Introduction to the Personality Disorders

 Basic Concept of a Personality Disorder

Personality disorders (PDs) tend to be pervasive, life long disorders. People with PDs carry with them destructive patterns of thinking, feeling, and behaving as their way of being and interacting with the world and others. In order to be classified as a personality disorder the personality traits must be inflexible, be maladaptive and cause functional impairment or subjective distress. Onset begins in adolescence or early adulthood and is generally stable over time. They tend to be incredibly difficult to treat, in no small part because people with personality disorders often do not view themselves as actually having a problem, and they tend to frame reality in terms of their needs and perceptions, and are unable to understand the perspectives of others. For instance, most people with Narcissistic personality disorder are actually convinced they are as wonderful as they profess themselves to be. Similarly, people who suffer from schizophrenia see no problem with the fact that they do not like people, this to them is not a disorder, only a character trait. A person with antisocial personality disorder might resist treatment because they see the psychologist as trying to gain dominance over them, viewing it as if the psychologist is trying to change them to be submissive, weak and pathetic like the way they view the psychologist has. On the other hand they may even think that the psychologist really is trying to help, but is simply confused about the harsh and cruel nature of reality. Another reason for why they are difficult to treat include their limited ability to receive, accept, or benefit from corrective feedback. Another difficulty during treatment is the strong counter-transference clinicians have while working with them.

People with PDs are also often fully mentally functional. Though their views of reality may be distorted or odd, this is not due to impairment in mental function. Many people at the top of corporations, for example the CEOs of Enron, could easily be diagnosed with antisocial PD. In this way, the PDs tend to be seen somewhat differently than the other ‘mental disorders’ instead is seen as a deficit. Those with PDs, it is quite literally a change in the nature of the cognition, rather than a reduction in the potency thereof, and due to this, treatment can be difficult. It is also different from those with mood disorders where the person is usually not as resistant to treatment. People with PD often have strong wills and ideas, and the intelligence to back up what they experience and rationalize it.

Also due to these traits, people do not often bring themselves in for treatment for personality disorders. People with personality disorders tend to be either court-ordered to attend therapy, as is often the case with antisocial personality disorder or borderline personality disorder. Those who are treated may be pushed into it by family and friends, which is the case more often in paranoid personality disorder or dependent personality disorder. This is very different from the anxiety or mood disorders, where the person quite often attends therapy in order to see an increase in the quality of their life. There are also very few, if any PDs that seem to respond well to pharmaceutical treatment in fact, there does not seem to be many treatments at all that seem to work well for this spectrum of disorders and each person suffering from them is not the same as the next. Prevalence rates for PD is about 10-15% of the general population, along with 50% in clinical settings and 50% in the inmate population meet the criteria for ASPD, Antisocial Personality Disorder.

The presence of other mental disorders, such as mood, anxiety, and psychotic disorders can worsen the course and severity of Personality Disorders. People with any one of the 10 Personality Disorders are at an increased likelihood of being diagnosed with another Personality Disorder. In clinical practice, clients will often have more than one PD and might have features of many (Substance Abuse and Mental Health Services Administration (SAMHSA), 2009).

Finally, the PDs are broken up into 3 clusters, named simply Cluster A, B and C. Cluster A focuses on the odd or eccentric disorders, cluster B focuses on the dramatic, emotional and erratic disorders and Cluster C focuses on the anxious and fearful disorders. The clusters are defined as follows:

Cluster A

Paranoid, Schizotypal, and Schiziod Personality Disorders

This cluster includes the “odd” or eccentric” disorders. Those who suffer from the Cluster A disorders may act socially detached, suspicious, and distrustful. These disorders are the closest PDs to the stereotypical psychiatric disorders: the psychotic disorders. With cluster A we see very odd behaviors, and a distinct separation from reality. However, this is not occurring on a sensory level as can be seen in the psychotic disorders. The schism (meaning break or gap, from which schizophrenia, schizotypal and schizoid got their name) from reality occurs on a cognitive level. In each of the Cluster A disorders, the nature of the separation is different. In Paranoia, where the person experiences delusions and is a generalized separation, the nature of the world itself (the fact that it is incredibly unlikely anyone cares enough to do anything to the paranoid person) is at a distance from the sufferer.

In Schizoid PD, the person is isolated from both enjoyment, and sociability. In Schizophrenia, the chasm, or breach, that must be crossed is to reality itself. Understanding of the rules of nature, or of social rules seems to be very difficult, but unlike in Schizoid PD, the desire to interact is there, and unlike Paranoid PD, people suffering from Schizophrenia do not have the anxieties or fears of the world or people in it.

Schizoid vs Schizotypal Personality Disorders
  • The major reason for the distinction is the relationship between schizotypal personality and schizophrenia.
  • There is a much higher prevalence of schizophrenia among first degree relatives of patients with schizotypal personality than among relatives of people with any other personality disorder.
  • Thinking is more distorted and closer to psychosis in schizotypal personality than in schizoid personality
  • Patients with schizoid personality disorder are more likely to seek therapy
  • Patients with schizotypal personality disorder are less likely to seek therapy, but are more likely to find a group of eccentrics who have similar beliefs.

Cluster B

Histrionic, Narcissistic, Antisocial, and Borderline Personality Disorder.

This cluster includes disorders where the individual is viewed as being overly emotional or erratic in his or her behavior. The individual’s behavior tends to be impulsive, may be dramatic, and may have antisocial features. People who suffer from Narcissism for example tend to have excessive amounts of vanity, fascination with themselves, above and beyond egocentrism. Antisocial personality disorder sufferers have an unusual disregard for others, including others rights and feelings. They may show no remorse for their actions, such as, hurting others and stealing. Unfortunately it is difficult to diagnose due to substance abuse is some situations. Borderline Personality Disorder is called such because it is close to being considered a psychiatric disorder. This disorder is characterized by extreme mood swings, impulsiveness and aggression.

Characteristics of People with Antisocial and Borderline Personality Disorders (SAMHSA, 2009)
Characteristic Antisocial Borderline
Affect Angry intimidation Angry self-harm
World View

If you don’t do what I want, you’ll be sorry

I deserve it all

They’re the ones with the problem

I’ve got to get you before you get me

I don’t deserve to exist

Help me, help me, but you can’t

Presenting Problem

Legal difficulties

polysubstance abuse

dependence

parasitic relationships

Self-harm

impulsive behavior

episodic polysubstance abuse

hot-and-cold relationships

Social Functioning Episodic achievement Gross dysfunctioning
Motivation Self-esteem Safety
Defenses

rationalization

projection

splitting

projection

Cluster C

Avoidant, Dependent, and Obsessive-Compulsive Personality Disorder.

This cluster includes the disorders where the individual appears anxious or fearful. In this specific instance, these disorders resemble Anxiety Disorders, which make it harder to differentially diagnose. These disorders are pretty much self explanatory in there title. Avoidant is just that, a tendency to avoid intimacy or interaction with others. Dependent is dependent on others and Obsessive-compulsive disorder, where the person repeats the same everyday activities repeatedly, has lack of openness and flexibility in their everyday functions and relationships. Fortunately this is highly treatable but not easily done, these people tend to dislike describing the events and situations that occur in their lives.

Some Statistics Regarding Personality Disorders

  • Personality disorders affect about 15 million adults in the United States. Approximately 10 to 13 percent of the U.S. population meets the diagnostic criteria for a personality disorder at some point in his or her life. These disorders, however, have the highest rate of misdiagnosis than any other categories. Personality disorders present themselves as being a maladaptive presence, meaning they develop highly unsuitably adaptive symptoms in the lives of those affected. Most people can live relatively normal lives with mild personality disorders, however in times of extreme stress, symptoms can increase and become disruptive in everyday activities.
  • The DSM-IV-TR defines a personality disorder as “…an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment… The clinician should assess the stability of personality traits over time and across different situations.”
  • Personality disorders are usually only diagnosed for person’s over the age 18. There is the exception that if the individual shows symptoms for at least, or above, 1 year then they can be diagnosed. As noted below, however, minors cannot be diagnosed with antisocial personality disorder.
  • 35% of admissions to a methadone maintenance program have a Personality Disorder (SAMHSA, 2009).

General diagnostic criteria for a Personality Disorder according to the DSM-IV-TR

  • An enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture. This pattern is manifested in two (or more) of the following areas:
  1. cognition (the ways of perceiving and interpreting self, other people, and events)
  2. affectivity (the range, intensity, ability, and appropriateness of emotional response)
  3. interpersonal functioning
  4. impulse control
  • The enduring pattern is inflexible and pervasive across a broad range of personal and social situations.
  • The enduring pattern leads to clinically significant distress or impairment in social, occupational, or other important areas of functioning.
  • The pattern is stable and continues for long durations, and its onset can be traced back to as far as adolescence or early adulthood.
  • The enduring pattern is not better accounted for as a manifestation or consequence of another mental disorder.
  • The enduring pattern is not due to the direct physiological effects of a substance (e.g., drug abuse, medication) or a general medical condition (e.g., head trauma).

DSM-V Changes

  • The work group recommends a major re-conceptualization of personality psychopathology with core impairments in personality functioning, pathological personality traits, and prominent pathological personality types. Personality disorders are diagnosed when core impairments and pathological traits are severe and other criteria are met. The criteria are as follows:
    • 5 identified severity levels of personality functioning
    • 5 personality disorder types, each defined by core PD components and a subset of:
      • 6 broad, higher order personality trait domains, with 4-10 lower order, more specific trait facets comprising each, for a total of 37 specific trait facets
    • a new general definition of personality disorder based on severe or extreme deficits in core components of personality functioning and elevated pathological traits
  • New general definition
    • Adaptive failure is manifested in one or both of the following area
      • Impaired sense of self-identity as evidence by one or more of the following:
        • Identity integration. Poorly integrated sense of self or identity (e.g., limited sense of personal unity and continuity; experiences shifting self-states; believes that the self presented to the world is a false appearance)
        • Integrity of self-concept. Impoverished and poorly differentiated sense of self or identity (e.g., difficulty identifying and describing self attributes; sense of inner emptiness; poorly defined interpersonal boundaries; definition of the self changes with social context)
        • Self-directedness. Low self-directedness (e.g., unable to set and attain satisfying and rewarding personal goals; lacks direction, meaning, and purpose in life)
      • Failure to develop effective interpersonal functioning as manifested by one or more of the following:
        • Empathy. Impaired empathic and reflective capacity (e.g., finds it difficult to understand the mental states of others)
        • Intimacy. Impaired capacity for close relationships (e.g., unable to establish or maintain closeness and intimacy; inability to function as an effective attachment figure; inability to establish and maintain relationships)
        • Cooperativeness. Failure to develop the capacity for pro-social behavior (e.g., failure to develop the capacity for socially typical moral behavior; absence of altruism, the sense of unselfish concern).
        • Complexity and integration of representations of others. Poorly integrated representations of others (e.g., forms separate and poorly related images of significant others)
    • Adaptive failure:
      • is associated with extreme levels of one or more personality traits.
      • is relatively stable across time and consistent across situations with an onset that can be traced back to adolescence.
      • is not solely explained as a manifestation or consequence of another mental disorder
      • is not solely due to the direct physiological effects of a substance (e.g., drug abuse, medication) or a general medical condition (e.g., severe head trauma)

(American Psychiatric Association (APA), 2010)

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