What are personality disorders?

Introduction

Personality is a term used to describe long-standing patterns of thinking, behaving, and feeling. A group of traits that are consistently displayed are considered to be part of a person’s personality. A person’s mood, for example, is considered to be a more fleeting expression of one’s overall personality. Personality comprises traits, attitudes, behaviors, and coping styles that develop throughout childhood and adolescence. Personality can be thought of as a relatively consistent style of relating to others and the environment, developing as a result of genetic and environmental influences. Psychologists have developed several theories to explain personality development. Austrian psychoanalyst Sigmund Freud
believed that personality development originates in early childhood. Freud proposed that personality emerges as a result of unconscious conflicts between unacceptable aggressive and hedonistic instincts and societal mores. According to Freud, unresolved unconscious conflicts from childhood later influence personality development. In contrast to Freud’s psychoanalytic theories about personality, other researchers focused on specific traits as the building blocks of personality development. Many classification systems have been developed in an attempt to organize and categorize personality traits and styles. The Big Five system proposes that five basic trait dimensions underlie personality structure: extroversion versus introversion, agreeableness versus disagreeableness, conscientiousness versus impulsiveness, emotional stability versus neuroticism, and openness to experience versus rigidity. Personality disorders may reflect extreme variants of these basic personality dimensions.

The personality disorders are a group of psychological disorders characterized by inflexible and maladaptive patterns of relating to others that result in impairments in day-to-day functioning. The personality disorders are reflected by personality traits that are significantly extreme or exaggerated, making it difficult to establish functional relationships with others. According to the
Diagnostic and Statistical Manual of Mental Disorders
(DSM-V) of the American Psychiatric Association, the personality disorders are defined by an enduring pattern of inner experience and behavior that is consistently dysfunctional and creates impairment in functioning. Symptoms of personality disorders are usually evident by early adulthood, coinciding with the developmental period when personality patterns have become established in most people. The DSM-V identifies ten major personality disorders: paranoid personality disorder, schizoid personality disorder, schizotypal personality disorder, borderline personality disorder, antisocial personality disorder, narcissistic personality disorder, histrionic personality disorder, avoidant personality disorder, dependent personality disorder, and obsessive-compulsive personality disorder. The personality disorders are broken down into three groups, or clusters, based on similar symptomatology.

Cluster A

The personality disorders in Cluster A consist of paranoid personality disorder, schizoid personality disorder, and schizotypal personality disorder. The behavior of people with a cluster A personality disorder is described as odd or eccentric.

Paranoid personality disorder is characterized by a pervasive distrust of others, chronic suspicion about others’ motives, and paranoid thinking. Others often avoid individuals with paranoid personality disorder, which reinforces their mistrust of others. The suspicion is chronic and creates a difficulty in establishing and maintaining interpersonal relationships. Paranoid personality disorder is more prevalent in males than females.

Schizoid personality disorder is characterized by a pervasive and long-lasting indifference toward others. The term “schizoid” was initially chosen to refer to the preliminary symptoms or latent symptoms of schizophrenia. A person with this disorder has little or no interest in interacting with others and is viewed as a loner. People with schizoid personality disorder have little interest in intimacy and tend to display a limited range of emotions. These individuals often are dull and lack a sense of humor. They are perceived by others as being aloof or apathetic and may appear disheveled or unkempt.

Schizotypal personality disorder is characterized by peculiar patterns of behaving and thinking. People with this disorder may express superstitious beliefs or may engage in fantasy-based thinking. Although their thought processes might be unusual, their beliefs are not considered to be of delusional proportions. Because the symptoms of cluster A personality disorders resemble symptoms of schizophrenia, researchers believe these disorders may be genetically related to schizophrenia.

Cluster B

The personality disorders of cluster B are borderline personality disorder, antisocial personality disorder, narcissistic personality disorder, and histrionic personality disorder. The cluster B personality disorders are described as dramatic, erratic, and emotional. The behavior of people with such a disorder creates significant impairment in establishing and maintaining interpersonal relationships. Borderline personality disorder (BPD) is the most prevalent personality disorder. It is diagnosed twice as often among women as men and is characterized by a long-standing and inflexible pattern of emotional instability and unstable personal relationships. Individuals with BPD have an intense fear of abandonment and tend to form intense and unstable relationships with others. They tend to fluctuate between having positive and negative feelings about significant people in their lives. This behavior is referred to as splitting and may contribute to the emotional instability displayed by these people. People with BPD often engage in self-destructive behavior, such as self-mutilation, suicidal acts, or drug abuse. Those with BPD report chronic feelings of emptiness.

Antisocial personality disorder is exemplified by an enduring pattern of behavior that disregards and violates the rights of others. The term “antisocial” refers to behaviors that are antisociety. Antisocial personality disorder is preceded by conduct disorder
in the adolescent stages of development. People with antisocial personality disorder often appear initially to be charming and intelligent, yet they are also manipulative and grandiose. They lack a moral code that would disallow unacceptable or hurtful behaviors. Therefore, an individual with antisocial personality disorder is likely to engage in criminal acts, manipulative behavior, and the exploitation of others.

Freud coined the term “narcissistic personality disorder” in reference to the Greek myth of Narcissus, who fell in love with his own reflection in a pool of water, preventing him from forming relationships with others. The essential feature of narcissistic personality disorder is an exaggerated sense of self-importance. This disorder is characterized by a need to be the center of attention and a preoccupation with fantasies of one’s success or power. A person with narcissistic personality disorder has difficulty understanding the feelings of others and constantly demands attention. These grandiose behaviors typically mask feelings of insecurity.

Symptoms of histrionic personality disorder include excessive emotionality and attention-seeking behavior. A person with histrionic personality disorder is overly dramatic and emotional and is inappropriately seductive to gain the attention of others. Histrionic personality disorder is more prevalent among females than males.

Cluster C

Cluster C disorders include avoidant personality disorder, dependent personality disorder, and obsessive-compulsive personality disorder. The behavior of people with a cluster C personality disorder is described as anxious or fearful.

People with avoidant personality disorder display a pervasive pattern of social discomfort and a fear of being disliked by others. Because of these feelings, a person with this disorder avoids social interactions with others. People with avoidant personality disorder are extremely shy and have great difficulty establishing interpersonal relationships. They want to be liked by others, but their social discomfort and insecurities prevent them from engaging in interpersonal relationships with others.

Dependent personality disorder is characterized by a chronic pattern of dependent and needy behavior, with an intense fear of being alone. People with this disorder attempt to please other people to avoid potential abandonment. They may say certain things just to be liked by others. They have difficulty making their own decisions and are submissive with others. Individuals with this disorder have difficulty separating from others.

Obsessive-compulsive personality disorder is characterized by an inflexible and enduring need for control and order. People who suffer from obsessive-compulsive personality disorder are so preoccupied with order and organization that they may lose sight of the main objective of an activity. People with this disorder are usually excessively work-oriented and have little patience for leisure time. They are intolerant of indecisiveness or emotionality in others and favor intellect over affect. People with this disorder are perceived as difficult to get along with and unwilling to be a team player. Obsessive-compulsive personality disorder is different from obsessive-compulsive disorder (OCD), which is categorized as an anxiety disorder and involves obsessive thoughts and compulsive behaviors.

Diagnosis

A number of issues have created debate related to the difficulty in and reliability of the diagnosis of personality disorders. The distinction between “normal” personality characteristics and a personality disorder is not necessarily clear in the clinical definition of a personality disorder. The DSM-V notes that when personality traits are inflexible and create distress or impairment in functioning they constitute a personality disorder. Some argue that there is considerable room for debate about the point at which a trait is considered to create impairment.

The personality disorders have been the subject of criticism by researchers because of the difficulty in diagnosing them reliably. Individuals with a personality disorder often display symptoms of other personality disorders. For example, researchers have debated about the distinction between schizoid personality disorder and avoidant personality disorder, as both disorders are characterized by an extreme in social isolation. Individuals with personality disorders are more likely than the general population to suffer from other psychological disorders, such as depression, bulimia, or substance abuse. This overlap of symptoms may lead to difficulty with diagnostic reliability. The personality disorders occur so frequently with other types of psychological disorders that it is challenging to sort through symptoms to determine what is evidence of each disorder. It is difficult to estimate the prevalence of personality disorders in the United States, as individuals with these disorders do not recognize that they are dysfunctional and are therefore less likely to seek treatment for their disorder.

Although it was not accepted as the official classification, an alternative, hybrid classification of personality disorders was included in the DSM-V for further study in response to the difficulties practitioners had with diagnosis. In this system, there are only six personality disorders: borderline personality disorder, obsessive-compulsive personality disorder, avoidant personality disorder, schizotypal personality disorder, antisocial personality disorder, narcissistic personality disorder. The method outlines specific impairments and traits that define each disorder. It also allows for a Personality Disorder-Trait Specified (PD-TS) diagnosis, where a practitioner may identity several traits of a disorder that a patient exhibits, even if they do not meet all the criteria to be diagnosed with the disorder itself.

Researchers have explored the problem of gender bias in the diagnosis of personality disorders. It is believed that some of the symptoms of certain personality disorders are more characteristic of one gender than the other. For example, the aggression and hostility associated with antisocial personality disorder may be traits associated more frequently with the average male population, thus affecting the diagnosis among men compared with women. This supposed gender bias is theorized to be related to the greater prevalence of borderline personality disorder and histrionic personality disorder among women compared with men. Perhaps some of the diagnostic symptoms of this disorder, such as emotionality or fears of abandonment, are simply behaviors more characteristic of the female population than the male population.

Causes

Various theories have been developed to explain the etiology of personality disorders. The biological perspective examines the roles of genetics and brain functioning in the development of personality disorders. Evidence suggests that the cluster A disorders (paranoid, schizoid, and schizotypal personality disorders) are more prevalent among first-degree relatives of individuals suffering from schizophrenia, suggesting a possible genetic commonality among those disorders.

The underlying symptoms of borderline personality disorder (impulsivity and emotionality) are inherited. Much research confirms that borderline patients are more likely to report a childhood family history that included sexual abuse, domestic violence, and the early loss (either through death or abandonment) of a parental figure. It is believed that this history may be related to the later development of borderline personality disorder. According to developmental theorist Erik H. Erikson
, a sense of basic trust during childhood is an essential component of normal personality development. Erikson stated that a basic sense of trust or mistrust in the self and the world develops in the first year of life. The experience of being abandoned by a parent, then, would foster a sense of mistrust in the world and would affect personality development. In the 1950’s, University of Wisconsin psychologist Harry Harlow explored the effects of attachment on later personality development. Harlow concluded that rhesus
monkeys who were separated from their mothers shortly after birth displayed abnormal behaviors later in life, such as unusual fear or aggression, difficulty engaging in mating behaviors, and difficulty with parenting their offspring. Maternally deprived animals, therefore, were more likely to display dysfunction, as is seen in individuals with disorders associated with maternal deprivation, such as borderline and antisocial personality disorders.

Genetic factors may be influential in the development of antisocial personality disorder, as children of biological parents who engage in criminal behavior are more likely to engage in criminal behavior themselves. Learning theorists
propose that antisocial behaviors may be learned by mimicking parents with similar behaviors. Individuals with antisocial personality disorder have displayed an abnormally low arousal level, which might enable them to ignore physiological cues that indicate danger or punishment. Research has also suggested that the unusually low level of arousal may cause the antisocial individual to engage in behaviors that increase physiological arousal, or create a “rush.”

Treatment

Treatment of a personality disorder is difficult because of certain key issues related to these disorders. People with personality disorders tend to lack insight about their dysfunctional ways of interacting with others. Because they do not see themselves as having a problem, they are unlikely to pursue treatment. When a person with a personality disorder does seek treatment, it is usually for some secondary issue, such as alcoholism or depression. People suffering from personality disorders tend to end therapy prematurely because of their perception that their behavior is not the source of problems. One of the central features of the personality disorders is an impaired ability to maintain relationships with others; therefore, developing a relationship with a therapist is difficult. When the opportunity for treatment does arise, treatment approaches differ depending on the unique characteristics of each of the personality disorders.

The treatment of borderline personality disorder has received much research attention. American psychologist Marsha M. Linehan is credited with the development of dialectical behavioral therapy (DBT), a treatment approach for borderline personality disorder that integrates cognitive, behavioral, and Zen principles to help the patient to develop essential coping skills. One of the basic tenets of DBT is that individuals with borderline personality disorder may react abnormally to a normal stimulus (such as an interaction with another person) because of negative or traumatic past experiences (such as sexual abuse). Such individuals may quickly display an increase in emotion and may take a longer period of time to reduce their emotional arousal. Treatment focuses on decreasing self-destructive behaviors and helping individuals to regulate their emotions.

People with antisocial personality disorder who participate in treatment usually are made to do so by the legal system. Efficacy of treatment interventions for the person with antisocial personality disorder is often measured in terms of the number of crimes committed by the person after treatment, rather than by any significant change in personality characteristics. Treating any substance abuse
issues is an integral component of treatment of antisocial personality disorder. Some believe that prevention is the most important part of managing antisocial behavior.

Researchers have found that low levels of antipsychotic medications are effective in alleviating some symptoms of schizotypal personality disorder. Several studies suggest that antipsychotic medications such as haloperidol may decrease symptoms of depression and impulsivity in the schizotypal individual. People with narcissistic personality disorder are more apt than those with other personality disorders to seek out treatment, using the therapist’s office as yet another stage to be the center of attention.

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