Classifying Personality Disorders

The DSM-5 defines personality disorders 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 consideration of cultural context is perhaps the most significant change in this definition from earlier editions. The DSM-5 suggests that the personality disorders can be grouped into three clusters, plus a “not otherwise specified” category, for a total of 11 specific diagnoses, the authors caution that the identified clusters have not been consistently validated and that individuals may present combinations of personality disorders from different clusters. Cluster A, the odd or eccentric types, are paranoid, schizoid, and schizotypal personality disorders. Cluster B, the dramatic, emotional, or erratic types, are antisocial, borderline, histrionic, and narcissistic personality disorders. And finally, Cluster C, the anxious or fearful types, are the avoidant, dependent, and obsessive-compulsive personality disorders.

The table provides a description of each of the DSM-5 personality disorders:

This list of 10 though does not fully cover all the different ways in which a personality can be maladaptive. DSM-5 also includes a “wastebasket” diagnosis of other specified personality disorder (OSPD) and unspecified personality disorder (UPD). This diagnosis is used when a clinician believes that a patient has a personality disorder but the traits that constitute this disorder are not well covered by one of the 10 existing diagnoses. OSPD and UPD, or as they used to be referred to in previous editions PDNOS (personality disorder not otherwise specified), are often one of the most frequently used diagnoses in clinical practice, suggesting that the current list of 10 is not adequately comprehensive (Widiger & Trull, 2007).

Slightly over 9% of the U.S. population suffers from a personality disorder, with avoidant and schizoid personality disorders the most frequent (Lezenweger, Lane, Loranger, & Kessler, 2007). Two of these personality disorders, borderline personality disorder and antisocial personality disorder, are regarded by many as especially problematic.

Description

Each of the 10 DSM-5 personality disorders is a constellation of maladaptive personality traits, rather than just one particular personality trait (Lynam & Widiger, 2001). In this regard, personality disorders are syndromes. For example, avoidant personality disorder is a pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation (APA, 2013), which is a combination of traits from introversion (e.g., socially withdrawn, passive, and cautious) and neuroticism (e.g., self-consciousness, apprehensiveness, anxiousness, and worrisome). Dependent personality disorder includes submissiveness, clinging behavior, and fears of separation (APA, 2013), for the most part a combination of traits of neuroticism (anxious, uncertain, pessimistic, and helpless) and maladaptive agreeableness (e.g., gullible, guileless, meek, subservient, and self-effacing). Antisocial personality disorder is, for the most part, a combination of traits from antagonism (e.g., dishonest, manipulative, exploitative, callous, and merciless) and low conscientiousness (e.g., irresponsible, immoral, lax, hedonistic, and rash). See the 1967 movie Bonnie and Clyde, starring Warren Beatty, for a nice portrayal of someone with antisocial personality disorder.

Some of the DSM-5 personality disorders are confined largely to traits within one of the basic domains of personality. For example, obsessive-compulsive personality disorder is largely a disorder of maladaptive conscientiousness, including such traits as workaholism, perfectionism, punctilious, ruminative, and dogged; schizoid is confined largely to traits of introversion (e.g., withdrawn, cold, isolated, placid, and anhedonic); borderline personality disorder is largely a disorder of neuroticism, including such traits as emotionally unstable, vulnerable, overwhelmed, rageful, depressive, and self-destructive (watch the 1987 movie Fatal Attraction, starring Glenn Close, for a nice portrayal of this personality disorder); and histrionic personality disorder is largely a disorder of maladaptive extraversion, including such traits as attention-seeking, seductiveness, melodramatic emotionality, and strong attachment needs (see the 1951 film adaptation of Tennessee William’s play Streetcar Named Desire, starring Vivian Leigh, for a nice portrayal of this personality disorder).

It should be noted though that a complete description of each DSM-5 personality disorder would typically include at least some traits from other domains. For example, antisocial personality disorder (or psychopathy) also includes some traits from low neuroticism (e.g., fearlessness and glib charm) and extraversion (e.g., excitement-seeking and assertiveness); borderline includes some traits from antagonism (e.g., manipulative and oppositional) and low conscientiousness (e.g., rash); and histrionic includes some traits from antagonism (e.g., vanity) and low conscientiousness (e.g., impressionistic). Narcissistic personality disorder includes traits from neuroticism (e.g., reactive anger, reactive shame, and need for admiration), extraversion (e.g., exhibitionism and authoritativeness), antagonism (e.g., arrogance, entitlement, and lack of empathy), and conscientiousness (e.g., acclaim-seeking). Schizotypal personality disorder includes traits from neuroticism (e.g., social anxiousness and social discomfort), introversion (e.g., social withdrawal), unconventionality (e.g., odd, eccentric, peculiar, and aberrant ideas), and antagonism (e.g., suspiciousness).

The APA currently conceptualizes personality disorders as qualitatively distinct conditions distinct from each other and from normal personality functioning. However, included within an appendix to DSM-5 is an alternative view that personality disorders are simply extreme and/or maladaptive variants of normal personality traits, as suggested herein. Nevertheless, many leading personality disorder researchers do not hold this view (e.g., Gunderson, 2010; Hopwood, 2011; Shedler et al., 2010). Researchers suggest that there is something qualitatively unique about persons suffering from a personality disorder, usually understood as a form of pathology in sense of self and interpersonal relatedness that is considered to be distinct from personality traits (APA, 2012; Skodol, 2012). For example, it has been suggested that antisocial personality disorder includes impairments in identity (e.g., egocentrism), self-direction, empathy, and capacity for intimacy, which are said to be different from such traits as arrogance, impulsivity, and callousness (APA, 2012).

Validity of Personality Disorders

In future revisions of the DSM, some of the personality disorders included in DSM-5 and DSM-4-TR will no longer be included. In fact, for DSM-5 it was originally proposed that four be deleted. The personality disorders that were slated for deletion were histrionic, schizoid, paranoid, and dependent (APA, 2012). The rationale for the proposed deletions was in large part because they are said to have less empirical support than the diagnoses that were at the time being retained (Skodol, 2012). There is agreement within the field with regard to the empirical support for borderline, antisocial, and schizotypal personality disorders (Mullins-Sweat, Bernstein, & Widiger, 2012; Skodol, 2012). However, there is a difference of opinion with respect to the empirical support for the dependent personality disorder (Bornstein, 2012; Livesley, 2011; Miller, Widiger, & Campbell, 2010; Mullins-Sweat et al., 2012).