are superior and one-of-kind, and therefore can only be truly appreciated or wants to work with other top-notch or exclusive groups or people
  • believes that others owe them special treatment or expect immediate submission to their wishes
  • lack of understanding and compassion for others' feelings or emotions
  • actions and manners are proud, conceited, and egotistical

Obsessive-compulsive personality disorder

A consistent finding of a fascination with control, flawlessness, and organization

This personality disorder typically presents by the patient's '20s and is evidenced by at least five of the following:

  • difficulty completing activities or projects due to a constant need for flawlessness, exacting precision
  • is uncompromising and extremely meticulous regarding decency, principles, or ideals
  • resistance to help or delegation of responsibility unless the helper agrees to the same high standards
  • highly inflexible and obstinate
  • focuses more on the instructions, directions, or guidelines of an activity or action in place of the underlying intent or goal of the activity or action
  • tends to hyperfocus on production and professional accomplishment to the detriment of social life, family time, or hobbies
  • difficulty parting with possessions or items, despite them being older, not practical or needed, and not emotionally attached to
  • tends to be limited with their financial habits, focused on saving for possible emergencies

Paranoid personality disorder

A ubiquitous wariness, doubt, and lack of trust regarding people's underlying motivation (i.e., malicious intent) that starts no later than the patient's '20s in various environments, as evidenced by at least four of the following:

  • a constant distraction by the thought that acquaintances, coworkers, and friends are not to be trusted or are betraying them
  • interprets harmless comments or situations as being hateful or dangerous
  • believes that others are out to destroy their standing or public persona, thus responding hastily with anger or retribution, despite the initial attack not being objectively observed as such by others
  • an unfounded belief that people are trying to take advantage of them, lying to them, or otherwise hurting them
  • a resistance to trust others with personal information due to an unsubstantiated concern that the confidant will then betray them using the intimate knowledge shared
  • will consistently carry resentment regarding prior wrongdoings or affronts
  • an unsubstantiated belief that their partner is unfaithful or cheating on them

The symptoms must be present outside of and notwithstanding a diagnosis of bipolar disorder, schizophrenia, or some other psychotic disorder or medical condition.

Schizoid personality disorder

A consistent lack of attachment to others and a limited display of emotions when interacting with others

This personality disorder typically presents by the patient's '20s and is evidenced by at least four of the following:

  • consistently picks actions or events that are performed alone
  • does not enjoy most (or any) events, actions, or hobbies
  • appears unaffected by people's positive or negative opinions of them
  • does not want or like to be emotionally close to people, including family members
  • minimal (or no) desire to have a sexual relationship with someone else
  • has very few (or no) people that they are emotionally close to outside of family
  • appears to display minimal attachment, emotion, or responsiveness

The symptoms must be present outside of and notwithstanding a diagnosis of bipolar disorder, schizophrenia, some other psychotic disorder, autism spectrum disorder, or other medical condition.

Schizotypal personality disorders

A consistent lack of close connections with people due to a lack of desire and decreased capability to foster these relationships, as well as mental misrepresentations and oddities of conduct

This personality disorder typically presents by the patient's '20s and is evidenced by at least five of the following:

  • fantastical thinking or strange ideas that are not mainstream and affect the patient's actions and decision-making
  • abnormal patterns of talking or mental processing (e.g., analogies/metaphors, non-specific, indirect)
  • displays of emotion that are limited or unsuitable
  • has very few (or no) people that they are emotionally close to outside of family
  • a false belief that random events in the world are directly related to them
  • atypical sensations, including physical perceptions that are false or not objectively observable by others
  • wariness, doubt, and lack of trust regarding people's underlying motivation
  • abnormal or bizarre appearance or actions
  • extreme, consistent, and unabating nervousness or concern regarding social interactions and events that are directly related to wariness and distrust regarding other's underlying motivation in place of poor self-regard

The symptoms must be present outside of and notwithstanding a diagnosis of bipolar disorder, schizophrenia, some other psychotic disorder, autism spectrum disorder, or other medical condition.

(APA, 2022a)

Other disorders, including depression, anxiety, or substance abuse, can present simultaneously with a personality disorder and complicate the diagnostic process. When individuals seek treatment for their symptoms, they often report feelings of depression or anxiety rather than the symptoms related to the personality disorder. It is essential to distinguish whether the secondary symptoms indicate the presence of a separate mental health condition or developed as a maladaptive response to the personality disorder. There is also an overlap of symptoms between personality disorders are other mental health disorders. A personality disorder should only be diagnosed when the above criteria are met, and the characteristics appear before early adulthood and affect the individual's long-term functioning. The symptoms must also be present outside of an acute episode caused by another mental health disorder and do not emerge in response to a particular situation. Personality disorders must also be differentiated from personality traits, and the patient's symptoms should be evaluated over time to make a diagnosis. Diagnosing personality disorders is also complicated when the individual does not believe their symptoms or behaviors are problematic or has no insight into their condition. In these circumstances, gathering supplemental information from friends or family members may be necessary as characteristics are more difficult to decipher (APA, 2022a; Zimmerman, 2022).

Screening Tools

Section 3 of the DSM-5-TR includes the DSM-5 model for personality disorders developed by the APA Board of Trustees, which attempts to address the shortcomings of the traditional diagnostic criteria. They created the personality trait model, which addresses five broad domains of personality trait changes. These domains include negative affectivity, detachment, antagonism, disinhibition, and psychoticism. These domains are then subdivided into 25 personality facets. An instrument known as the Personality Inventory for DSM-5 (PID-5) is composed of 220 items that address all 25 personality facets. The PID-5 can be completed by the patient or by an individual that knows them well, but it can be time-consuming, taking on average 20-30 minutes to complete. Although the PID-5 does not require a lot of provider time, it is still considered too long, and many patients become frustrated and do not fill it out as accurately or entirely as desired due to fatigue. However, if completed and appropriately reviewed by the HCP, this tool is the most accurate in diagnosing personality disorders (APA, 2022a).

The APA (2023) website offers three versions of this form in their DSM-5-TR online assessment measures. Included is their brief form (PID-5-BF), the original PID-5, and an informant form (PID-5-IRF) specifically designed to be completed by the affected individual's family and friends. The PID-5-BF only has 25 questions, so it is less time-consuming to complete but offers much less insight into the patient's condition and should only be used as a follow-up screening tool to monitor the severity of symptoms and improvement in functioning over time rather than as an initial assessment (APA, 2023). The following are the 25 statements included in the PID-5-BF (APA, 2013):

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 being 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 people's 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 4-point scale associated with the individual's responses to the statement. A response of very false or often false is scored a 0; sometimes or somewhat false is scored a 1; sometimes or somewhat true is scored a 2; and very true or often true is scored a 3. Each statement is associated with a particular personality trait domain; negative affect (8, 9, 10, 11, and 15); detachment (4, 13, 14, 16, and 18); antagonism (17, 19, 20, 22, 25); disinhibition (1, 2, 3, 5, 6); and psychoticism (7, 12, 21, 23, and 24). The individual statement scores are added for a total/partial raw domain score, and an average is applied based on how many questions were answered. If the individual leaves seven or more questions on the entire assessment unanswered, scoring should not be completed; if two or more questions in each domain are left unanswered, scoring for that domain should not be completed. Each domain can have a score between 0 and 15. A higher score indicates a higher level of dysfunction in a particular domain. 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, 2013).

Another tool developed to reduce the length of assessment for personality disorders is the Standardized Assessment of Personality-Abbreviated Scale (SAPAS). The SAPAS was initially created in 2003 using eight items taken from the opening section of the Standardized Assessment of Personality (SAP), an informant-based interview tool used to diagnose a personality disorder (Moran et al., 2003). The SAPAS asks the following yes/no questions (Moran et al., 2003):

  1. In general, do you have difficulty making and keeping friends?
  2. Would you normally describe yourself as a loner?
  3. In general, do you trust other people?
  4. Do you normally lose your temper easily?
  5. Are you normally an impulsive sort of person?
  6. Are you normally a worrier?
  7. In general, do you depend on others a lot?
  8. In general, are you a perfectionist?

A response of yes to three or more of the eight questions indicates the presence of a personality disorder; however, this screening tool can not differentiate between different personality disorders (Moran et al., 2003).

Another screening tool is the Iowa Personality Disorder Screener (IPDS), which Langbehn and colleagues developed in 1999. This 11-item screening tool asks the patient to consider their thoughts and feelings in recent weeks or months and how they differed from when they felt like their usual self. It can be used in the outpatient psychiatric setting to determine if a personality disorder is present (PsychTools, 2018). The following yes/no questions are included (Langbehn et al., 1999):

  1. 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?
  2. 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?
  3. 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?
  4. Do you find that most people will take advantage of you if you let them know too much about you?
  5. a. Do you generally feel nervous or anxious around people?
    b. Do you avoid situations where you have to meet new people?
  6. 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?
  7. a. Do you keep changing how 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?
  8. Do you often get angry or irritated because people don't recognize your special talents or achievements as much as they should?
  9. 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?
  10. Do you tend to hold grudges or give people the silent treatment for days at a time? 
  11. 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?

Differential Diagnoses

As previously noted, there are often overlapping features among mental health disorders, and this can make a differential diagnosis even more complex. A developmental history, pre-condition history, and informant observations and perceptions can help identify differential diagnoses. Personality disorders can also mimic many of the signs and symptoms associated with other psychiatric disorders. Examples are the dependency features of major depression, the antisocial behaviors in substance abuse, or the narcissistic behaviors of mania within the bipolar spectrum (APA, 2022a; Brudey, 2021). 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)
  • psychotic disorders, including schizophrenia (reality is interpreted abnormally) or schizoaffective disorder (a chronic condition characterized by hallucinations or delusions and symptoms of a mood disorder)
  • anxiety disorders
  • bipolar disorder
  • substance abuse disorders
  • pathological gambling
  • developmental disorders
  • attention deficit hyperactivity disorder (ADHD)
  • post-traumatic stress disorder (PTSD; 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; APA, 2022a; Brudey, 2021)


Management of Personality Disorders

Psychotherapy is the gold standard treatment of personality disorders. Individual and group therapy are beneficial, but the patient must be willing and motivated to participate in treatment and change their behavior (Zimmerman, 2022). The commonly used psychotherapy types include (APA, 2022b; Johnson et al., 2018):

  • Cognitive-behavioral therapy (CBT) focuses on changing dysfunctional emotions, thoughts, or behaviors through interrogation and discovery of negative or irrational thoughts and beliefs; these dysfunctional thoughts are then replaced with reality or solutions to the dysfunctional thoughts.
  • Dialectical behavior therapy (DBT) helps the individual learn to communicate in ways that are assertive but maintain self-respect and strengthen relationships. It focuses on the therapeutic skills of mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness. It provides patients with the skills to manage unhealthy emotions and decrease conflict in relationships. This is the most researched therapy method for the treatment of borderline personality disorder.
  • 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 how they affect current behavior, thinking, or relationships.
  • Group therapy involves one or more psychologists leading a group of 5 to 15 patients, typically meeting 1 to 2 hours each week. The groups typically focus on a specific problem, such as a type of personality disorder or a symptom, such as anxiety. Participation in group therapy can help the individual recognize and build camaraderie with others with similar issues and gain perspective.
  • Psychoeducation involves teaching the patient or their family about their illness, ways of coping, and available treatment options.

These therapies can aid the patient in gathering insight into their condition and understanding the effects of their behaviors on their life and the others around them. The focus is on learning coping skills for the symptoms, thereby reducing the problematic behaviors to improve daily function and relationships (See the NursingCE course on Psychotherapy for more information). Personality disorders are not typically responsive to pharmaceutical treatment; however, anxiolytics, antidepressants, and mood-stabilizing medications have successfully targeted specific symptoms of various personality disorders, such as anxiety or depression. These medications are also contraindicated in certain personality disorders, as their use can increase the severity of some symptoms. 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, especially selective serotonin reuptake inhibitors (SSRIs), are not recommended for patients with narcissistic personality disorder as the grandiose behavior and lack of empathy for others can increase with use. Otherwise, these medication groups can be used when psychotherapy is unsuccessful but require a team approach that may include primary care providers, psychiatrists, or psychologists for medication management (APA, 2022b; Bateman et al., 2015; Zimmerman, 2022). See Table 3 for supportive medications for symptomatic treatment.


Table 3

Supportive Medications for Symptomatic Treatment of Personality Disorders

Medication Category

Targeted Symptoms



  • anxiety
  • agitation
  • insomnia
  • alprazolam (Xanax)
  • lorazepam (Ativan)
  • diazepam (Valium)


  • depressed mood
  • anger
  • impulsivity
  • irritability
  • hopelessness
  • fluoxetine (Prozac)
  • citalopram (Celexa)
  • sertraline (Zoloft)
  • paroxetine (Paxil)

Mood stabilizers

  • mood swings
  • irritability
  • impulsivity
  • aggression
  • lithium carbonate (Lithobid)
  • carbamazepine (Tegretol)
  • oxcarbazepine (Trileptal)
  • valproate (Depakene)
  • clozapine (Clozaril, Clopine)

(APA, 2022b; Zimmerman, 2022)

Additionally, active participation in the treatment plan by the individual and their family is essential to success. The patient should be educated on additional self-care and coping mechanisms (APA, 2022b). These techniques include:

  • learning more about the condition to empower the individual to understand symptoms and how to manage them
  • increasing physical activity and participating in an exercise program can help alleviate symptoms of depression, stress, and anxiety
  • avoiding alcohol and illicit drugs as these can increase the severity of symptoms and interact with prescribed medications
  • getting regular check-ups with an HCP to maintain overall health
  • taking medications as prescribed
  • joining a support group specific to personality disorders
  • engaging in reflective journaling
  • utilizing stress management techniques such as yoga or meditation
  • staying connected to family and friends and avoiding isolation (APA, 2022b)

Managing and coping with a personality disorder can challenge the patient and their family and friends. Support and education regarding effective coping mechanisms can benefit all individuals involved. It is vital to remember that this is not an isolated event but an ongoing, lifelong treatment process geared toward managing the symptoms, pitfalls, and successes of personality disorders. Personality disorders can cause significant impairment in daily functioning with personal and professional relationships, yet they can also lead to extraordinary achievements. For instance, an individual with narcissistic personality disorder can be confident, highly self-motivated, and ambitious, with leadership skills that allow them to utilize people and situations to maximum advantage. Someone with narcissistic personality disorder is more likely to hold a high-level executive position. An individual with borderline personality disorder can be charming, witty, and the "life of the party." Executives with personality disorders have been called successful psychopaths, and criminals with the same condition unsuccessful psychopaths. The differentiator between the two pathways seems to be that successful psychopaths have a conscience, whereas unsuccessful ones do not. Their success comes from being able to control impulses and act responsibly. Unsuccessful psychopaths cannot restrain their destructive tendencies enough to build relationships (APA, 2022b; Lasko & Chester, 2020).


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American Psychiatric Association. (2022a). Diagnostic and statistical manual of mental disorders (5th ed., text rev.) (DSM-5-TR). https://doi.org/10.1176/appi.books.9780890425787

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Lasko, E. N., & Chester, D. S. (2020). What makes a 'successful' psychopath? Longitudinal trajectories of offenders' antisocial behavior and impulse control as a function of psychopathy. Personality Disorders: Theory, Research, and Treatment, 12(3), 207-215. https://doi.org/10.1037/per0000421

Moran, P., Leese, M., Lee, T., Walters, P., Thornicroft, G., & Mann, A. (2003). Standardised assessment of personality-abbreviated scale (SAPAS): Preliminary validation of a brief screen for personality disorder. The British Journal of Psychiatry, 183(3), 228-232. https://doi.org/10.1192/bjp.183.3.228

Mundt, A. P., & Baranyi, G. (2020). The unhappy mental health triad: Comorbid severe mental illnesses, personality disorders, and substance use disorders in prison populations. Frontiers in Psychiatry, 11. https://doi.org/10.3389/fpsyt.2020.00804

Perugula, M. L., Narang, P. D., & Lippmann, S. B. (2017). The biological basis to personality disorders. The Primary Care Companion for CNS Disorders, 19(2). https://doi.org/10.4088/PCC.16br02076

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Solmi, M., Dragioti, E., Croatto, G., Radua, J., Borgwardt, S., Carvalho, A. F., Demurtas, J., Mosina, A., Kurotschka, P., Thompson, T., Cortese, S., Shin, J. I., & Fusar-Poli, P. (2021). Risk and protective factors for personality disorders: An umbrella review of published meta-analyses of case-control and cohort studies. Frontiers in Psychiatry, 12. https://doi.org/10.3389/fpsyt.2021.679379

Yasmeen, S., Tangney, J. P., Stuewig, J. B., Hocter, C., & Weimer, L. (2022). The implications of borderline personality features for jail inmates' institutional misconduct and treatment-seeking. Personality Disorders: Theory, Research, and Treatment, 13(5), 505-515. https://doi.org/10.1037/per0000518

Zimmerman, M. (2022). Overview of personality disorders. Merck Manual Professional Version. https://www.merckmanuals.com/professional/psychiatric-disorders/personality-disorders/overview-of-personality-disorders

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