Personality Disorders

Personality disorders can have a profound impact on an individual's life, affecting their sense of self, relationships, work, and overall well-being. They are characterised by impairments in personality functioning, which often result in an instability in the experience of the sense of self and difficulties with relationships. Individuals that struggle with personality disorders may experience difficulties in regulating their emotions, maintaining stable relationships, and having a consistent sense of self. The most common symptoms include patterns of devaluation and idealisation of self and others, impulsivity, and intense mood swings.

First indicators of personality disorder usually appear in adolescence or early adulthood. Trauma, neglect, or abuse during childhood are considered as important contributors to the development of personality disorders.

Some personality disorders, such as borderline personality disorder (BPD), are shown to have good prospects of treatment using psychotherapy.

Types of Personality Disorders

There are various categorisations of personality disorders. Because of its prevalence in the diagnostic process the personality disorders stated below are the main types as included in DSM-5 (APA, 2013):

• Paranoid Personality Disorder is characterised by the individual’s persistent distrust, suspiciousness, and seeing others as malevolent. The individual will see others as exploitative or deceiving without any basis for it. They may have doubts about the loyalty of others and have difficulties trusting them. This may be accompanied with difficulties in confiding in others due to fears of information being used maliciously. They are prone to baring grudges and being suspicious about infidelity.

• Schizoid Personality Disorder is characterised by detachment from social relationships and difficulties with expressing emotions in relationships. Individuals with schizoid personality disorder are deterred by and do not enjoy close relationships. As such, they tend to resort to solitary activities and social avoidance. Their avoidance may also be evident in their lack of interest for sex. They normally have few social relationships, which will also tend to be distant. Such individuals may also be indifferent to the criticism or praise from others and may exhibit emotional detachment and a sense of coldness.

• Schyzotypal Personality Disorder

• Antisocial Personality Disorder is characterised by disregard for others and the lack of boundaries with others that often results in violation of rights of others, which may include failure to adhere to social norms. Such individuals will usually be deceitful, manipulative, and exploitative. Impulsivity, irritability, and predominance of aggression in their relating with others are also common, including a lack of remorse for the damage or pain caused to others.

• Borderline Personality Disorder (BPD) is one of the most prevalent types of personality disorder. It is characterised by instability in interpersonal relationships, the sense of self and self-esteem, as well as difficulties with emotional regulation. Individuals with borderline personality disorder tend to be preoccupied with fears of abandonment and present with an experience of internal emptiness. They also tend to shift their view of themselves and others from idealisation to devaluation. Often impulsivity will be present, predominantly in the areas of spending, sex, substance abuse, reckless driving, binge eating. Underlying aggression may cause anger outbursts and difficulties controlling anger. Suicidal ideation and self-mutilation may also be present. Anxiety and depression are symptoms that often accompany BPD.

• Narcissistic Personality Disorder (NPD) is characterised by disturbances in identity that result in persistent grandiosity and, a sense of entitlement, and the need for admiration. Interpersonally, individuals with NPD present with lack of empathy and lack of capacity for intimacy in relationships. They will tend to exhibit a sense of self-importance, specialness, uniqueness, and superiority and fantasies of grander involving success, power, or beauty. They will often be exploitative, manipulative, and arrogant. Envy will also tend to be present, however, often projected onto others (seeing others as envious). People with NPD may struggle with regulating their emotions and can become easily angered or upset when they feel slighted or criticised.

• Avoidant Personality Disorder is characterised by social inhibition, feelings of inadequacy, and hypersensitivity to criticism of others. There is a general sense of inferiority. Such individuals tend to avoid occupational activities that involve working with others due to their vulnerability to criticism and rejection. Because of such vulnerability, they tend to engage in situations where they are certain of being liked. They may exhibit with fears of being shamed and ridiculed in intimate relationships.

• Dependent Personality Disorder (DPD) is characterised by a need to be taken care of. Individuals with dependent personality disorder tend to be submissive, clingy and needy in their relationships, with fear of separation at the core of such behaviour. They tend to take on opinions of others and not know what opinions they have of their own. Such individuals normally have difficulties with everyday tasks and tend to feel inapt in tackling the adult world. They tend to experience others as adults but not themselves and, therefore, often feel helpless and unable to do things on their own. Because of their fears of separation and aloneness, a pattern of going into another relationship immediately as one ends is also common. One of the most prevalent characteristics of individuals with DPD is their avoidance and fear of conflict.

• Obsessive-Compulsive Personality Disorder

Diagnosing Personality Disorders

Diagnosis of personality disorders, especially in psychiatric setting, currently still falls back on the so-called categorical diagnostic model, which is a model that has historically prevailed. Because of the controversies associated with this model and the lack of its usefulness in the process of psychotherapy, there have been calls for a change towards the so-called dimensional model of diagnosis. The latter would, rather than fall back on the use of categorical traits for the diagnosis, base the diagnosis on the level of personality functioning, including impairments of identity, and its impact on interpersonal relationships.

There are, however, issues with the categorical model when the diagnosis is needed for the purpose of psychotherapeutic treatment. This is why in psychotherapy, there is a tendency towards the dimensional diagnostic model which is based on assessing the level of personality functioning and other impairments associated with it as well as assessing the underlying internal conflicts and the trauma associated with them.

Apart from controversies around categorical model of diagnosis, there are further controversies associated with diagnosing personality disorder. These are related to stigmatisation associated the diagnostic “labelling” and the lack of attention to the underlying trauma that may have caused or contributed to the development of the disorder.

Diagnosing personality disorder can be complex due to the overlapping symptoms between different types. Furthermore, because types of personality disorder are arbitrarily set, individuals will often present with more than one. Also, personality disorder may be also be present at subclinical level, which means that a diagnosis may not be given, however, the individual may still have their quality of life reduced significantly because of the symptoms associated with the disorder.

Cultural elements and factors of cultural diversity also need to be taken into account when diagnosing personality disorder because some personality features may be culturally predetermined or enhanced.

When diagnosing personality disorder, it is also important to be mindful of the potential for misdiagnosis. For instance, depression and anxiety are common symptoms associated with personality disorders, so misdiagnosis with depressive disorder or generalised anxiety disorder (GAD) may occur. Also, because of the overlap in symptoms and co-morbidity, a misdiagnosis with complex PTSD or bipolar disorder is also possible. The latter is especially the case when the features of the personality disorder are not distinct and the disorder may be present at subclinical level.

Treatment of Personality Disorders

Treatment of personality disorder depends on the type of the disorder, however, it predominantly takes the form of psychotherapy and other supportive therapies. Because personality disorders present with high comorbidity with other mental health conditions—such as like depression, anxiety, eating disorders, substance abuse, addiction—treatment may involve also treatment or management of these co-occurring conditions.

Psychotherapeutic treatments for personality disorders have been evolving rapidly in the recent years and research shows that especially borderline personality disorder (BPD) is highly responsive to psychotherapy. As such, according to treatment guidelines, for instance NICE guidelines and APA guidelines, psychotherapy is first-line treatment for BPD.

Because personality disorders tend to have an impact also on the individual’s social circle, romantic relationships, and their families, treatment may also include psycho-education and other support for the loved ones.

References:

American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). American Psychiatric Press.