Personality Disorders – What are they?

A personality disorder is a mental health condition categorized by an inability to tolerate stressful and emotionally challenging situations, causing unhelpful thoughts and behaviors that impact interpersonal relationships, school or work, and daily functioning.

According to the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-5) ^[1], there are 10 types of personality disorder with varying symptoms, which are grouped, depending on their similarities, into three clusters.

Cluster A personality disorders

Cluster A symptoms and behaviors are categorized as eccentric, odd, and distrustful. Although these types include disordered thinking, psychosis is not present.

Paranoid

Symptoms of paranoid personality disorder include ^[1][2]:

• Lack of trust: believing that others are lying to you, using you, or intending to harm you, or that if you share any personal information with another person then they will betray you.
• Being suspicious: feeling very jealous and suspicious of your partner, believing that they are unfaithful, or seeing threatening or persecutory messages in innocuous places or comments.
• Doubting others: finding itdifficult to believe in the loyalty or trustworthiness of others, causing you to struggle with forming or maintaining friendships and relationships.
• Holding grudges: not being able to let go of a past wrongdoing, regardless of the severity.
• Feeling anxious: feeling constantly anxious and finding it difficult to relax, which may come across to others as anger, hostility, or irritability.

Schizoid

Symptoms of schizoid personality disorder include ^[1][2]:

• Preferring to be alone: avoiding social activities or professions, preferring independence and self-sufficiency, with no desire to have friends.
• Blunted emotions: lacking facial expressions, gestures, and emotional responses, which may appear to others as being cold, withdrawn, or depressed.
• No interest in sexual activity: avoiding romantic or sexual partners and forming no attachments with others.
• Unaffected by praise or criticism: placing no importance on others’ views of yourself and not considering there to be any issues with your behavior or presentation.

Schizotypal

Symptoms of schizotypal personality disorder include ^[1][2][3]:

• Ideas of reference: believing that your own behavior or action has caused something to happen, or that a random occurrence is directly related to you.
• Odd thoughts and speech: thinking or speaking about things that are confusing or don’t make sense to others, or jumping between ideas.
• Odd or eccentric behavior and appearance: including inappropriate or blunted responses.
• Odd beliefs: including believing you can read minds or see the future.
• Suspiciousness and paranoia: being very untrusting of others, so avoiding forming friendships and relationships, and feeling socially anxious.

Cluster B personality disorders

Cluster B symptoms and behaviors are categorized as dramatic, emotional, and impulsive.  

Antisocial

Symptoms of antisocial personality disorder include ^[1][4]:

• Criminal activity:knowingly committing crimes and having a disregard for what is deemed acceptable behavior, stemming from a general belief that the rules don’t apply to them.
• No remorse:lacking empathy or regret for hurting or upsetting someone or causing emotional or physical damage.
• Lying:using manipulation and deceit for personal gain.
• Irresponsible and impulsive behavior:often without considering the safety of yourself or others, causing detrimental consequences to personal or professional relationships.
• Aggression:including verbal or physical aggression, fighting with others regularly.

Borderline

Symptoms of borderline personality disorder include ^[1][5]:

• Unstable relationships: includingregularly changing relationships, intense and changeable feelings about a partner, fear of abandonment, and desperate efforts to retain relationships.
• Impulsive behavior: including unsafe sex, substance misuse, reckless driving, and excessive spending.
• Mood swings: rapidlychanging moods, including sadness, anxiety, and intense anger, often verbally or physically lashing out at others.
• Self-harming behavior: including cutting, burning, or overdose, and regular thoughts, threats, or attempts at suicide.
• Lack of self-identity: unclear idea of who you are, what you believe in, or if you are a good person.

Histrionic

Symptoms of histrionic personality disorder include ^[1][6]:

• Erratic moods: being overly emotional or expressive, but changing emotions quickly, showing shallow and superficial responses.
• Attention seeking behavior: feeling uncomfortable when you’re not the center of attention, so using dramatic or overly sexualized behaviors or bright and provocative clothing to draw attention.
• Impressionable: being very easily influenced or led by others, feelings a desire to please others.
• Vague and impressionistic speech:speaking about things theatrically but with little detail or substance, as an attempt to impress others.

Narcissistic

Symptoms of narcissistic personality disorder include ^[1][7]:

• Grandiose ideas:having an inflated sense of importance, power, or intelligence, believing you are better than others and behaving as such, putting your own needs first.
• Exploiting others:using others for emotional, financial, or professional gain.
• Lacking empathy:inability to show compassion or remorse after physically or emotionally hurting someone, or when others are upset.
• Aggression:being verbally or physically aggressive towards others, particularly when you feel envious of others’ success, or when you believe you have not been treated as special or important.

Cluster C personality disorders

Cluster C symptoms and behaviors are categorized as anxious and fearful.

Avoidant

Symptoms of avoidant personality disorder include ^[1][8]:

• Emotional inhibition:not showing any emotional expression to others, for fear of being shamed.
• Avoiding social interactions:remaining isolated from others to prevent being rejected.
• Fear of embarrassment:believing that you will do something to embarrass yourself if you interact with others.
• Feeling inferior:believing you are not good enough or are inadequate.
• Sensitive:being very upset by criticism or remarks about your work or behaviors.

Dependent

Symptoms of dependent personality disorder include ^[1][9]:

• Fear of being alone:feeling the need to always be in a relationship so that you constantly have someone to care for you.
• Needing constant support:struggling to make even minor decisions or being unable to enact important decisions without support and advice.
• Never expressing dissatisfaction: being unable to state a varying opinion or say when you are upset with someone, for fear of them no longer wanting to be involved with you.
• Low self-worth: intense feelings of being inadequate and incapable.

Obsessive-Compulsive

Symptoms of obsessive-compulsive personality disorder include ^[1][10]:

• Need for perfection:feeling anxious if something is not exactly as you feel it should be, setting very high or unattainable standards for yourself at work, being afraid of making mistakes, and being unable to ask others to help with work for fear that they will make mistakes.
• Work oriented:entirely focused on professional work, with little desire for social interactions.
• Rigid thinking:being unable to change your views, professionally, personally, or morally.
• Hoarding:being unable to throw objects away, so retaining everything, but in an ordered and precise manner.

What causes personality disorders?

Genes

Although the impact of genetics on the development of a personality disorder is not completely understood, there is a belief that genes can contribute. For example, some research has found links in family members with personality disorders in the genes that impact the neurotransmitters serotonin, dopamine, and norepinephrine, which aid in mood regulation ^[11].

Several people with personality disorders have a parent with a similar diagnosis, which suggests there is a genetic link, but this may be due to upbringing rather than genes ^[12]. It is widely accepted that further research is required in this area, to better understand the genetic factors involved.

Environment

Many social and environmental factors can increase the risk of developing a personality disorder, including poverty and poor education ^[2][11].

Cultural factors may also impact this risk, as indicated by the fact that the prevalence of personality disorders differs in countries around the world.

Early life

Growing up in a home with volatile interpersonal dynamics, or with a parent who has a mental health condition or substance use disorder, can increase the risk of developing a personality disorder.

Experiencing sexual, physical, or emotional abuse, neglect, or a traumatic event in childhood has been shown to greatly increase the risk of personality disorders ^{[2][4][5][6][9][11]}.

Risk factors

Age can be a risk factor in developing a personality disorder as, typically, they will emerge in adolescence and may reduce in severity with age. However, while symptoms of antisocial and borderline personality disorder typically get better with age, this may not apply to other personality disorders. 

Gender is also a factor, as the prevalence of certain types of personality disorder differ between males and females. For example, antisocial personality disorder is more likely to be diagnosed in males, while borderline, histrionic, and dependent personality disorders are more likely to be diagnosed in females ^[11].

How are personality disorders diagnosed?

Personality disorders can be very challenging to diagnose, as the various symptoms can be similar to several other mental health conditions, including depression, anxiety disorders, bipolar disorder, and schizophrenia or psychosis. The presenting symptoms may also overlap criteria of more than one personality disorder type, making a specific diagnosis more challenging.

As such, when attempting to diagnose a personality disorder, a doctor or mental health professional will try to gather as much information as possible, to give them a clear understanding of the individual’s symptoms and lifestyle ^[11][12].

They will gather a full history of mental and physical health conditions within the individual and their family, potentially requesting information from family members, healthcare professionals who have previously been involved, and police, if criminal behavior has been observed.

The doctor will ask the individual to explain the symptoms and emotional changes they may have experienced, with a view to gather an understanding of how well they are able to regulate their emotional and behavioral responses to certain situations, including whether they have experienced any thoughts or behaviors of harming themselves or others.

The doctor will ask several questions to try and gain an understanding of the individual’s views of themselves, reality, their relationships, their professional life, and any other aspects of their daily life, while determining how their symptoms may have affected these areas of their life.

With the information they have gathered, the doctor will then use the diagnostic criteria in the DSM-5 ^[1] to make a diagnosis, thereby informing how treatment should be administered.

How are personality disorders treated?

Therapy

Therapeutic interventions, either alone or alongside medication, are generally the most effective treatment for most personality disorders ^[11][13].

However, this requires commitment and attendance, which can be challenging, particularly for those with narcissistic personality disorder, who may question or refuse this treatment, or Cluster A types, who may be suspicious or untrusting.

As such, the development of a therapeutic relationship is crucial to positive and effective treatment, which may require differing strategies for each personality disorder type and each individual.

Individual psychotherapy can be helpful for all types, in understanding and dealing with the underlying causes of the disorder and reducing any trust issues, anxieties, or aggression that may be present.

Group therapy can be helpful, particularly for Cluster B types, but may not be appropriate for Clusters A and C, due to their respective trust and social anxiety issues.

Cognitive behavioral therapy (CBT) can help to reduce negative thoughts and the associated harmful or aggressive behaviors, and increase confidence and independence.

Dialectical behavior therapy (DBT) is a therapy based on CBT, specifically designed to treat borderline personality disorder, and is considered the most effective treatment for this type ^[5].

Medication

There are no approved medications for the treatment of personality disorders, but medication may be prescribed to reduce certain symptoms.

For example, antipsychotic medication may be prescribed to treat certain personality disorders, to reduce disordered thinking or impulsivity ^[2], while antidepressant medication, particularly selective serotonin reuptake inhibitors (SSRIs), might be prescribed to reduce feelings of depression and anxiety ^[11].