Personality disorder

Personality disorders (PD) are a class of

Treatment for personality disorders is primarily psychotherapeutic. Evidence-based psychotherapies for personality disorders include cognitive behavioral therapy, and dialectical behavior therapy especially for borderline personality disorder.^[10][11] A variety of psychoanalytic approaches are also used.^[12]

Personality disorders are associated with considerable

• the International Classification of Diseases (11th revision, ICD-11) published by the World Health Organization
• the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition, DSM-5) by the American Psychiatric Association.

The ICD is a collection of alpha-numerical codes which have been assigned to all known clinical states, and provides uniform terminology for medical records, billing, statistics and research. The DSM defines psychiatric diagnoses based on research and expert consensus. Both have deliberately aligned their diagnoses to some extent, but some differences remain. For example, the ICD-10 included narcissistic personality disorder in the group of other specific personality disorders, while DSM-5 does not include enduring personality change after catastrophic experience. The ICD-10 classified the DSM-5 schizotypal personality disorder as a form of schizophrenia rather than as a personality disorder. There are accepted diagnostic issues and controversies with regard to distinguishing particular personality disorder categories from each other.^[15] Dissociative identity disorder, previously known as multiple personality as well as multiple personality disorder, has always been classified as a dissociative disorder and never was regarded as a personality disorder.^[16]

DSM-5

The most recent fifth edition of the Diagnostic and Statistical Manual of Mental Disorders stresses that a personality disorder is an enduring and inflexible pattern of long duration leading to significant distress or impairment and is not due to use of substances or another medical condition. The DSM-5 lists personality disorders in the same way as other mental disorders, rather than on a separate 'axis', as previously.^[17]

DSM-5 lists ten specific personality disorders: paranoid, schizoid, schizotypal, antisocial, borderline, histrionic, narcissistic, avoidant, dependent and obsessive–compulsive personality disorder.

The DSM-5 also contains three diagnoses for personality patterns not matching these ten disorders, which nevertheless exhibit characteristics of a personality disorder:^[18]

• Personality change due to another medical condition – personality disturbance due to the direct effects of a medical condition
• Other specified personality disorder – disorder which meets the general criteria for a personality disorder but fails to meet the criteria for a specific disorder, with the reason given
• Unspecified personality disorder – disorder which meets the general criteria for a personality disorder but is not included in the DSM-5 classification

These specific personality disorders are grouped into the following three clusters based on descriptive similarities:

Cluster A (odd or eccentric disorders)

Cluster A personality disorders are often associated with schizophrenia: in particular, schizotypal personality disorder shares some of its hallmark symptoms with schizophrenia, e.g., acute discomfort in close relationships, cognitive or perceptual distortions, and eccentricities of behavior. However, people diagnosed with odd–eccentric personality disorders tend to have a greater grasp on reality than those with schizophrenia. People with these disorders can be paranoid and have difficulty being understood by others, as they often have odd or eccentric modes of speaking and an unwillingness and inability to form and maintain close relationships. Though their perceptions may be unusual, these anomalies are distinguished from delusions or hallucinations as people with these would be diagnosed with other conditions. Significant evidence suggests a small proportion of people with Cluster A personality disorders, especially schizotypal personality disorder, have the potential to develop schizophrenia and other psychotic disorders. These disorders also have a higher probability of occurring among individuals whose first-degree relatives have either schizophrenia or a Cluster A personality disorder.^[19]

• Paranoid personality disorder – pattern of irrational suspicion and mistrust of others, interpreting motivations as malevolent
• Schizoid personality disorder – cold affect and detachment from social relationships, apathy, and restricted emotional expression
• Schizotypal personality disorder – pattern of extreme discomfort interacting socially, and distorted cognition and perceptions

Cluster B (emotional or erratic disorders)

Cluster B personality disorders are characterized by dramatic, impulsive, self-destructive, emotional behavior and sometimes incomprehensible interactions with others.^[20]

• Antisocial personality disorder – pervasive pattern of disregard for and violation of the rights of others, lack of empathy, and lack of remorse, callousness, bloated self-image, and manipulative and impulsive behavior
• Borderline personality disorder – pervasive pattern of abrupt emotional outbursts, fear of abandonment, unhealthy attachment, altered empathy,^[21] and instability in relationships, self-image, identity, behavior and affect, often leading to self-harm and impulsivity
• attention-seeking behavior, including excessive emotions, an impressionistic style of speech, inappropriate seduction, exhibitionism
  , and egocentrism
• Narcissistic personality disorder – pervasive pattern of superior grandiosity, haughtiness, need for admiration, deceiving others, and lack of empathy (and, in more severe expressions, criminal behavior with remorse)^[22]

Cluster C (anxious or fearful disorders)

• Avoidant personality disorder – pervasive feelings of social inhibition and inadequacy, and extreme sensitivity to negative evaluation
• Dependent personality disorder – pervasive psychological need to be cared for by other people
• Obsessive–compulsive personality disorder – rigid conformity to rules, perfectionism, and control to the point of exclusion of leisurely activities and friendships (distinct from obsessive–compulsive disorder)

DSM-5 general criteria

Both the DSM-5 and the ICD-11 diagnostic systems provide a definition and six criteria for a general personality disorder. These criteria should be met by all personality disorder cases before a more specific diagnosis can be made.

The DSM-5 indicates that any personality disorder diagnosis must meet the following criteria:^[18]

• There is 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:
  • Cognition (i.e., ways of perceiving and interpreting self, other people, and events)
  • Affectivity (i.e., the range, intensity, lability, and appropriateness of emotional response)
  • Interpersonal functioning
  • 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 functioning, in social, occupational, or other important areas.
• The pattern is stable and of long duration, and its onset can be traced back at least to adolescence or early adulthood.
• The enduring pattern is not better explained as a manifestation or consequence of another mental disorder.
• The enduring pattern is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., head trauma).

ICD-11

The ICD-11 personality disorder section differs substantially from the previous edition, ICD-10. All distinct PDs have been merged into one: personality disorder (6D10), which can be coded as mild (6D10.0), moderate (6D10.1), severe (6D10.2), or severity unspecified (6D10.Z). There is also an additional category called personality difficulty (QE50.7), which can be used to describe personality traits that are problematic, but do not meet the diagnostic criteria for a PD. A personality disorder or difficulty can be specified by one or more prominent personality traits or patterns (6D11). The ICD-11 uses five trait domains:

1. Negative affectivity (6D11.0) – including anxiety, separation insecurity, distrustfulness, worthlessness and emotional instability
2. Detachment (6D11.1) – including social detachment and emotional coldness
3. Dissociality (6D11.2
   ) – including grandiosity, egocentricity, deception, exploitativeness and aggression
4. Disinhibition (6D11.3) – including risk-taking, impulsivity, irresponsibility and distractibility
5. Anankastia (6D11.4) – including rigid control over behaviour and affect and rigid perfectionism

Listed directly underneath is borderline pattern (6D11.5), a category similar to borderline personality disorder. This is not a trait in itself, but a combination of the five traits in certain severity.

In the ICD-11, any personality disorder must meet all of the following criteria:^[23]

• There is an enduring disturbance characterized by problems in functioning of aspects of the self (e.g., identity, self-worth, accuracy of self-view, self-direction), and/or interpersonal dysfunction (e.g., ability to develop and maintain close and mutually satisfying relationships, ability to understand others' perspectives and to manage conflict in relationships).
• The disturbance has persisted over an extended period of time (e.g., lasting 2 years or more).
• The disturbance is manifest in patterns of cognition, emotional experience, emotional expression, and behaviour that are maladaptive (e.g., inflexible or poorly regulated).
• The disturbance is manifest across a range of personal and social situations (i.e., is not limited to specific relationships or social roles), though it may be consistently evoked by particular types of circumstances and not others.
• The symptoms are not due to the direct effects of a medication or substance, including withdrawal effects, and are not better accounted for by another mental disorder, a disease of the nervous system, or another medical condition.
• The disturbance is associated with substantial distress or significant impairment in personal, family, social, educational, occupational or other important areas of functioning.
• Personality disorder should not be diagnosed if the patterns of behaviour characterizing the personality disturbance are developmentally appropriate (e.g., problems related to establishing an independent self-identity during adolescence) or can be explained primarily by social or cultural factors, including socio-political conflict.

ICD-10

The ICD-10 lists these general guideline criteria:^[24]

• Markedly disharmonious attitudes and behavior, generally involving several areas of functioning, e.g. affectivity, arousal, impulse control, ways of perceiving and thinking, and style of relating to others;
• The abnormal behavior pattern is enduring, of long standing, and not limited to episodes of mental illness;
• The abnormal behavior pattern is pervasive and clearly maladaptive to a broad range of personal and social situations;
• The above manifestations always appear during childhood or adolescence and continue into adulthood;
• The disorder leads to considerable personal distress but this may only become apparent late in its course;
• The disorder is usually, but not invariably, associated with significant problems in occupational and social performance.

The ICD adds: "For different cultures it may be necessary to develop specific sets of criteria with regard to social norms, rules and obligations."^[24]

Chapter V in the ICD-10 contains the mental and behavioral disorders and includes categories of personality disorder and enduring personality changes. They are defined as ingrained patterns indicated by inflexible and disabling responses that significantly differ from how the average person in the culture perceives, thinks, and feels, particularly in relating to others.^[25]

The specific personality disorders are:

In addition to classifying by category and cluster, it is possible to classify personality disorders using additional factors such as severity, impact on social functioning, and attribution.^[41]

Severity

This involves both the notion of personality difficulty as a measure of subthreshold scores for personality disorder using standard interviews and the evidence that those with the most severe personality disorders demonstrate a "ripple effect" of personality disturbance across the whole range of mental disorders. In addition to subthreshold (personality difficulty) and single cluster (simple personality disorder), this also derives complex or diffuse personality disorder (two or more clusters of personality disorder present) and can also derive severe personality disorder for those of greatest risk.

There are several advantages to classifying personality disorder by severity:^[41]

• It not only allows for but also takes advantage of the tendency for personality disorders to be comorbid with each other.
• It represents the influence of personality disorder on clinical outcome more satisfactorily than the simple dichotomous system of no personality disorder versus personality disorder.
• This system accommodates the new diagnosis of severe personality disorder, particularly "dangerous and severe personality disorder" (DSPD).

Effect on social functioning

Social function is affected by many other aspects of mental functioning apart from that of personality. However, whenever there is persistently impaired social functioning in conditions in which it would normally not be expected, the evidence suggests that this is more likely to be created by personality abnormality than by other clinical variables.^[43] The Personality Assessment Schedule^[44] gives social function priority in creating a hierarchy in which the personality disorder creating the greater social dysfunction is given primacy over others in a subsequent description of personality disorder.

Attribution

Many who have a personality disorder do not recognize any abnormality and defend valiantly their continued occupancy of their personality role. This group have been termed the Type R, or treatment-resisting personality disorders, as opposed to the Type S or treatment-seeking ones, who are keen on altering their personality disorders and sometimes clamor for treatment.^[41] The classification of 68 personality disordered patients on the caseload of an assertive community team using a simple scale showed a 3 to 1 ratio between Type R and Type S personality disorders with Cluster C personality disorders being significantly more likely to be Type S, and paranoid and schizoid (Cluster A) personality disorders significantly more likely to be Type R than others.^[45]

There is a considerable personality disorder diagnostic co-occurrence. Patients who meet the DSM-IV-TR diagnostic criteria for one personality disorder are likely to meet the diagnostic criteria for another.^[47] Diagnostic categories provide clear, vivid descriptions of discrete personality types but the personality structure of actual patients might be more accurately described by a constellation of maladaptive personality traits.

Sites used DSM-III-R criterion sets. Data obtained for purposes of informing the development of the DSM-IV-TR personality disorder diagnostic criteria.

Abbreviations used: PPD – Paranoid Personality Disorder, SzPD – Schizoid Personality Disorder, StPD – Schizotypal Personality Disorder, ASPD – Antisocial Personality Disorder, BPD – Borderline Personality Disorder, HPD – Histrionic Personality Disorder, NPD – Narcissistic Personality Disorder, AvPD – Avoidant Personality Disorder, DPD – Dependent Personality Disorder, OCPD – Obsessive–Compulsive Personality Disorder, PAPD – Passive–Aggressive Personality Disorder.

The disorders in each of the three clusters may share with each other underlying common vulnerability factors involving cognition, affect and impulse control, and behavioral maintenance or inhibition, respectively. But they may also have a spectrum relationship to certain syndromal mental disorders:^[47]

• Paranoid, schizoid or schizotypal personality disorders may be observed to be premorbid antecedents of delusional disorders or schizophrenia.
• Borderline personality disorder is seen in association with
  eating disorders, ADHD, ASD, or a substance use disorder
  .
• Avoidant personality disorder is seen with social anxiety disorder.

Impact on functioning

It is generally assumed that all personality disorders are linked to impaired functioning and a reduced quality of life (QoL) because that is a basic diagnostic requirement. But research shows that this may be true only for some types of personality disorder.

In several studies, higher levels of disability and lower QoL were predicted by avoidant, dependent, schizoid, paranoid, schizotypal and antisocial personality disorders. This link is particularly strong for

One study investigated some aspects of "life success" (status, wealth and successful intimate relationships). It showed somewhat poor functioning for schizotypal, antisocial, borderline and dependent PD, schizoid PD had the lowest scores regarding these variables. Paranoid, histrionic and avoidant PD were average. Narcissistic and obsessive–compulsive PD, however, had high functioning and appeared to contribute rather positively to these aspects of life success.[9]

There is also a direct relationship between the number of diagnostic criteria and quality of life. For each additional personality disorder criterion that a person meets there is an even reduction in quality of life.^[49] Personality disorders – especially dependent, narcissistic, and sadistic personality disorders – also facilitate various forms of counterproductive work behavior, including knowledge hiding and knowledge sabotage.^[50]

Issues

In the workplace

Depending on the diagnosis, severity and individual, and the job itself, personality disorders can be associated with difficulty coping with work or the workplace—potentially leading to problems with others by interfering with

In 2005 and again in 2009, psychologists Belinda Board and Katarina Fritzon at the University of Surrey, UK, interviewed and gave personality tests to high-level British executives and compared their profiles with those of criminal psychiatric patients at Broadmoor Hospital in the UK. They found that three out of eleven personality disorders were actually more common in executives than in the disturbed criminals:

• manipulation
• Narcissistic personality disorder: including grandiosity, self-focused lack of empathy for others, exploitativeness and independence.
• Obsessive–compulsive personality disorder: including perfectionism, excessive devotion to work, rigidity, stubbornness and dictatorial tendencies.^[53]

According to leadership academic Manfred F.R. Kets de Vries, it seems almost inevitable that some personality disorders will be present in a senior management team.^[54]

In children

Early stages and preliminary forms of personality disorders need a multi-dimensional and early treatment approach. Personality development disorder is considered to be a childhood risk factor or early stage of a later personality disorder in adulthood.^[55] In addition, in Robert F. Krueger's review of their research indicates that some children and adolescents do experience clinically significant syndromes that resemble adult personality disorders, and that these syndromes have meaningful correlates and are consequential. Much of this research has been framed by the adult personality disorder constructs from Axis II of the Diagnostic and Statistical Manual. Hence, they are less likely to encounter the first risk they described at the outset of their review: clinicians and researchers are not simply avoiding use of the PD construct in youth. However, they may encounter the second risk they described: under-appreciation of the developmental context in which these syndromes occur. That is, although PD constructs show continuity over time, they are probabilistic predictors; not all youths who exhibit PD symptomatology become adult PD cases.^[55]

Versus normal personality