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(See also Dissociative Disorders: Dissociative Identity Disorder.)

Personality disorders are pervasive, inflexible, and stable patterns of behavior that cause significant distress or functional impairment. Ten distinct personality disorders have been identified and grouped into 3 clusters. All are believed to be caused by a combination of genetic and environmental factors. Diagnosis is clinical. Treatment is with psychotherapy and sometimes drug therapy.

Personality traits are patterns of thinking, perceiving, reacting, and relating that are relatively stable over time and in various situations. Personality traits are usually evident from late adolescence or early adulthood, and although many traits persist throughout much of life, some fade with aging and some can be modified. Personality disorders exist when these traits become so rigid and maladaptive that they impair functioning. Mental coping mechanisms (defenses) that are used unconsciously at times by everyone tend to be immature and maladaptive in people with personality disorders (see Table 1: Personality Disorders: Coping Mechanisms).

Table 1
Coping Mechanisms Mechanism Definition Result Personality Disorders Involved Projection Attribution of a person's unacknowledged feelings to other people Leads to prejudice, fears of intimacy, excessive suspicion and vigilance, and injustice collecting Typical of paranoid and schizotypal personalities Used by people with borderline, antisocial, or narcissistic personality when under acute stress Splitting Black-or-white, all-or-nothing perceptions or thinking, in which people are divided into all-good idealized saviors or all-bad evildoers Avoids the discomfort of feeling ambivalent (ie, having loving and angry feelings for the same person), uncertain, and helpless Typical of borderline personality Acting out A direct behavioral expression of an unconscious wish or impulse that enables a person to avoid being conscious of the accompanying painful or pleasurable effect Self-mutilation, often manifested as cutting, is a form of acting out Leads to many delinquent, reckless, promiscuous, and substance-abusing acts, which can become so habitual that the actor remains unaware and dismissive of the feelings that initiated the acts Self-mutilation counteracts psychogenic pain from feelings of rejection and other stresses Very common in people with antisocial, cyclothymic, or borderline personality Turning aggression against self Turning angry feelings toward other people toward the self; when indirect, called passive aggression, when direct, called self-mutilation (see Acting out, above) Internalizes feelings about other people's failures; engages in silly, provocative clowning Underlies passive-aggressive and depressive personality Dramatic in people with borderline personality, who express anger toward others in self-mutilation Fantasy A tendency to use imaginary relationships and private belief systems to resolve conflict and relieve loneliness Leads to eccentricity and avoidance of intimacy Used by people with avoidant or schizoid personality, who, in contrast to psychotic people, do not believe in and thus do not act on their fantasies Hypochondriasis (see Somatoform and Factitious Disorders: Hypochondriasis) Uses physiologic complaints to gain attention May gain nurturant attention from other people; may express anger toward other people without their knowing it Used by people with dependent, histrionic, or borderline personality

People with personality disorders are often frustrating and even infuriating to people around them (including physicians). Most are distressed about their lives and have impaired work or social relationships. Personality disorders often coexist with mood, anxiety, substance abuse, and eating disorders. People with severe personality disorders are at high risk of hypochondriasis and violent or self-destructive behaviors. They may have inconsistent, detached, overemotional, abusive, or irresponsible styles of parenting, leading to physical and mental problems in their children.

About 13% of the general population is affected. Antisocial personality disorder occurs in about 2%, with men outnumbering women 6:1. Borderline personality disorder occurs in about 1%, with women outnumbering men 3:1.

Classification

The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition Text Revision (DSM-IV-TR) recognizes 10 distinct personality disorders and divides them into 3 clusters:

• A: Odd/eccentric
• B: Dramatic/erratic
• C: Anxious/fearful

Cluster A: Patients tend to be detached and distrustful.

Paranoid personality involves coldness and distancing in relationships, with a need for control and a tendency toward jealousy if attachments are formed. Affected people are often secretive and untrusting. They tend to be suspicious of changes and frequently find hostile and malevolent motives behind other people's acts. Often, these hostile motives represent projections (see Table 1: Personality Disorders: Coping Mechanisms) of their own hostilities onto others. Their reactions sometimes surprise or scare others. They then use the resulting anger of or rejection by others (ie, projective identification) to justify their original feelings. Paranoid people tend to feel a sense of righteous indignation and often take legal action against others. These people may be highly efficient and conscientious, although they usually need to work in relative isolation. This disorder must be differentiated from paranoid schizophrenia.

Schizoid personality is characterized by introversion, social withdrawal, isolation, and emotional coldness and distancing. Affected people are often absorbed in their own thoughts and feelings and fear closeness and intimacy with other people. They are reticent, are given to daydreaming, and prefer theoretical speculation to practical action.

Schizotypal personality, like schizoid personality, involves social withdrawal and emotional coldness but also includes oddities of thinking, perception, and communication, such as magical thinking, clairvoyance, ideas of reference, or paranoid ideation. These oddities suggest schizophrenia (see Schizophrenia and Related Disorders: Schizophrenia) but are never severe enough to meet its criteria. People with schizotypal personality are believed to have a muted expression of the genes that cause schizophrenia.

Cluster B: Patients tend to be emotionally unstable, impulsive, and intense.

Borderline personality is marked by unstable self-image, mood, behavior, and relationships. Affected people tend to believe they were deprived of adequate care during childhood and consequently feel empty, angry, and entitled to nurturance. As a result, they relentlessly seek care and are sensitive to its perceived absence. Their relationships tend to be intense and dramatic. When feeling cared for, they appear like lonely waifs who seek help for depression, substance abuse, eating disorders, and past mistreatments. When they fear the loss of the caring person, they frequently express inappropriate and intense anger. These mood shifts are typically accompanied by extreme changes in their view of the world, themselves, and other people—eg, from bad to good, from hated to loved. When they feel abandoned, they dissociate or become desperately impulsive. Their concept of reality is sometimes so poor that they have brief episodes of psychotic thinking, such as paranoid delusions and hallucinations. They often become self-destructive and may cut themselves (self-mutilate) or attempt suicide. They initially tend to evoke intense, nurturing responses in caretakers, but after repeated crises, vague unfounded complaints, and failures to comply with therapeutic recommendations, they are viewed as help-rejecting complainers. Borderline personality tends to become milder or to stabilize with aging. (See also the American Psychiatric Association's Guideline Watch: Practice Guideline for the Treatment of Patients With Borderline Personality Disorder.)

Antisocial personality is marked by the callous disregard for the rights and feelings of other people. Affected people exploit others for materialistic gain or personal gratification. They become frustrated easily and tolerate frustration poorly. Characteristically, they act out (see Table 1: Personality Disorders: Coping Mechanisms) their conflicts impulsively and irresponsibly, sometimes with hostility and violence. They usually do not anticipate the consequences of their behaviors and typically do not feel remorse or guilt afterward. Many of them have a well-developed capacity for glibly rationalizing their behavior or blaming it on others. Dishonesty and deceit permeate their relationships. Punishment rarely modifies their behavior or improves their judgment. Antisocial personality often leads to alcoholism, drug addiction, promiscuity, failure to fulfill responsibilities, frequent relocation, and difficulty abiding by laws. Life expectancy is decreased, but the disorder tends to diminish or stabilize with aging.

Narcissistic personality involves grandiosity. Affected people have an exaggerated sense of superiority and expect to be treated with deference. Their relationships are characterized by a need to be admired, and they are extremely sensitive to criticism, failure, or defeat. When confronted with a failure to fulfill their high opinion of themselves, they can become enraged or seriously depressed and suicidal. They often believe other people envy them. They may exploit others because they think their superiority justifies it.

Histrionic personality involves conspicuous attention seeking. Affected people are also overly conscious of appearance and are dramatic. Their expression of emotions often seems exaggerated, childish, and superficial. Still, they frequently evoke sympathetic or erotic attention from other people. Relationships are often easily established and overly sexualized but tend to be superficial and transient. Behind their seductive behaviors and their tendency to exaggerate somatic problems (ie, hypochondriasis) often lie more basic wishes for dependency and protection.

Cluster C: Patients tend to be nervous and passive or rigid and preoccupied.

Dependent personality is characterized by the surrender of responsibility to other people. Affected people may submit to others to gain and maintain support. For example, they often allow the needs of people they depend on to supersede their own. They lack self-confidence and feel intensely inadequate about taking care of themselves. They believe that others are more capable, and they are reluctant to express their views for fear that their aggressiveness will offend the people they need. Dependency in other personality disorders may be hidden by obvious behavioral problems; eg, histrionic or borderline behaviors mask underlying dependency.

Avoidant personality is marked by hypersensitivity to rejection and fear of starting relationships or anything new because of the risk of failure or disappointment. Because affected people have a strong conscious desire for affection and acceptance, they are openly distressed by their isolation and inability to relate comfortably to other people. They respond to even small hints of rejection by withdrawing.

Obsessive-compulsive personality is characterized by conscientiousness, orderliness, and reliability, but inflexibility often makes affected people unable to adapt to change. They take responsibilities seriously, but because they hate mistakes and incompleteness, they can become entangled with details and forget their purpose. As a result, they have difficulty making decisions and completing tasks. Such problems make responsibilities a source of anxiety, and they rarely enjoy much satisfaction from their achievements. Most obsessive-compulsive traits are adaptive, and as long as they are not too marked, people who have them often achieve much, especially in the sciences and other academic fields in which order, perfectionism, and perseverance are desirable. However, they can feel uncomfortable with feelings, interpersonal relationships, and situations in which they lack control, they must rely on other people, or events are unpredictable.

Other personality types: Several other personality types have been described but are not classified as disorders in the DSM-IV-TR.

Passive-aggressive (negativistic) personality typically produces the appearance of ineptness or passivity, but these behaviors are covertly designed to avoid responsibility or to control or punish other people. Passive-aggressive behavior is often evidenced by procrastination, inefficiency, or unrealistic protests of disability. Frequently, affected people agree to do tasks they do not want to do and then subtly undermine completion of the tasks. Such behavior usually serves to deny or conceal hostility or disagreements.

Cyclothymic personality (see also Mood Disorders: Cyclothymic Disorder) alternates between high-spirited buoyancy and gloomy pessimism; each mood lasts weeks or longer. Characteristically, the rhythmic mood changes are regular and occur without justifiable external cause. When these features do not interfere with social adaptation, cyclothymia is considered a temperament and is present in many gifted and creative people.

Depressive personality is characterized by chronic moroseness, worry, and self-consciousness. Affected people have a pessimistic outlook, which impairs their initiative and disheartens other people. Self-satisfaction seems undeserved and sinful. They unconsciously believe their suffering is a badge of merit needed to earn the love or admiration of others.

Diagnosis

Specific personality disorders are diagnosed based on DSM-IV-TR criteria. The general criteria in DSM-IV-TR emphasize the need to consider whether other mental or physical disorders (eg, depression, substance abuse, hyperthyroidism) can account for the patient's patterns of behavior.

Patients' emotional reactions and their perspectives on what causes their problems and how other people treat them can provide information about their disorder. Diagnosis is based on observing repetitive patterns of behavior or perceptions that cause distress and impair social functioning. Because the patient often lacks insight into these patterns, physicians may initially seek information from and evaluation by others who interact with the patient. Often, physicians suspect a personality disorder based on their own discomfort, typically if they begin to feel angry or defensive.

Treatment

Although treatment differs according to the type of personality disorder, some general principles apply:

• Family members and friends can act in ways that either reinforce or diminish the patient's problematic behavior or thoughts; thus, their involvement is helpful and often essential.
• An early effort should be made to get patients to see that the problem is really based on who they are.
• Treating a personality disorder takes a long time; repetitious confrontation in prolonged psychotherapy or by peer encounters is usually required to make patients aware of their defenses, beliefs, and maladaptive behavior patterns.

Because personality disorders are particularly difficult to treat, therapists need experience, enthusiasm, and an understanding of the patient's expected areas of emotional sensitivity and usual ways of coping. Kindness and guidance alone do not change personality disorders. Treatment may involve a combination of psychotherapy and drug therapy. However, symptoms typically are not very responsive to drugs.

Relief of anxiety or depression is the first goal, and drug therapy can be helpful. Reducing environmental stress can also quickly relieve such symptoms

Maladaptive behaviors, such as recklessness, social isolation, lack of assertiveness, or temper outbursts, can be changed in months. Group therapy and behavior modification, sometimes within day hospital or residential settings, are effective. Participation in self-help groups or family therapy can also help change socially undesirable behaviors. Behavioral change is most important for patients with borderline, antisocial, or avoidant personality disorder. Dialectical behavioral therapy (DBT) is effective for borderline personality disorder. DBT, which involves weekly individual psychotherapy and group therapy as well as telephone contact with therapists between scheduled sessions, seeks to help patients understand their behaviors and teach them problem solving and adaptive behaviors. Psychodynamic therapy is effective for patients with borderline and avoidant personality disorders. Such therapies help patients with personality disorders reorganize feeling states in themselves and think about the effect their behaviors have on other people.

Interpersonal problems, such as dependency, distrust, arrogance, and manipulativeness, usually take > 1 yr to change. The cornerstone for effecting interpersonal changes is individual psychotherapy that helps patients understand the sources of their interpersonal problems. A therapist must repeatedly point out the undesirable consequences of the patient's thought and behavior patterns and must sometimes set limits on the patient's behavior. Such therapy is essential for patients with histrionic, dependent, or passive-aggressive personality disorder. For some patients with personality disorders that involve how attitudes, expectations, and beliefs are mentally organized (eg, narcissistic or obsessive-compulsive types), psychoanalysis is recommended, usually for ≥ 3 yr.

Last full review/revision September 2007 by John G. Gunderson, MD

Content last modified September 2007