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Personality disorders are a class of social disorders characterised by enduring maladaptive patterns of behavior, cognition and inner experience, exhibited across many contexts and deviating markedly from those accepted by the individual's culture. These patterns develop early, are inflexible and are associated with significant distress or disability. The definitions may vary some according to other sources.
Official criteria for diagnosing personality disorders are listed in the diagnostic manual of the American Psychiatric Association and in the mental and behavioral disorders section of the ICD manual of the World Health Organization. The DSM-5 published in 2013 now lists personality disorders in exactly the same way as other mental disorders, rather than on a separate 'axis' as previously.
Personality, defined psychologically, is the set of enduring behavioral and mental traits that distinguish human beings. Hence, personality disorders are defined by experiences and behaviors that differ from societal norms and expectations.
Those diagnosed with a personality disorder may experience difficulties in cognition, emotiveness, interpersonal functioning or control of impulses. In general, personality disorders are diagnosed in 40-60 percent of psychiatric patients, making them the most frequent of all psychiatric diagnoses.These behavioral patterns in personality disorders are typically associated with substantial disturbances in some behavioral tendencies of an individual,usually involving several areas of the personality, and are nearly always associated with considerable personal and social disruption.
A person is classified as having a personality disorder if their abnormalities of behavior impair their social or occupational functioning. Additionally, personality disorders are inflexible and pervasive across many situations, due in large part to the fact that such behavior may be ego-syntonic (i.e. the patterns are consistent with the ego integrity of the individual) and are, therefore, perceived to be appropriate by that individual.
This behavior can result in maladaptive coping skills, which may lead to personal problems that induce extreme anxiety, distress or depression. These patterns of behavior typically are recognized in adolescence and the beginning of adulthood and, in some unusual instances, childhood.
There are many issues with classifying a personality disorder - is it really a disorder, or just difficulties getting on socially? There are many categories of definition, some mild and some extreme. Because the theory and diagnosis of personality disorders stem from prevailing cultural expectations, their validity is contested by some experts on the basis of invariable subjectivity. They argue that the theory and diagnosis of personality disorders are based strictly on social, or even sociopolitical and economic considerations.
The two major systems of classification, the ICD and DSM, have deliberately merged their diagnoses to some extent, but some differences remain. For example, ICD-10 does not include narcissistic personality disorder as a distinct category, while DSM-5 does not include enduring personality change after catastrophic experience or after psychiatric illness. ICD-10 classifies 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. ICD classifies Transsexualism as a personality disorder; while DSM-5 addresses Gender dysphoria.
World Health Organization
The ICD-10 section on mental and behavioral disorders 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. The specific personality disorders are: paranoid, schizoid, dissocial, emotionally unstable (borderline type and impulsive type), histrionic, anankastic, anxious (avoidant) and dependent. There is also an 'Others' category involving conditions characterized as eccentric, haltlose (derived from "haltlos" (German) = drifting, aimless and irresponsible), immature, narcissistic, passive-aggressive or psychoneurotic. An additional category is for unspecified personality disorder, including character neurosis and pathological personality.
There is also a category for Mixed and other personality disorders, defined as conditions that are often troublesome but do not demonstrate the specific pattern of symptoms in the named disorders. Finally there is a category of Enduring personality changes, not attributable to brain damage and disease. This is for conditions that seem to arise in adults without a diagnosis of personality disorder, following catastrophic or prolonged stress or other psychiatric illness.
American Psychiatric Association
The Diagnostic and Statistical Manual of Mental Disorders (currently the DSM-5) provides a definition of a General personality disorder that stress such disorders are an enduring and inflexible pattern of long duration that lead to significant distress or impairment and are not due to use of substances or another medical condition. DSM-5 lists ten personality disorders, grouped into three clusters. The DSM-5 also contains three diagnoses for personality patterns that do not match these ten disorders, but nevertheless exhibit characteristics of a personality disorder.
Cluster A (odd disorders)
Paranoid personality disorder: characterized by a pattern of irrational suspicion and mistrust of others, interpreting motivations as malevolent
Schizoid personality disorder: lack of interest and detachment from social relationships, and restricted emotional expression
Schizotypal personality disorder: a pattern extreme discomfort interacting socially, distorted cognitions and perceptions
Cluster B (dramatic, emotional or erratic disorders)
Antisocial personality disorder: a pervasive pattern of disregard for and violation of the rights of others, lack of empathy
Borderline personality disorder: pervasive pattern of instability in relationships, self-image, identity, behavior and affects often leading to self-harm and impulsivity
Histrionic personality disorder: pervasive pattern of attention-seeking behavior and excessive emotions
Narcissistic personality disorder: a pervasive pattern of grandiosity, need for admiration, and a lack of empathy
Cluster C (anxious or fearful disorders)
Avoidant personality disorder: pervasive feelings of social inhibition and inadequacy, extreme sensitivity to negative evaluation
Dependent personality disorder: pervasive psychological need to be cared for by other people.
Obsessive-compulsive personality disorder (not the same as obsessive-compulsive disorder): characterized by rigid conformity to rules, perfectionism and control
Other personality disorders
Personality change due to another medical condition - is a personality disturbance due to the direct effects of a medical condition
Other specified personality disorder - symptoms characteristic of a personality disorder but fails to meet the criteria for a specific disorder, with the reason given
Personality disorder not otherwise specified
Some types of personality disorder were in previous versions of the diagnostic manuals but have been deleted. This includes two types that were in the DSM-III-R appendix as "Proposed diagnostic categories needing further study" without specific criteria, namely Sadistic personality disorder (a pervasive pattern of cruel, demeaning and aggressive behavior) and Self-defeating personality disorder (masochistic personality disorder) (characterised by behaviour consequently undermining the person's pleasure and goals). The psychologist Theodore Millon and others consider some relegated diagnoses to be equally valid disorders, and may also propose other personality disorders or subtypes, including mixtures of aspects of different categories of the officially accepted diagnoses.
Additional classification factors
Except for classifying by category and cluster, it is possible to classify personality disorders using such additional factors as severity, impact on social functioning, and attribution.
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:
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 versus personality disorder.
This system accommodates the new diagnosis of severe personality disorder, particularly "dangerous and severe personality disorder" (DSPD). Politicians and the public both want to know who comprise the most dangerous group.
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. The Personality Assessment Schedule 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.
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. 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.
The DSM-IV lists General diagnostic criteria for a personality disorder, which must be met in addition to the specific criteria for a particular named personality disorder. This requires that there be (to paraphrase):
An enduring pattern of psychological experience and behavior that differs prominently from cultural expectations, as shown in two or more of: cognition (i.e. perceiving and interpreting the self, other people or events); affect (i.e. the range, intensity, lability, and appropriateness of emotional response); interpersonal functioning; or impulse control.
The pattern must appear inflexible and pervasive across a wide range of situations, and lead to clinically significant distress or impairment in important areas of functioning.
The pattern must be stable and long-lasting, have started as early as at least adolescence or early adulthood.
The pattern must not be better accounted for as a manifestation of another mental disorder, or to the direct physiological effects of a substance (e.g. drug or medication) or a general medical condition (e.g. head trauma).
The ICD-10 'clinical descriptions and diagnostic guidelines' introduces its specific personality disorder diagnoses with some general guideline criteria that are similar. To quote:
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."
In clinical practice, individuals are generally diagnosed by an interview with a psychiatrist based on a mental status examination, which may take into account observations by relatives and others. One tool of diagnosing personality disorders is a process involving interviews with scoring systems. The patient is asked to answer questions, and depending on their answers, the trained interviewer tries to code what their responses were. This process is fairly time consuming.
The issue of the relationship between normal personality and personality disorders is one of the important issues in personality and clinical psychology. The personality disorders classification (DSM IV TR and ICD-10) follows a categorical approach that views personality disorders as discrete entities that are distinct from each other and from normal personality. In contrast, the dimensional approach is an alternative approach that personality disorders represent maladaptive extensions of the same traits that describe normal personality. Thomas Widiger and his collaborators have contributed to this debate significantly. He discussed the constraints of the categorical approach and argued for the dimensional approach to the personality disorders. Specifically, he proposed that Five Factor Model of personality is alternative to the classification of personality disorders. For example, this view specifies that Borderline Personality Disorder can be understood as a combination of emotional lability (i.e., high neuroticism), impulsivity (i.e., low conscientiousness), and hostility (i.e., low agreeableness). Many studies across cultures have explored the relationship between personality disorders and the Five Factor Model This research has demonstrated that personality disorders largely correlate in expected ways with measures of the Five Factor Model and has set the stage for including the Five Factor Model within the upcoming DSM-5.
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, DpPD - Depressive Personality Disorder, n/a - not available.
In children and adolescents
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. In addition, in Robert F.Krueger's review of their research indicates that some children and adolescents do suffer from clinically significant syndromes that resemble adult personal 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.
There are numerous possible causes of mental disorders, and they may vary depending on the disorder, the individual, and the circumstances. There may be genetic dispositions as well as particular life experiences, which may or may not include particular incidents of trauma or abuse. A study of almost 600 male college students, averaging almost 30 years of age and who were not drawn from a clinical sample, examined the relationship between childhood experiences of sexual and physical abuse and currently reported personality disorder symptoms. Childhood abuse histories were found to be definitively associated with greater levels of symptomatology. Severity of abuse was found to be statistically significant, but clinically negligible, in symptomatology variance spread over Cluster A, B and C scales.
Child abuse and neglect consistently evidence themselves as antecedent risks to the development of personality disorders in adulthood. In the following study, efforts were taken to match retrospective reports of abuse with a clinical population that had demonstrated psychopathology from childhood to adulthood who were later found to have experienced abuse and neglect. In a study of 793 mothers and children, researchers asked mothers if they had screamed at their children, and told them that they didn’t love them or threatened to send them away. Children who had experienced such verbal abuse were three times as likely as other children (who didn't experience such verbal abuse) to have borderline, narcissistic, obsessive-compulsive or paranoid personality disorders in adulthood. The sexually abused group demonstrated the most consistently elevated patterns of psychopathology. Officially verified physical abuse showed an extremely strong correlation with the development of antisocial and impulsive behavior. On the other hand, cases of abuse of the neglectful type that created childhood pathology were found to be subject to partial remission in adulthood.
The prevalence of personality disorder in the general community was largely unknown until surveys starting from the 1990s. In 2008 the median rate of diagnosable PD was estimated at 10.6%, based on six major studies across three nations. This rate of around one in ten, especially as associated with high use of services, is described as a major public health concern requiring attention by researchers and clinicians. The prevalence of individual personality disorders ranges from about 2% to 3% for the more common varieties, such as schizotypal, antisocial, borderline, and histrionic, to 0.5-1% for the least common, such as narcissistic and avoidant.
A screening survey across 13 countries by the World Health Organization using DSM-IV criteria, reported in 2009 a prevalence estimate of around 6% for personality disorders. The rate sometimes varied with demographic and socioeconomic factors, and functional impairment was partly explained by co-occurring mental disorders. In the US, screening data from the National Comorbidity Survey Replication between 2001 and 2003, combined with interviews of a subset of respondents, indicated a population prevalence of around 9% for personality disorders in total. Functional disability associated with the diagnoses appeared to be largely due to co-occurring mental disorders (Axis I in the DSM).
A UK national epidemiological study (based on DSM-IV screening criteria), reclassified into levels of severity rather than just diagnosis, reported in 2010 that the majority of people show some personality difficulties in one way or another (short of threshold for diagnosis), while the prevalence of the most complex and severe cases (including meeting criteria for multiple diagnoses in different clusters) was estimated at 1.3%. Even low levels of personality symptoms were associated with functional problems, but the most severely in need of services was a much smaller group.
Comorbidity in personality disorders
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. 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.
Relationship between personality disorder subtypes and other mental disorders
The disorders in each of the three clusters may share some underlying common vulnerability factors involving cognition, affect and impulse control, and behavioral maintenance or inhibition, respectively, and may have a spectrum relationship to certain syndromal mental disorders:
Paranoid or schizotypal personality disorders may be observed to be premorbid antecedents of delusional disorders or schizophrenia.
Borderline personality disorder is seen in association with mood and anxiety disorders and with impulse control disorders, eating disorders, ADHD, or a substance use disorder.
Avoidant personality disorder is seen with social anxiety disorder.
There are many different forms (modalities) of treatment used for personality disorders:
Individual psychotherapy has been a mainstay of treatment. There are long-term and short-term (brief) forms.
Family therapy, including couples therapy.
Group therapy for personality dysfunction is probably the second most used.
Psychological-education may be used as an addition.
Self-help groups may provide resources for personality disorders.
Psychiatric medications for treating symptoms of personality dysfunction or co-occurring conditions.
Milieu therapy, a kind of group-based residential approach, has a history of use in treating personality disorders, including therapeutic communities.
There are different specific theories or schools of therapy within many of these modalities. They may, for example, emphasize psychodynamic techniques, or cognitive or behavioral techniques. In clinical practice, many therapists use an 'eclectic' approach, taking elements of different schools as and when they seem to fit to an individual client. There is also often a focus on common themes that seem to be beneficial regardless of techniques, including attributes of the therapist (e.g. trustworthiness, competence, caring), processes afforded to the client (e.g. ability to express and confide difficulties and emotions), and the match between the two (e.g. aiming for mutual respect, trust and boundaries)
The management and treatment of personality disorders can be a challenging and controversial area, for by definition the difficulties have been enduring and affect multiple areas of functioning. This often involves interpersonal issues, and there can be difficulties in seeking and obtaining help from organizations in the first place, as well as with establishing and maintaining a specific therapeutic relationship. On the one hand, an individual may not consider themselves to have a mental health problem, while on the other, community mental health services may view individuals with personality disorders as too complex or difficult, and may directly or indirectly exclude individuals with such diagnoses or associated behaviors. The disruptiveness people with personality disorders can create in an organisation makes these, arguably, the most challenging conditions to manage.
Apart from all these issues, an individual may not consider their personality to be disordered or the cause of problems. This perspective may be caused by the patient's ignorance or lack of insight into their own condition, an ego-syntonic perception of the problems with their personality that prevents them from experiencing it as being in conflict with their goals and self-image, or by the simple fact that there is no distinct or objective boundary between 'normal' and 'abnormal' personalities. Unfortunately, there is substantial social stigma and discrimination related to the diagnosis.
The term 'personality disorder' encompasses a wide range of issues, each with different a level of severity or disability; thus, personality disorders can require fundamentally different approaches and understandings. To illustrate the scope of the matter, consider that while some disorders or individuals are characterized by continual social withdrawal and the shunning of relationships, others may cause fluctuations in forwardness. The extremes are worse still: at one extreme lie self-harm and self-neglect, while at another extreme some individuals may commit violence and crime. There can be other factors such as problematic substance use or dependency or behavioral addictions. A person may meet criteria for multiple personality disorder diagnoses and/or other mental disorders, either at particular times or continually, thus making coordinated input from multiple services a potential requirement.
Therapists in this area can become disheartened by lack of initial progress, or by apparent progress that then leads to setbacks. Clients may be experienced as negative, rejecting, demanding, aggressive or manipulative. This has been looked at in terms of both therapist and client; in terms of social skills, coping efforts, defence mechanisms, or deliberate strategies; and in terms of moral judgements or the need to consider underlying motivations for specific behaviors or conflicts. The vulnerabilities of a client, and indeed therapist, may become lost behind actual or apparent strength and resilience. It is commonly stated that there is always a need to maintain appropriate professional personal boundaries, while allowing for emotional expression and therapeutic relationships. However, there can be difficulty acknowledging the different worlds and understandings that client and therapist may live with. A therapist may assume that the kinds of relationships and ways of interacting that make them feel safe and comfortable, have the same effect on clients. As an example at one extreme, people who may in their lives have been used to hostility, deceptiveness, rejection, aggression or abuse, may in some cases be made confused, intimidated or suspicious by presentations of warmth, intimacy or positivity. On the other hand, reassurance, openness and clear communication are usually helpful and needed. It can take several months of sessions, and perhaps several stops and starts, to begin to develop a trusting relationship that can meaningfully address issues.
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 interpersonal relationships. Indirect effects also play a role; for example, impaired educational progress or complications outside of work, such as substance abuse and co-morbid mental diseases, can plague sufferers. However, personality disorders can also bring about above-average work abilities by increasing competitive drive or causing the sufferer to exploit his or her co-workers. In 2005, 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:
Histrionic personality disorder: including superficial charm, insincerity, egocentricity and 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.
According to leading leadership academic Manfred F.R. Kets de Vries, it seems almost inevitable these days that there will be some personality disorders in a senior management team.
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