The Business of Practice

Personality Disorders

Personality disorders are characterized by maladaptive thinking, feeling, and behaving. Individuals consistently and pervasively deviate from the expectations of one’s culture, and they experience distress or problems in functioning.

Personality Disorders

What are Personality Disorders?

Personality disorders are a cluster of behavioral symptoms that occur over a long period. Although many people have some of these behaviors over time to a lesser degree, the long-term pattern impacts a person’s ability to function and their relationships.

There are ten personality disorders grouped into three clusters based on similar characteristics and symptoms. 

  • Cluster A: odd, eccentric thinking or behavior
  • Cluster B: dramatic, overly emotional, or unpredictable thinking or behavior
  • Cluster C: anxious, fearful thinking or behavior

Each personality disorder has specific diagnostic instructions, and it is not necessary to exhibit all the signs and symptoms listed to be diagnosed.


Individuals diagnosed with one personality disorder often have traits of at least one other. Patients will rarely present with symptoms that neatly fit into one category (although this is possible). A more likely scenario is that the patient will have a mix of symptoms across categories. A clinician will have to determine which are most prevalent to return a comprehensive diagnosis to inform treatment. 

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR), is used by mental health professionals in the United States to classify mental disorders. According to the DSM, to be diagnosed with a personality disorder symptoms must:

  • Begin in adolescence or early adulthood
  • Create distress or impairment for an individual
  • Be stable over time

Personality Disorder Clusters and Traits

Cluster A: Odd, eccentric thinking or behavior

Schizoid Personality Disorder
--
Paranoid Personality Disorder
-- 
Schizotypal Personality Disorder
 

Schizoid Personality Disorder 

Characterized as humorless or cold, have trouble expressing emotion, and avoidant of social situations

  • Lack interests in social relationships, avoid close relationships, inability to read social cues 
  • Detached and apathetic - little or no pleasure from anything, does not enjoy activities others find enjoyable 
  • Restricted emotional expressions, trouble expressing emotions and reacting appropriate to emotional situations
Prefer to be alone rather than spending time with others, social withdrawal is voluntary - isolated, reclusive, quiet and unsocial


Paranoid Personality Disorder

Characterized as suspicious of others motives and fear that others intend to harm them:

  • Irrational suspicion of others motives and difficulty trusting others
  • Often accusatory that others are being disloyal without evidence and unjustified fear that spouse or romantic partner is unfaithful
  • Avoid sharing personal information with others due to fear of retribution 
  • Hold grudges and exhibit anger at perceived attacks - sees harmless comments as insults or attacks

Schizotypal Personality Disorder 

Characterized as unusual, distrustful, few interpersonal relationships, and social anxiety 

  • Odd, eccentric thoughts or behavior, lack of emotions or emotions are inappropriate for the situation
  • Distorted cognitions and perceptions: belief they can influence others with their thoughts, thinking that messages have a hidden meaning for them, hearing a voice talking to them
  • Peculiar appearances, unusual dressing, and poor communication due to peculiar speech or unusual speaking patterns
  • Lack close friends, suspicious of others for no reason, social anxiety 


Cluster B: Dramatic, overly emotional, or unpredictable thinking or behavior

Antisocial Personality Disorder
--
Narcissistic Personality Disorder
-- 
Borderline Personality Disorder
 

Antisocial Personality Disorder

Characterized by a pervasive pattern of disregard for and violation of the rights of others that begins in childhood or early adolescence and continues into adulthood

  • Deceit and manipulation are central features of this personality disorder, including lying, using an alias, or conning others
  • Impulsivity may be manifested by a failure to plan, and decisions are often made on the spur of the moment, without forethought nor consideration for the consequences to self or others 
  • Consistently and highly irresponsible, maybe be indicated by the abandonment of employment or repeated unexplained absences from work, and financial irresponsibility 
  • Minimizing the harmful consequences of their actions, being indifferent to the feelings of others or showing little remorse for the consequences of their actions

Narcissistic Personality Disorder

Characterized by a pervasive pattern of grandiosity, need for admiration, and lack of empathy that begins in early adulthood and is present in various contexts

  • Need for constant attention and admiration, with an expectation that others will cater to them and that they will be given whatever they desire with little concern about the desires of others 
  • Use others to meet their own needs without regard for others needs
  • Emotionally cold and lacking reciprocal interest in others — use others for their gain and can ‘dispose’ of others when no longer helpful 
  • Blame problems in their lives on the inadequacies of others and have difficulty taking personal responsibility for their actions

Borderline Personality Disorder

Characterized by a pervasive pattern of instability in interpersonal relationships, self-image, and affect in which marked impulsivity is a feature 

  • Unstable and intense relationships – alternating between idealizing and devaluing others 
  • The impulsivity characteristic of this disorder can be self-damaging, such as when individuals engage in reckless or unsafe behaviors including reckless driving, binge eating, unsafe sex, substance use, self-mutilation, or suicidal gestures 
  • Feelings of depression, loneliness, emptiness, and despair are common 
  • More prevalent in individuals who have histories of childhood abuse, abandonment, inconsistent attachments to caregivers, and those with a family history of the disorder

Histrionic Personality Disorder 

Characterized by a clear attention-seeking pattern, excessive emotionality, and dramatic or sexually provocative to gain attention 

  • As individuals with histrionic personality disorder crave attention, they speak dramatically with strong opinions but few facts or details to back them up 
  • Vulnerable to the influence of others and have a tendency to believe that relationships are closer than they are 
  • Require constant attention and praise – depending heavily on being noticed and approved
  • May be uncomfortable when they are not the center of attention and may use physical appearance to draw others attention

Cluster C: Anxious, inhibited, fearful thinking or behavior

Avoidant Personality Disorder
--
Dependent Personality Disorder
-- 
Obsessive-Compulsive Personality Disorder

Avoidant Personality Disorder 

Characterized by feeling lonely but avoiding others due to fear of rejection, criticism, and inadequacy 

  • Feeling timid and shy, social inhibition and avoid new activities or meeting new people
  • Lack of intimate relationships to avoid feeling shame or mockery
  • Avoid situations with a lot of people or interactions, including work or school, due to Intense fear of rejection and disappointing others
  • Extremely sensitive to negative evaluations but desire companionship 

Dependent Personality Disorder 

Characterized by a close attachment to a few individuals, lack of self-confidence, and concern about ability to make the right decision

  • Psychological need to be cared for by other people and generally have a fear of being alone
  • Low confidence and feeling the need for others to take care of them, make decisions for them, and assume responsibilities for them. May stay in an abusive or unhealthy relationship 
  • Avoid disagreeing with people, being clingy, or submissive toward others
  • Often in a relationship (from a young age) distraught if a relationship ends, can’t make decisions of their own, and feel a desperate need to start a new relationship quickly


Obsessive-Compulsive Personality Disorder

Characterized by a need to keep up a sense of order and control, trouble delegating tasks, lacking generosity and affection

  • Rigid and inflexible, preoccupied to rule conformity, schedules, orderliness, and details 
  • Focused on perfectionism, and control. Upset when they can not meet personal standards that are often impossible to meet
  • Needs everything to go according to their plan, to the point they exclude leisurely activities and friendships. 
  • Not wanting to throw away broken or unused items and extremely frugal with money

Diagnosing

Personality disorders are more challenging to diagnose than other mental health conditions, like depression or anxiety. This is because everyone has a unique personality, which shapes how they think about themselves and others and how interact with the world. 

To assess for a personality disorders, mental health professionals will ask questions about:

  • An individual’s perception of themself, others, and events
  • Their emotional responses 
  • How they view interpersonal relationships
  • How impulses are managed

Personality Disorders and Addiction

Personality disorders cannot directly result from a substance use issue or a general medical condition. But, there is a connection between personality disorders and substance use disorders. However, researchers and clinicians would caution against a single, generic personality that is more prone to addiction

Research has suggested that cluster B personality disorders are most related to substance use. It is also the cluster with the greatest predominance of symptoms related to impulsivity, which has been demonstrated as a vulnerability factor for addiction. However, just because a person has some of the traits associated with addiction does not mean that they are – or will become an addict. 

Personality disorders that fall within Cluster B have characteristics that make up the stereotype of someone with an addiction. Yet, the DSM does not recognize "addictive personality" within the classification system. In fact, the stereotype of the addictive personality mischaracterizes many individuals who have a substance-use disorder. 

Treatment

Therapy is an effective way to treat personality disorders. 

  • Allows individuals to gain insight and knowledge about the condition and talk about their thoughts, feelings, and behaviors. 
  • Enables individuals to learn about how their behavior affects others. They can learn skills to manage or cope with the symptoms to lower distress and problems with functioning. 
  • Help a person have more meaningful relationships and better understand their thoughts and emotions. 
  • As with all mental health conditions, the type of treatment will depend on the kind of personality disorder, its severity, and an individual’s circumstances.

Common psychotherapies include:

  •   Psychoanalytic or psychodynamic therapy
  •   Dialectical behavior therapy
  •   Cognitive-behavioral therapy
  •   Group therapy
  •   Psychoeducation  

Psychotropic medication, there is no medication specifically to treat personality disorders but uch as an antidepressant, anti-anxiety medication, a mood stabilizer, or an antipsychotic may help treat symptoms. Individuals with severe or prolonged symptoms would benefit from a multidisciplinary approach, including a general practitioner, psychiatrist, psychologist, and family or friends.

  • Antidepressant - treat symptoms of depression, reduce impulsive behavior, and feelings of anger and frustration
  • Anti-anxiety medication - manage symptoms of dread or perfectionism
  • Mood stabilizer - decrease mood swings and make irritability and aggression less intense
  • Antipsychotic - helpful for those who may distorted perceptions of reality or experience things that aren’t there

Family members can be important in an individual’s recovery and can work with the individual’s health care provider on the most effective ways to help and support. But having a family member with a personality disorder can also be distressing and stressful. Therefore, family members may benefit from talking with a mental health provider who can provide help coping with difficulties.

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