Personality Disorders

Key takeaways

• Personality disorders are enduring conditions that affect how someone thinks, feels, and behaves

• Personality disorders are divided into clusters (A, B, and C) based on their common symptoms

• Diagnosing and treating personality disorders is difficult, but being aware of the condition can help improve health

Understanding personality disorders

Personality plays a significant role in determining how we react to the world around us. A personality disorder occurs when someone’s personality creates significant problems, especially when their personality traits are particularly rigid and make it hard for them to adapt to different situations.^[1]

Everyone’s personality is different, and the majority of variations or differences are not considered signs of a disorder. Someone with a personality disorder has thoughts, feelings, and behaviors that are significantly different from the normal range that would be expected.

In DSM-V, personality disorders are grouped into clusters based on similar patterns of symptoms.

Cluster A personality disorders

Cluster A personality disorders are characterized by odd or eccentric thinking and behavior.^[2]Someone with one of these disorders may have beliefs that appear illogical and unreasonable to others.

There are three personality disorders included in cluster A^[1]

• Paranoid personality disorder

• Schizoid personality disorder

• Schizotypal personality disorder

Symptoms of cluster A disorders

The main symptoms seen within Cluster A personality disorders are:^[3]

• Social withdrawal

• Strange beliefs, including paranoia

• Difficulty forming close relationships

These symptoms are not equally common across all Cluster A personality disorders.

Paranoid personality disorder

Someone with paranoid personality disorder has unfounded beliefs that other people are trying to cause them harm. This causes distrust of others, whether close associates or strangers.^[4]

Schizoid personality disorder

Someone with schizoid personality disorder is detached from close interpersonal relationships, and often disinterested in acquiring them. When they interact with others, they exhibit few emotions.^[5]

Schizotypal personality disorder

Someone with schizotypal personality disorder experiences little need or desire for close interpersonal relationships. They can find such relationships uncomfortable. They may also express strange beliefs and a distorted view of reality.^[6]

Cluster B personality disorders

Cluster B personality disorders are characterized by dramatic emotions and impulsive behavior. People with one of these disorders can experience intense emotions that change suddenly. They have trouble regulating these emotions.

There are four Cluster B personality disorders.^[1]

• Antisocial personality disorder

• Borderline personality disorder

• Histrionic personality disorder

• Narcissistic personality disorder

Symptoms of cluster B disorders

The main symptoms associated with Cluster B personality disorders are:^[3]

• Impulsive behavior

• Emotional instability

• Difficulty maintaining stable relationships

Antisocial personality disorder

People with antisocial personality disorder (ASPD) display consistent signs of rule-breaking, often causing harm to others. They may disregard social norms and rarely express regret or remorse for their actions^[7]

Borderline personality disorder

Borderline personality disorder (BPD) is characterized by powerful mood swings, unstable self-image, and difficulty regulating emotions. This can lead to difficulty maintaining healthy relationships. People with BPD can be impulsive and can often engage in self-harming behaviors.^[3]

BPD is the most common personality disorder encountered in the emergency room and other primary care settings.^[8]

Histrionic personality disorder

Histrionic personality disorder has some similarities with BPD. They are both marked by an unstable self-image and intense emotions. People with histrionic personality disorder engage in exaggerated attention-seeking behaviors, which can disrupt deeper, more meaningful relationships.^[9]

Narcissistic personality disorder

People with narcissistic personality disorder typically display a high sense of their own self-importance in combination with low levels of empathy for others. They may exaggerate their achievements in the pursuit of praise or admiration.^[10]

Cluster C personality disorders

Cluster C personality disorders all include fearful or anxious emotions. These are not transient. Instead, individuals with Cluster C personality disorders describe themselves as fearful or anxious people.

There are three Cluster C personality disorders^[1]

• Avoidant personality disorder

• Dependent personality disorder

• Obsessive-compulsive personality disorder

Symptoms of Cluster C disorders

The main symptoms shown by people with a Cluster C personality disorder are:^[3]

• Anxiety

• Fear of abandonment

• Excessive need for control

• Perfectionism

Avoidant personality disorder

Someone with avoidant personality disorder is extremely sensitive to criticism and rejection, and socially anxious. Despite this, they have a strong desire for social connections and companionship. They will often feel inadequate and may avoid social situations because of their fear of rejection.^[11]

Dependent personality disorder

People with dependent personality disorder are strongly reliant on others to help care for them. They are typically submissive and unassertive, lacking self-confidence and worrying about being left alone.^[12]

Obsessive-compulsive personality disorder

It’s important not to confuse obsessive-compulsive personality disorder with obsessive-compulsive disorder. Someone with obsessive-compulsive personality disorder will often be highly perfectionist, have a strong need for control, and be resistant to change.^[13]

The prevalence of personality disorders

Personality disorders are relatively common, with estimates consistently showing that approximately 9% of the population is affected in the United States. This is similar to the level of personality disorders found in other Western countries.^[14][15]

Cluster B personality disorders are less common than other personality disorders, affecting 1.5% of Americans, compared with 5.7% for Cluster A and 6% for Cluster C.

Diagnosing personality disorders

Diagnosing personality disorders can be difficult. People with personality disorders often do not recognize that they have a problem, meaning that they rarely seek a diagnosis or help for these conditions. As a result, diagnosis of a personality disorder will often occur when someone seeks help for other issues.

Diagnosing personality disorders can take more time than some other diagnoses because the clinician needs to interact with the patient and try to understand their thoughts and feelings about themselves, the world, and other people.^[1]Comorbidity, where someone has multiple conditions at the same time, is common with personality disorders, so clinicians may also need to investigate whether symptoms could be the result of multiple personality disorders or a combination of different mental health issues.^[2]

During the diagnostic process, a clinician is looking for evidence that the patient’s problems^[2]

• Cause a functional impairment in their life, for example, distress or an inability to function in a work or relationship setting

• Are not confined to one area of their life

• Have been present since at least early adulthood

When diagnosing someone with a personality disorder, clinicians follow a series of steps, evaluating their overall functioning, looking for symptoms in their sense of self and interpersonal relationships, and checking that the symptoms are not considered culturally appropriate for the pateitns culture and that they can’t be explained by other medical conditions or substance use.^[16]

Clinicians are cautious when diagnosing someone with a personality disorder before the age of 18, as the personality is still developing.^[17]

Recognizing it is time to get help

It can be hard for someone with a personality disorder to recognise that they need help. Often, it takes the encouragement of someone close to them.^[1]Similarly, people rarely seek help for their personality disorder. Instead, they look for help with other problems that are caused by their personality disorder.^[2]

If you think you might have a personality disorder, mention this to your healthcare provider. They will be able to explore the idea with you more deeply and suggest next steps. It may also help them to understand your overall health and well-being needs.

How personality disorders affect the individual

Having a personality disorder can cause significant problems in different aspects of someone’s life. Most personality disorders lead to difficulties in close personal relationships, including those with friends, family, and romantic partners.^[1]

In some cases, personality disorders can lead to poor professional and academic outcomes.^[2]BPD, in particular, can lead to periods of mental health crisis, which may require hospital treatment and place strain on school or work attendance.^[8]

There are high levels of comorbidity, both between personality disorders and with other mental health conditions, leading to worse health outcomes.^[18]People with personality disorders also report experiencing more pain and are at higher risk of stroke and heart disease, among other health issues.^[2]

People with personality disorders have much higher rates of suicide than the rest of the population. For those receiving outpatient treatment, one study found that the risk of suicide was over 17 times higher than normal for women and 11 times higher for men. The risks were even higher for those receiving inpatient treatment.^[19]

Receiving a diagnosis of a personality disorder can also come with challenges. Some patients find that they are stigmatized for their condition, even by some health professionals.^[8]

How personality disorders affect others

Personality disorders don’t just affect the person with the disorder. Friends and family can also struggle.

People who care for someone with a Cluster A personality disorder may feel rejected or struggle to maintain close relationships in the face of social withdrawal and paranoia.

Cluster B personality disorders, especially antisocial personality disorder and narcissistic personality disorders, can be difficult for friends and family. People with these disorders may show little empathy and care for the feelings of others, which can be particularly damaging for their spouse or children. For example, 82% of people living with someone with narcissistic personality disorder had an anxiety disorder themselves.^[20]

Friends and family of those with a Cluster C personality disorder or BPD may find themselves being pushed into unsustainably intense relationships or pressured into providing high levels of attention and support.^[21]This can sometimes be to the detriment of their own well-being.

Treatment for personality disorder

Treatment for personality disorders is notoriously difficult. In most cases, a personality disorder is a long-standing mindset, incorporating thoughts, feelings, and behaviors that the person concerned doesn’t necessarily find problematic. By the time a condition is diagnosed, these are extremely well-established.

Treating personality disorders is also often complicated by the presence of other mental health disorders that co-occur with personality disorders. There is no standardized treatment for personality disorders, with doctors advised to approach each case individually. In many cases, the greatest improvements for patients are found by treating comorbid conditions.^[1]

This is especially true in terms of pharmacotherapy. There are no medications currently licensed by the FDA for the treatment of personality disorders.^[2]Medications such as antidepressants, antipsychotics, or benzodiazepines can be used to treat comorbid mental disorders, but they do not treat the underlying personality disorder.

Some researchers claim that there is little evidence for almost any treatments, while others suggest that treatments such as dialectical behavior therapy (DBT) and psychodynamic therapies can be effective.^[8]More recent research tends to be more optimistic about the ability to treat personality disorders. Treatment for personality disorders often prioritizes harm minimization and symptom management.^[22]

Self-management for personality disorders

While there are few evidence-based treatments for personality disorders, there are steps people with these disorders can take to try to minimize how much it impacts their lives.^[17]

One of the biggest challenges of personality disorders is that, to the person with the disorder, it often doesn’t seem as though there is anything wrong. As a result, one of the main goals of self-management is increased self-awareness. It’s helpful to learn as much as you can about the disorder. Learning about your personality disorder can also help you understand ways in which you are different from the people around you and might enable you to make sense of their behavior.

You might also want to get in touch with a support group for people with similar disorders. Such groups can allow you to feel seen and understood. You are also able to share coping strategies with other people who face similar struggles to you. Similarly, writing and mindfulness practices can help increase self-awareness and self-acceptance.

Finally, adopting a healthy lifestyle is always beneficial, especially for those who might be predisposed to risk-taking behavior or who regularly feel anxious. Ensuring that you get sufficient sleep and exercise, having a healthy diet, and avoiding drugs and alcohol can give you the energy and mental resources you need to take care of yourself.

Final thoughts

Personality disorders don’t represent character flaws and don’t come with a moral judgment. Although they are difficult to treat, psychosocial therapy, improved self-awareness, and patience can allow people with these disorders to overcome many of the challenges they face.