Personality Disorders

What Is A Personality Disorder?

The personality disorders classified in the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) cause significant problems in a person’s ability to manage work, interpersonal relationships, and social life. They lead to severe difficulty dealing with stress, personal issues, and overall daily functioning and interaction with the world. People with personality disorders have thoughts and exhibit behaviors considered to be both inflexible and unhealthy.

The long-term experiences, mannerisms, and patterns of behavior exhibited by people with personality disorders differ notably from those of most people and affect at least two of the following domains:

• Self-control of behavior
• Ways of relating to others
• Emotional responses
• Way of viewing themselves and other people

Many people with a personality disorder are not aware that they have a related problem. Additionally, a person can be diagnosed with one or more personality disorders.

What Are The Types Of Personality Disorders?

The personality disorders listed in the DSM-5 are classified into three groups: cluster A, cluster B, and cluster C.

Cluster A Personality Disorders

People with cluster A personality disorders exhibit eccentric and odd behavior. Cluster A includes:

• Paranoid personality disorder
• Schizoid personality disorder
• Schizotypal personality disorder

Paranoid Personality Disorder

People with paranoid personality disorder show patterns of being suspicious of others and often perceive them as being spiteful or mean-spirited; they assume that others will deceive or harm them. As a result, they refrain from confiding in others and developing close interpersonal relationships.

According to the DSM-5, the prevalence of paranoid personality disorder is between 2.3% and 4.4% in Americans, with this disorder diagnosed more often in males.

Risk factors for paranoid personality disorder include a family history of schizophrenia and other mental health disorders with features of delusionality and feelings of persecution.

Schizoid Personality Disorder

Schizoid personality disorder involves being solitary, introverted, and displaying patterns of being withdrawn from others and society. People with this mental health condition often seem distant, self-absorbed, emotionally cold, or cut off from others. Being fearful of developing close relationships and being intimate are also characteristics. Another quality perceived in people with this disorder is frequent daydreaming instead of acting practically.

Schizoid personality disorder is most prevalent in males, especially in offender populations and among those with immediate family members with schizophrenia. Additionally, people with this disorder may be more likely to later receive a diagnosis of schizophrenia, which shows a close association between the two diagnoses.

Being abandoned during childhood and being reared by caregivers who fail to meet emotional needs leads to an increased risk of developing schizoid personality disorder. Other causative factors are feeling emotionally disconnected as a child and being hypersensitive during the teenage years.

Schizotypal Personality Disorder

According to the DSM-5, the prevalence of schizotypal personality disorder is between 0.6% and 3.9%, with the disorder slightly more common among men.

A diagnosis of schizotypal personality disorder involves:

• Discomfort in close interpersonal relationships.
• Exhibiting behavior considered to be eccentric.
• Having distorted cognitions.
• Excessive social anxiety.

In addition, people with schizotypal personality disorder often have odd beliefs, manners of speech, and other behaviors considered to be peculiar.

Risk factors for developing schizotypal personality disorder include having a relative with either schizophrenia or another diagnosable psychotic disorder, social influence, and childhood experiences, including familiar emotional bonds.

Cluster B Personality Disorders

In cluster B personality disorders, a person is seen as being overly emotional, dramatic, or displaying other erratic qualities. The four personality disorders in this category include antisocial, borderline, histrionic, and narcissistic personality disorder.

Antisocial Personality Disorder

According to the Substance Abuse and Mental Health Services Administration (SAMHSA), a higher number of men than women are affected by antisocial personality disorder.

People with antisocial personality disorder often show the following:

• Frequent patterns of disregarding or violating others’ rights and boundaries and not conforming to societal norms
• Displays of impulsivity
• Lying to and deceiving other people

Showing displays of cruelty to animals and intentional fire-setting seen in childhood are linked to the later development of antisocial personality disorder. Additionally, having had an alcoholic or antisocial parent in childhood causes an increased risk of its development.

Borderline Personality Disorder

The prevalence of borderline personality disorder is 1.4% of the adult American population.Those with borderline personality disorder have severe difficulty managing their own emotions. Symptoms include:

• Impulsive behavior and unstable self-perception, often causing severe difficulty in relationships
• Uncertainty about self-identity, resulting in rapidly changing values and personal interests
• Quickly changing views of others, which can lead to unstable and emotionally intense relationships

Borderline personality disorder traits also include perceiving things in extremes, as people with this condition will often see things as being completely good or completely bad.

According to SAMHSA, research shows that people with borderline personality disorder may have unique brain structures and functions, particularly in areas related to emotion regulation and impulse control. It is noted, however, that it is unclear whether these factors cause the disorder or are a result of it.

As with other personality disorders, social, environmental, and cultural factors are known risks. People with this disorder may have experienced unstable and invalidating relationships during childhood, a history of early abuse (physical, emotional, or sexual), abandonment, and other emotional hardships. Other risk factors are disruptive early family life and early communication problems among family members.

Histrionic Personality Disorder

The DSM-5 states that 1% to 3% of adults in the US are affected by histrionic personality, which is more common in women than in men.

Histrionic personality disorder is displayed by particular types of behavior. They include the following:

• Attention-seeking behavior
• Excessive emotionality, often displayed by exaggerated and mercurial emotions
• Use of physical appearance to increase attention, often dressing and styling themselves in ways that are perceived to be exaggerated or bizarre

Those with histrionic personality disorder also do not like it when they are not the center of attention. This can cause them notable discomfort.

Narcissistic Personality Disorder

Narcissistic personality disorder is seen in up to 5% of the US population and is seen between 50-70% more commonly in males than in females.

People with narcissistic personality disorder lack empathy. They show the following traits:

• Lack of empathy
• A need for admiration from others
• Self-entitlement
• An exaggerated sense of self-importance
• Patterns of taking advantage of others

Those with narcissistic personality disorder also show other particular symptoms. This includes a pattern of taking advantage of other people.

According to the DSM-5, neglectful, overprotective, and overly judgmental parenting may be causative factors in the development of narcissistic personality disorder. Others may include rejection in childhood, a history of excessive parental praise, and early abuse or other trauma.

Cluster C Personality Disorders

People with cluster C  disorders are considered abnormally fearful and anxious. The three cluster C disorders are avoidant personality disorder, dependent personality disorder, and obsessive-compulsive personality disorder (OCPD).

Avoidant Personality Disorder

Avoidant personality disorder is shown by:

• Feelings of inadequacy
• Severe sensitivity to criticism
• Patterns of extreme shyness
• Unwillingness to become close with others unless they feel certain they will be liked by them due to feelings of social ineptness

People with avoidant personality disorder often do not feel good enough and fear rejection.

The DSM-5 states that attachment issues in infancy may contribute to the development of avoidant personality disorder. In addition, having a childhood consisting of peer rejection, not learning to trust others, and developing a tendency to be suspicious of others may be contributing factors in its development.

Dependent Personality Disorder

According to SAMHSA, 0.49% of people have dependent personality disorder, and it is diagnosed at a much higher frequency in females. Those with dependent personality disorder often have the following symptoms:

• Acting clingy and submissive
• Having a pattern of needing to be cared for by others
• Difficulty making decisions without receiving reassurance from other people
• Fear of or inability to care for oneself

Dependent personality disorder frequently comes with feelings of loneliness. People with this condition tend to feel helpfulness when they are alone.

Obsessive-Compulsive Personality Disorder

OCPD is seen more commonly in adults who have achieved an education level of high school completion or less. OCPD is two times more common in males than in females and affects 2.1% to 7.9% of American adults. It is thought to be the most common of the personality disorders.

People with OCPD have these traits:

• Excessive preoccupation with control, perfection, orderliness, and organization
• A severe focus on details
• A stubborn and extreme sense of morality
• Difficulty or an inability to socialize or partake in pleasurable activities

Causative factors of OCPD include learning in childhood to model compulsive behaviors exhibited by someone close to a person. Another causative factor may be having experienced maternal verbal abuse early on and other parenting styles, such as those that are highly protective, controlling, or punitive. In these scenarios, this disorder may develop to avoid punishment. Other familial traits thought to contribute are perfectionism, compulsivity, and a restricted range of emotional displays.

Other Personality Disorders

The DSM-5 lists a few additional personality disorder classifications including other specified personality disorder, unspecified personality disorder, and personality disorder-trait specified. These three are diagnosed in people who exhibit clinically significant problems with their personality functioning that are not accounted for by the other types of personality disorders.

Who Do Personality Disorders Affect?

A 2020 study published in Current Psychiatry Reportsstated that among community-dwelling residents aged 50 and older, individuals diagnosed with personality disorders were more likely to be younger, male, and more highly educated than those without personality disorders. Notably, though, borderline, narcissistic, and schizotypal personality disorders were not included in this assessment.

According to the National Institute of Mental Health, race has not been found to be associated with the prevalence of personality disorders in the population.

How Common Are Personality Disorders?

About 9% of adults in the United States are estimated to have one or more diagnosable personality disorders.

While Current Psychiatry Reportsnoted that 10.7% of adults aged 50 and older have a diagnosed personality disorder, the highest rate in this study was OCPD at 6.5%. Conversely, the lowest prevalence for community-dwellers aged 50 and up was reported to be dependent personality disorder at 0.4%, followed by 0.8% for histrionic personality disorder.

What Causes Personality Disorders?

The specific cause of personality disorders is unknown, although genetics, early life experiences, family history, and other environmental factors are considered likely to play a role in their development.

Other causes may include:

• Childhood experiences of abuse and trauma
• Brain injuries
• Heavy metal poisoning
• Medical conditions, including those that may have caused neuronal damage
• Having an immediate family member with a personality disorder

What Are The Symptoms Of Personality Disorders?

Symptoms differ among the many personality disorders, as described in the DSM-5. Professionals assess these various symptoms to diagnose personality disorders.

Paranoid Personality Disorder

Paranoid personality disorder involves difficulty relaxing, being excessively on guard, and limiting social activities. Other symptoms include the following:

• A tendency to be unforgiving and hold grudges
• Being overly sensitive and having difficulty accepting criticism
• Perceiving others to be exploitative or deceiving and having problems trusting or believing others are loyal or committed
• Fear of confiding in people or sharing personal information due to a fear it will then be used against them
• Perceiving that their character is being attacked
• Incorrectly assuming malicious intent from others’ looks and remarks
• Unjustifiably being suspicious of others, such as worrying that partners or spouses are cheating on them
• Being cold, distant, jealous, and controlling in an attempt to avoid betrayal
• Inability to see one’s own role in problems or interpersonal conflicts

People with this disorder rarely derive pleasure from activities and tend to choose jobs that require little interaction with other people.

Schizotypal Personality Disorder

People with schizotypal personality disorder often lack close relationships with others outside their immediate family members. They experience persistent and excessive social anxiety. Additional symptoms include:

• Flat affect, meaning emotional numbing
• Unusual mannerisms or emotional responses perceived to be limited or culturally inappropriate
• Having an odd way of dressing, including wearing odd or mismatched clothing or appearing messy or disheveled
• Incorrectly interpreting events, such as perceiving something harmless or inoffensive as containing a direct and sometimes harmful meaning
• Oddly rambling or speaking in other unusual ways
• Having illusions or experiencing delusions, such as sensing the presence of another person who is not actually there

Schizotypal personality disorder can involve constantly doubting that others are loyal or having other paranoid or suspicious thoughts. Superstitions may also be present. People with this disorder might believe they have supernatural powers such as telepathy.

Antisocial Personality Disorder

Symptoms of antisocial personality disorder include frequent lying, stealing, and fighting. Anger and arrogance are also often seen. Other symptoms include the following:

• Displaying witty and charming mannerisms
• Repeatedly breaking the law
• Skill at flattery as well as manipulating other people’s emotions
• Substance misuse

People with antisocial personality disorder also lack feelings of remorse and guilt. They often disregard the safety of oneself and others.

Borderline Personality Disorder

Borderline personality disorder involves an intense fear of abandonment and an inability to tolerate being alone. Distorted self-perceptions are common. Additional symptoms include:

• Feelings of emotional emptiness
• Frequent displays of anger
• Self-harm
• Recurrent instances of emotional crisis
• Impulsive behavior
• Risk-taking, such as gambling, substance misuse, binge eating, and risky sexual behavior

People diagnosed with borderline personality disorder often have problems at work, with family, and in other interpersonal relationships. There is a strong correlation with depression and suicide attempts.

Histrionic Personality Disorder

Those with histrionic personality disorder display manipulative behaviors. They are often flirtatious, seductive, and sexually provocative. Other symptoms include:

• Extreme preoccupation with one’s appearance
• Exaggerated or theatrical emotional expression
• Shallow and disproportionate emotional reactions perceived to be culturally disproportionate
• A compulsive desire to receive attention, often seen in overly dramatic behavior

With histrionic personality disorder, there is a tendency to be easily influenced and highly suggestible. People with this condition often also quickly and inappropriately assume familiarity or intimacy with others.

Narcissistic Personality Disorder

Narcissistic personality disorder involves a craving for admiration from others and feeling depressed or empty when not given external validation. Manipulation or exploitation of others is often seen. Other symptoms include:

• Lack of or limited empathy, along with superficial relationships
• Inflated feelings of self-importance that come with a sense of superiority and entitlement
• Difficulty or inability to experience intimacy or interpersonal attachment
• Inability to deal with criticism from other people and having an easily disrupted sense of identity
• Envy of other people or perception that others envy them
• Severe sensitivity to criticism and subsequent withdrawal from or avoidance of situations in which personal failure is feared

Those with narcissistic personality disorder often secretly feel shame, humiliation, and insecurity. There is an increased risk of attempting or completing suicide.

Avoidant Personality Disorder

People with avoidant personality disorder often have feelings of inadequacy and inferiority. They are reluctant to take chances or try new activities. It also includes the following symptoms:

• Assessing oneself as being unskilled or unappealing
• Fear of criticism and disapproval and subsequent reluctance to develop interpersonal relationships
• Intense anxiety and fear when in social settings and avoidance of certain activities
• Misinterpreting feedback from others as being negative or critical

With avoidant personality disorder, extreme feelings of shyness and self-consciousness due to worry of embarrassment or perceived failure are often seen. This can result in being passive and reserved as well as self-isolating.

Dependent Personality Disorder

People with dependent personality disorder often need others to assume their responsibilities. They frequently have feelings of helplessness or vulnerability when alone. This personality disorder is also characterized by the following:

• Fear of showing disagreement with others and of the disapproval it could cause
• Severe difficulty making everyday decisions without receiving advice, approval, or reassurance from someone else
• Difficulty related to or inability to embark on tasks or projects without external support or assistance
• A pervasive need to receive excessive support or nurturing from others
• Allowing oneself to be mistreated rather than be criticized or rejected

A person with dependent personality disorder is often clingy, needy, and submissive as a result of fearing being abandoned. They may desperately look for a new relationship when another one has ended due to an unrealistic or disproportionate fear of being alone and an inability to care for oneself.

Obsessive-Compulsive Personality Disorder

Obsessive-compulsive personality disorder involves stubbornness and inflexible cognitive patterns. The following symptoms are also seen:

• Disruptive preoccupation with personal perfectionism that impedes the completion of important tasks
• Difficulty or inability to negotiate or delegate tasks to other people if they are not willing to do things in a particular and rigid way
• Prioritizing productivity at work and other areas
• Being excessively worried about details, schedules, rules, and organization
• Severely and sometimes unnecessarily trying to limit spending to save money

Those with OCPD often have extreme difficulty accepting the beliefs and values of other people while being obsessed with following one’s own. They often also have difficulty or are unable to get rid of used, worn-out, or unneeded belongings.

How Are Personality Disorders Diagnosed?

Mental health professionals diagnose personality disorders after they have evaluated a person’s related symptoms, such as long-term manners of functioning and interacting with the world. They can only be diagnosed in those aged 18 and older, as personalities are not fully formed before that point.

To be diagnosed, a person’s healthcare provider will ensure a thorough medical exam has been conducted to rule out other possible causes of the symptoms. A mental health evaluation will be conducted to assess for personality disorder symptoms as well as the severity and effects on a person. Individual experiences and a family history of medical issues, substance misuse, and mental health conditions will also be explored in depth.

Can Personality Disorders Be Prevented?

According to the DSM-5, the ways to prevent personality disorders are unknown other than by decreasing and preventing childhood abuse and other trauma. Despite this, seeking treatment can help reduce the problems they cause, including disruption to relationships and daily functioning.

How Are Personality Disorders Treated?

Psychotherapy is the most common form of treatment for personality disorders, but medication and lifestyle changes have also been found helpful in symptom relief and management.

Psychotherapy

Psychotherapy can be effective in the treatment of personality disorders, as it helps a person understand their disorder and what may be causing and contributing to its symptoms. It lets people explore and talk about their emotions, cognitions, and actions related to the personality disorder and understand how it affects themselves and others. In addition, psychotherapy can provide insight into how to manage and reduce problems and how they affect daily functioning and interpersonal relationships.

Multiple modalities of therapy have been shown to be effective in the treatment of personality disorders and can be administered via individual and group therapy. These include:

• Cognitive-behavioral therapy (CBT)
• Dialectical behavioral therapy (DBT)
• Psychodynamic/psychoanalytic therapy

These types of therapy can involve psychoeducation, which consists of educating a person (and often their family and other loved ones) about their mental health condition, its diagnosis and treatment, and ways of coping and feeling better. The manner of treatment depends on which personality disorder a person has, how severe it is, how it impacts their life, and other factors. A key element in receiving treatment is finding a mental health provider with whom a trusting relationship can be built.

Medication

There are no FDA-approved medications for treating personality disorders. Despite this, certain medications may be used to treat symptoms of depression, anxiety, and mood instability in people with these conditions. A team approach involving family members or other loved ones working with a person’s mental health professional is often helpful.

Lifestyle Changes

As in the treatment of all mental health disorders, people getting help for personality disorders are best served by participating in creating their treatment plan and working on its implementation. Other elements of coping and self-care are also helpful in managing symptoms, which include:

• Exercise and other physical activity
• Self-expressive writing exercises
• Relaxation and mindfulness techniques, including meditation and yoga
• Avoiding isolation by maintaining healthy relationships with friends, family, and community members
• Maintaining abstinence from misuse of alcohol and drugs
• Keeping up with medical care
• Participating in support groups with people experiencing similar mental health conditions

Many people with personality disorders also have comorbid diagnosable mental health conditions such as ADHD, PTSD, and depression. It is important that these are also treated.

For people with antisocial personality disorder, behavioral treatments can be helpful. These provide rewards for appropriate behaviors alongside negative consequences when unhelpful and harmful behaviors are displayed. This personality disorder, in particular, can be very difficult to treat, and people with it rarely seek out treatment of their own volition.

How To Get Help

If you think that you or someone you care about may have a personality disorder, help is available. Remember that many people have personality disorders, and they are not something to be ashamed of.

Contacting your doctor or any other mental or healthcare professional is always an option. They can perform an assessment and help you start your healing journey. Various resources and information are available on many websites, including SAMHSA and the National Institute of Mental Health. You can also contact SAMHSA 24 hours a day at 1-800-662-HELP (4357). Further confidential support is available by calling the National Hotline for Mental Health Crises and Suicidal Prevention at 988.