Personality disorders, formerly known as character disorders, make up a class of heterogeneous mental disorders characterized by chronic, maladaptive, and rigid patterns of cognition, affect, and behavior. They are coded on Axis II of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) and reflect patterns of thought, affect, and behavior that deviate from the expectations of a person’s culture and impair social and occupational functioning. Some, but not all, cause emotional distress. Personality disorders do not stem from inadequate reactions to acute stress, but rather, they develop gradually and are expressed in adolescence or early adulthood. Many traits associated with personality disorders may be shared by nondisordered individuals. Although the signs and symptoms of personality disorders may describe characteristics that all people exhibit from time to time to a certain extent, a personality disorder is defined by the maladaptive pervasiveness and inflexibility of certain character traits.
Specific Personality Disorders
The DSM-IV arranges personality disorders into three clusters on the basis of similarities among the disorders.
Cluster A: Individuals with these disorders often seem odd or eccentric. The symptoms of these disorders are somewhat similar to the less severe symptoms of schizophrenia, especially in its prodromal or residual phases. This cluster includes paranoid, schizoid, and schizotypal personality disorders.
Cluster B: Individuals with these disorders are commonly described as dramatic, impulsive, and erratic. This cluster includes histrionic, narcissistic, antisocial, and borderline personality disorders.
Cluster C: Individuals with these disorders often present as anxious and fearful. It can be difficult to distinguish these personality disorders from the anxiety-based Axis I disorders in some individuals. This cluster includes avoidant, dependent, and obsessive-compulsive personality disorders.
Paranold Personality Disorder
Individuals with paranoid personality disorder (PPD) are suspicious of others, expecting to be mistreated by others. They expect harm to come to themselves and are sensitive to any evidence of impending attacks, without sufficient basis or without considering alternative explanations. They tend to see themselves as blameless, instead finding fault for their misfortunes in others, and they are likely to look for clues that validate their expectations. They are preoccupied with doubts about the loyalty or trustworthiness of others and are, therefore, unlikely to confide in others. They are hypersensitive in interactions with others, often ascribing pejorative intent to even benign remarks or events. Behaviorally, they are often described as “vigilant,” and their interpersonal relationships are marked by hostility. Their internal anxiety is related to their almost constant fear of being harmed by others. They commonly bear grudges and are unlikely to forgive perceived slights, often reacting with anger. Although some individuals diagnosed with PPD exhibit transient psychotic symptoms (e.g., persecutory delusions), they are typically in contact with reality and do not exhibit the perceptual disturbances and cognitive and behavioral disorganization often found in psychoses. Some research has suggested that PPD may be more closely related to delusional disorder than schizophrenia. PPD occurs more frequently in men and is most likely comorbid with schizotypal, avoidant, and borderline personality disorders. Its prevalence rate in the general population is between 2% and 4%, and its prevalence in outpatient psychiatric settings is about 4%.
Schizoid Personality Disorder
Individuals with schizoid personality disorders (SPD) typically exhibit an inability to form social relationships, including relationships with their family, as well as a lack of interest in doing so. The DSM-IV criteria for SPD include a pattern of detachment from social relationships and a restricted range of affect in interpersonal settings, as evidenced by at least four of the following characteristics: the individual with SPD neither desires nor enjoys close relationships (including with his or her family); almost always chooses solitary activities; has little or no interest in sexual experiences; takes pleasure in few activities; lacks friends or confidants (except for first-degree relatives); is indifferent to praise or criticism; exhibits emotional detachment, coldness, or flattened affect. Although it was earlier believed that SPD was a precursor to schizophrenia, there has been no strong genetic link found between these two disorders. Research has suggested that there are genetic links between SPD and Asperger syndrome, autism, and pervasive developmental disorder, not otherwise specified. Recent epidemiological studies suggest that the prevalence rate of SPD in the general population is between 1% and 3%, and the prevalence rate in outpatient psychiatric settings is about 1%. The preference for solitude and the lack of general distress in SPD may account for the low prevalence rates in psychiatric populations. Behaviorally, individuals with SPD are often described as “loners” or “lethargic,” and interpersonally they desire distance from others. They are likely to feel comfortable with the interpersonal emptiness of their lives.
Schizotypal Personality Disorder
Individuals with schizotypal personality disorder (STPD) typically have odd or peculiar beliefs or appearance accompanied by social and interpersonal deficits. They tend to have cognitive and perceptual disturbances and are eccentric in their communication with others. Like individuals with schizoid personality disorder, those with STPD are socially isolated and withdrawn, but the schizotypal personality also involves oddities of thought, speech, and perception. DSM-IV diagnostic criteria for STPD include a pervasive pattern of social and interpersonal deficits marked by acute discomfort with close relationships as well as eccentricities in thought, perceptions, and behavior, as evidenced by at least five of the following: ideas of reference (but not delusions of reference); odd or magical thinking; unusual perceptual experiences; odd thinking and speech; suspiciousness or paranoid thinking; inappropriate or constricted affect; odd, eccentric behavior or appearance; lack of a close friend other than first-degree relatives; and excessive social anxiety that is associated with paranoid fears. Individuals with STPD may present with an erratic or bizarre manner, peculiar speech (vague or overelaborated), ruminative thinking, and atypical perceptual experiences that do not reach the level of psychosis (e.g., illusions). These individuals may report being clairvoyant or telepathic and are likely to be superstitious. Epidemiological studies place prevalence rates in the general population at less than 1% and prevalence rates in outpatient psychiatric settings at less than 1%. Research has suggested a genetic link between STPD and schizophrenic spectrum disorders. Oddities of speech and behavior have been found in children who later develop the disorder.
Histrionic Personality Disorder
Histrionic personality disorder (HPD), formerly called hysterical personality, describes individuals who are overly dramatic, attention seeking, and highly emotional. They are often uncomfortable in situations where they are not the center of attention, and they are likely to exhibit sexually seductive or provocative behavior in their interactions with others. They consistently use their physical appearance (i.e., unusual clothes, makeup, hair color) to draw attention to themselves. They exhibit rapidly shifting, shallow emotions that are often theatrical and exaggerated. Their speech is impressionistic but lacking in detail. They often misinterpret relationships to be more intimate than they actually are, and they are often highly suggestible. They are usually self-centered and can be overconcerned about the approval of others. Behaviorally, they may be seen as seductive, and interpersonally, they tend to have stormy interpersonal relationships. They often are seen as emotionally labile, capricious, and emotionally superficial. HPD has a prevalence rate in the general population of about 2% and is more common among women. It remains unclear whether the differential rate of diagnosis is due to gender bias. Comorbidity with borderline personality disorder is relatively high. The prevalence rate in outpatient psychiatric settings is about 1%. The lower prevalence rate in psychiatric settings may be due to the culturally adaptive characteristics associated with the symptoms of the disorder.
Narcissistic Personality Disorder
Individuals with narcissistic personality disorder (NPD) have a grandiose view of their own uniqueness or worth, a preoccupation with being admired, a preoccupation with fantasies of success, and a lack of empathy for others. They often present as conceited and boastful, they are self-centered, they have a sense of entitlement, and they have a tendency to try to dominate conversations with others. They, therefore, frequently alienate others, and their lack of empathy makes the creation and maintenance of meaningful relationships difficult. Although they are sensitive to criticism, they present as arrogant and superior as a way of protecting themselves. They are often envious of others or believe that others are envious of them. When their expectations of others are not met, they are likely to react with rage, avoiding shame or dysphoria. Like individuals with borderline personality, those with NPD are likely to vacillate between idealizing and devaluing others, depending on how the other person makes them feel about themselves. Recent epidemiological studies indicate that the prevalence rate of NPD in the general population is less than 1% and that prevalence in outpatient psychiatric populations is about 2%. Some studies suggest that it may be more frequently observed in men than in women.
Antisocial Personality Disorder
Individuals with antisocial personality disorder (ASPD) consistently violate and show disregard for the law or the rights of others. They control or manipulate others without remorse or shame. This pattern of deceit and manipulation begins in childhood or early adolescence and is reflected in at least three of the following DSM-IV diagnostic criteria: failure to conform to social norms as indicated by unlawful behaviors; deceitfulness; impulsivity, aggressiveness, and irritability; reckless disregard for the safety of self or others; irresponsibility in work or financial matters; and lack of remorse. Furthermore, a prerequisite for the diagnosis is the presence of conduct disorder prior to age 15. Thus, for a diagnosis of ASPD, not only should there be antisocial behavior, but this pattern of behaviors should have begun in childhood. Historically, the diagnosis was synonymous with psychopathy, but this term has come to have a specific meaning (see below). Behaviorally, antisocial individuals may be described as aggressive and controlling, and interpersonally, they manipulate others through deceit or coercion. Antisocial individuals are likely to take risks, break laws, and seek excitement and sensation. They fail to plan ahead, as evidenced by impulsive and reckless behaviors. They seldom take responsibility for their behaviors, and they are motivated by their own selfish needs. They lack the responsibility and feelings for others that are required to maintain meaningful long-term relationships and are likely to be occupationally and financially irresponsible. They may be cunning, glib, and socially skilled, thereby hiding their selfish motives from others. They are likely to be easily bored and have a low tolerance for frustration or depression, acting out aggressively in response to negative emotions. Once they have acted out aggressively, they are unlikely to experience remorse for any harm to others. Any overt expression of shame or remorse is likely to be shallow, transient, or insincere. Antisocial individuals are unlikely to seek mental health treatment independently, instead presenting for treatment when coerced by others, especially legal authorities. Epidemiological research suggests that prevalence rates in the general population is about 1% to 4% and prevalence in outpatient psychiatric settings between 3% and 4%. The prevalence is thought to be three times higher in men than in women and much higher among young adults than older adults. Diagnosis is also more common among people of low socioeconomic status. It has been estimated that about 75% of convicted felons meet the diagnostic criteria for ASPD. ASPD is comorbid with a number of other diagnoses, especially substance abuse.
Although psychopathy is not included in the DSM-IV, it is a widely accepted and clearly defined personality disorder supported by a growing body of empirical research. Despite a significant overlap in the diagnostic criteria for antisocial personality disorder, psychopathy remains a distinct disorder. Whereas the diagnosis of antisocial personality disorder focuses primarily on overt behaviors, psychopathy also includes affective and interpersonal deficits. Although the majority of psychopaths would meet the diagnostic criteria for antisocial personality disorder, only a minority of antisocial individuals would also meet the criteria for psychopathy. The “psychopathic personality” was described by Emil Kraepelin in 1915 while referring to a subgroup of criminals who lacked a sense of morals. In 1941, Hervey Cleckley elaborated the construct through detailed case studies in his groundbreaking book, The Mask of Sanity. Cleckley’s conceptualization of the psychopathic personality as manipulative, selfish, impulsive, and lacking empathy, remorse, and anxiety has since remained more or less intact. The defining characteristics of psychopathy include a combination of both interpersonal and affective deficits as well as overt antisocial behavior. These two factors were referred to as primary and secondary psychopathy, respectively, and remain at the foundation of modern assessment.
Borderline Personality Disorder
The term borderline personality was originally used to refer to individuals who were thought to be on the “border” between neurosis and psychosis. As it is currently defined, however, borderline personality disorder (BPD) is characterized by instability in affect, interpersonal relationships, and self-image, as well as markedly impulsive behavior. Individuals with BPD exhibit serious disturbances in basic identity. As a result of their unstable self-images, they also have highly unstable and intense interpersonal relationships, characterized by alternating between extremes of idealization and devaluation of others. They make desperate efforts to avoid real or imagined abandonment. Borderline individuals commonly have an intolerance for being alone. Their behavioral impulsivity may be in the areas of sex, gambling, spending sprees, substance abuse, reckless driving, or binge eating. Recurrent suicidal behavior is common, including self-mutilation or “cutting” behavior. Suicide attempts or gestures are often clearly manipulative, intended to elicit the response of others. They report chronic feelings of emptiness and often have difficulty controlling inappropriate expressions of anger. They may experience transient stress-related symptoms such as paranoid ideation or severe dissociative symptoms. BPD is one of the most lethal psychiatric disorders, with up to 10% of identified patients completing suicides. Those who successfully suicide are more likely to have comorbid major depressive disorder and/or a family history of substance abuse. Recent studies estimate that prevalence rates in the general population are at about 1% and about 9% in an outpatient psychiatric setting. Women are three times more likely than men to be diagnosed with the disorder. There is an ongoing debate regarding the possibility of gender bias and the power of applying the label of borderline to a female patient. BPD is associated with increased utilization of psychological services and psychopharmacological treatment. Recent research has suggested that the etiology of BPD can be explained by an interaction of genetic/biological and environmental factors. Comorbidity is found with substance abuse, PTSD, eating disorders, mood disorders, and personality disorders from Cluster A.
Avoidant Personality Disorder
Individuals with avoidant personality disorder (AVPD) have a pattern of extreme social inhibition and withdrawal due to the fear of being rejected, embarrassed, or criticized. They often report feelings of inadequacy. Because of their hypersensitivity to criticism and potential rejection, they avoid other people, but, unlike schizoid individuals, they desire interpersonal contact and are often lonely or bored. DSM-IV diagnostic criteria include at least four of the following characteristics: avoidance of occupational activities that involve significant interpersonal contact due to a fear of criticism, disapproval, or rejection; unwillingness to get involved in relationships unless certain of being liked; restraint in intimate relationships due to a fear of being shamed or ridiculed; preoccupation with being criticized or rejected in social situations; inhibition in new interpersonal situations due to feelings of inadequacy; view of self as socially inept, unappealing, or inferior; reluctance to take personal risks or engage in new activities that might result in embarrassment. Behaviorally, individuals with AVPD are described as shy and guarded, and although they desire interpersonal relationships, they are unlikely to engage in them. They may present as aloof and apprehensive and are likely to make little eye contact. Epidemiological estimates place the prevalence of AVPD at between 2% and 5% in the general population and at about 15% in an outpatient psychiatric setting.
Dependent Personality Disorder
Individuals with dependent personality disorder (DPD), due to a lack of both self-confidence and autonomy, have an intense need to be taken care of. They view themselves as weak and incompetent and others as strong, leading to submissive and clinging behaviors due to an extreme fear of separation. They cultivate relationships that provide protection and support, and they often defer to others excessively. They often fail to express anger at or disagreement with others for fear of losing their support and love, and they are prone to being involved in psychologically or physically abusive relationships. They often have difficulty making everyday decisions without excessive advice and reassurance from others, and they look for others to assume responsibility for major areas of their lives. They have difficulty initiating projects due to lack of self-confidence in their judgment or abilities. They often will volunteer to do things that are unpleasant in order to obtain nurturance from others. They report feeling uncomfortable or helpless when they are alone due to an exaggerated fear of being incapable of caring for themselves. When a close relationship ends, they often will seek another relationship immediately as a source of support. Current estimates suggest that the prevalence rate of the disorder is 0.5% in the general population and around 1.5% in an out-patient psychiatric population. These data conflict with the DSM-IV assertion that DPD is one of the most frequently reported personality disorders encountered in outpatient clinics. Studies on inpatient rates suggest a higher prevalence rate, between 15% and 25%. DPD frequently co-occurs with other personality disorders as well as mood, anxiety, and eating disorders.
Obsessive-Compulsive Personality Disorder
Individuals with obsessive-compulsive disorder (OCPD) exhibit a pervasive pattern of perfectionism, orderliness, and control that interferes with flexibility, efficiency, task completion, and social interactions. Such individuals are often driven to maintain mental and interpersonal control through their preoccupation with details, lists, schedules, and rules. Their perfectionism interferes with their ability to complete a task because they believe that they cannot meet their overly strict standards. Although they are excessively devoted to work to the exclusion of leisure activities and friendships, they often are inefficient in work because they are preoccupied with trivial details. They tend to be inflexible about matters of morality, ethics, or values. Behaviorally, they are often described as stubborn and perfectionist, and they may have difficulty with interpersonal relationships due to their inflexibility. Although it was previously thought that OCPD reflected a predisposition for Axis I obsessive-compulsive disorder, more recent research suggests that OCPD is more highly comorbid with avoidant personality disorder. Prevalence rates in the general population are estimated to be between 2% and 8% and between 8% and 9% in an outpatient psychiatric setting.
Categorical Versus Dimensional Approaches
One of the most controversial topics in psychopathology over the past few decades has been the classification of personality disorders. The categorical model (e.g., DSM) assumes that personality disorders can be defined by a relatively small number of “disorders” or “types” that are essentially orthogonal. Each disorder has a specific set of symptoms and signs, and individuals within each diagnostic category are presumed to make up a homogeneous group. Dimensional approaches would replace the categorical classification now in use with a recognition that mental disorders lie on a continuum with mildly disturbed and normal behavior rather than being qualitatively distinct. Personality disorders, therefore, could be regarded as extreme variants of common personality characteristics, and personality disorder symptoms could be described in terms of relative standing on a number of traits. Personality disorders were first placed on a separate axis in the DSM in 1980, based primarily on the expert opinions of DSM work group members and without strong empirical evidence that these disorders existed with discrete and distinct clinical features. Later researchers have argued that the categorical classification approach of the DSM is inadequate. For example, they point to high levels of comorbidity; many individuals meet the diagnostic criteria for more than one personality disorder or for a personality disorder and an Axis I disorder. Work continues on the development of dimensional models (e.g., the five-factor model). Nonetheless, until a unified system of classification is developed and agreed on, the categorical system employed by the DSM will be the mostly widely-used by clinicians.
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