What are Personality Disorders?

A cluster of (personality) traits and behavioral patterns that represent inflexible, long-standing, deeply-rooted ways of thinking, feeling, and acting about/toward oneself and others.

*Psychiatric Disorders have symptoms while Personality Disorders has characteristics*

Personality:

• “Normal” personality means having and using a psychological toolkit comprised of a variety of traits along with an observing ego (like having a mirror that keeps you accountable & allows us to perceive and change our behavior)

• Personality traits and Personality are our resources.

  • Enable the person to handle diverse demands of life

  • Provide flexibility and adaptability

  • Allow an individual to observe and to self-correct a mistake

  • Facilitate the ability to problem solve

Personality Disorder:

• Cluster of (personality) traits and behavioral patterns that represent inflexible, long-standing, deeply-rooted ways of thinking, feeling, and acting about/toward oneself and others

• The patterns are manifested in two (or more) of the following:

  • Cognition and perception of self and others

  • Affectivity (emotions)

  • Interpersonal functioning

  • Impulse control

• Pattern is inflexible and pervasive across personal and social situations

• Leads to clinically significant distress (not necessarily to the individual with the personality disorder but, rather, to those around them/living with them)

• Onset can be traced back to at least adolescence or early adulthood

• NOT diagnosed in childhood

• Overall prevalence rates approximately 15-19% of individuals in the general population have at least one personality disorder

Causal/Contributing (or Risk) Factors:

• Temperament

• Genetic contribution

• Brain abnormalities

• Learning-based habit patterns and maladaptive cognitive styles

• Early abuse and/or neglect

• Attachment - parent/child

• Sociocultural factors (e.g. social stressors like 9/11, global pandemic, etc.)

Diagnosing Personality Disorders:

• Characterizing personality disorders is difficult AND diagnosing them reliably is even more so

• The majority of people with a personality disorder never come into contact with mental health services

  • Usually in context of another mental disorder or because they are at risk of losing a job or marriage

  • May enter treatment at time of crisis (commonly after self-harming or breaking the law).

• Nonetheless, personality disorders are important to us as clinicians

  • Predisposed to other disorders

  • Affect the presentation and management of existing disorder(s)

Cluster-A Disorders:

(the odd and eccentric behaviors)

Presence of odd, bizarre, and eccentric social behaviors. Characteristics can also be described as accusatory, aloof, awkward.

Paranoid Personality Disorder (accusatory)

Pervasive pattern of distrust and suspiciousness of others and others’ motives are interpreted as malevolent as reflected by:

• Distrustful and suspicious of people

• Assume others will disappoint, manipulate, and talk behind their back

• Project blame onto others and hold grudges

• Refuse to seek professional help

However, these individuals are not delusional.

2021 ICD-10-CM Diagnosis Code: F60.0 — Learn more

Schizoid Personality Disorder (aloof)

Pervasive pattern of detachment from social relationships and a restricted range of emotional expression as reflected by:

• Indifference to close relationships including family

• Prefer to be alone

• No desire to love or be loved

• Takes pleasure in few, if any, activities

• Cold, reserved, withdrawn (flat/blunted affect)

• Indifferent to praise or criticism

• Insensitive to feelings of others

2021 ICD-10-CM Diagnosis Code: F60.1 — Learn more

Schizotypal Personality Disorder (awkward):

Pervasive pattern of acute discomfort in close relationships, cognitive or perceptual distortions, and eccentricities in behavior as reflected by:

• Ideas of reference (not delusions)

• Odd beliefs or magical thinking that influences behavior

• Unusual perceptual experiences

• Odd thinking and speech

• Odd/eccentric behavior and appearance

• Suspiciousness or paranoid ideation

• Inappropriate affect

• Lack of close relationships other than first degree relatives

  • BUT a strong desire to have them

• Excessive social anxiety that does not diminish with familiarity

2021 ICD-10-CM Diagnosis Code: F21 — Learn more

NOTE: Schizotypal Personality Disorder is similar to Schizophrenia. It is possible to have a diagnosis of Schizotypal Personality Disorder and later be diagnosed with Schizophrenia. Schizophrenia is a psychotic disorder and is considered more severe.

Cluster-B Disorders:

(the dramatic and emotional behaviors)

Central features of the personality or character consist of overly emotional, dramatic, or erratic behavior.

Antisocial Personality Disorder (Lesser version of psychopathy):

Pervasive pattern of a disregard for and violation of the rights of others, as reflected by:

• Failure to conform to social norms

• Deceitfulness

• Impulsivity

• Aggressiveness

• Disregard for safety of self or others

• Irresponsibility

• Lack of remorse

2021 ICD-10-CM Diagnosis Code: F60.2 — Learn more

Other facts about ASPD:

• An individual must be 18 or older to get this diagnosis

• A Conduct Disorder (CD) must be evidenced before age 15

• ASPD is found in more men than women - up to 5:1 ratio

• ASPD is NOT psychopathy, it is a less extreme version of it.

• The “typical” trajectory to ASPD and beyond looks like this: *Oppositional Defiant Disorder (childhood) —> Conduct Disorder (early adolescence) —>  Antisocial Personality Disorder (18+ years old) —> Psychopathy (18+ years old)

• Psychopathy is NOT a DSM diagnosis but, rather, a more colloquial term. It is a term used clinically, predominantly in a prison population.

Narcissistic Personality Disorder:

Pervasive pattern of grandiosity, need for admiration, and lack of empathy, as reflected by:

• Grandiose sense of self-importance

• Fantasies of success, power, brilliance, beauty, or ideal love

• Seek special, high-status people and institutions

• Require excessive admiration

• Come across as pretentious, self-centered, and entitled

• Relationship and work problems - exploitative, further their own agenda

• Typically lack empathy and tend to be oblivious to others’ feelings

• Envious of others and believe others are envious of them

• Arrogant, haughty behavior and/or attitude

• Behind mask of self-confidence, fragile self-esteem - vulnerable to criticism

  • What they seek - mirrors and omnipotent others

• 2021 ICD-10-CM Diagnosis Code: F60.81 — Learn more

Histrionic Personality Disorder:

Pervasive pattern of excessive emotionality and attention seeking as reflected by:

• Must be center of attention

• Interactions often seductive and provocative behavior

• Quickly shifting and shallow expression of emotions

• Use physical appearance to draw attention to themselves

• Speak in an excessively impressionistic way, lacks in detail

• Exaggerated emotional reactions, approaching theatricality, in everyday behaviors

• Easily influenced by others (suggestible)

• Superficial relationships

2021 ICD-10-CM Diagnosis Code: F60.4 — Learn more

Other facts about HPD:

• Presence - dramatic and colorful

• Sexuality - flirtatious and seductive

• Behavior - can seem ludicrous

• Relationships - intense and brief

• Result - tiring to be around and embarrassing

• Background - oedipal issues (such as daddy issues)

Borderline Personality Disorder:

Pervasive pattern of instability in interpersonal relationships, self-image, and affect, and marked impulsivity as reflected by: (need 5 out of the 9)

• Frantic efforts to avoid real or imagined abandonment

• Unstable and intense interpersonal relationships

• Identity disturbance

• Impulsivity in at least two areas that are potentially self-damaging

• Recurrent suicidal behavior, thoughts, gestures, threats, or self-harming behavior

• Affective instability (mood shifts)

  • Instability => emotional, behavioral, sense of self, and interpersonal

  • Behavioral => often do extreme things to keep individuals from leaving them (terrified of abandonment)

  • Sense of self => constantly shifting identity

  • Interpersonal => extremely volatile

  • Way of relating => “splitting” - world is either all good or all bad

• Feelings of emptiness

• Inappropriate, intense anger and/or difficultly controlling anger

• Transient, stress-related paranoid ideation or severe dissociative symptoms

2021 ICD-10-CM Diagnosis Code: F60.3 — Learn more

Other facts about BPD:

• The hallmark feature of BPD is stable instability.

  • Instability: emotional, behavioral, sense of self, & interpersonal

• It is the only Personality Disorder with a successful treatment—Dialectical Behavioral Therapy.

Theory of Borderline Personality Disorder (BPD):

Biological vulnerability + invalidating environments = BPD

• Biological Vulnerability:

  • Genetic

  • Hyperreactive emotional response—something is causing this.

• Invalidating environment: (usually family)

  • Hostile, abusive, negating, and critical

  • Childhood sexual abuse

HOWEVER, often there is “no explanation” in environment; thus many assume a biological vulnerability as a precursor.

Dialectical Behavior Therapy (DBT) for BPD:

Dialectical Behavior Therapy is a cognitive behavioral treatment developed by Marsha Linehan (Psychologist).

• Treating Borderline Personality Disorder — Read now

• Reduce frequency of self-destructive acts and improve client’s ability to handle disturbing emotions (such as anger and dependency)

• Emphasizes individual psychotherapy and group skills training classes to help people learn and use new skills and strategies to develop a life that they experience as worth living

• Primary dialectic is between the seemingly opposite strategies of acceptance and change

  • Two sets of acceptance-oriented skills (mindfulness and distress tolerance)

  • Two sets of change-oriented skills (emotion regulation and interpersonal effectiveness)

• Will have individual and group skills

Clinicians and DBT:

• Take over a primary role in treatment

• Provide a therapeutic structure

• Support the client

• Involve the client in therapeutic process

• Take an active role in treatment

• Manage the client’s suicidal threats or self-harming acts

• Be self-aware and ready to consult with colleagues

Cluster-C Disorders:

(the anxious and fearful behaviors)

Characterized by overly anxious or fearful style, particularly with regard to interpersonal relationships.

Avoidant Personal Disorder:

Pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation as reflected by:

• Shy, socially inhibited, low self-esteem

• Desires relationships but avoids social situations

• Sees themselves as incapable, inadequate, and undesirable

• Terrified at the prospect of being publicly embarrassed

• Extremely sensitive to rejection and ridicule

• Withdrawn, unlikely to experience intimacy, and unable to feel pleasure

2021 ICD-10-CM Diagnosis Code: F60.6 — Learn more

Dependent Personality Disorder:

Pervasive patterns of submissive and clinging behavior related to an excessive need to be taken care of as reflected by:

• Intense fear of separation and rejection

• Tends to be extremely passive

• Overly depend on and cling to others => unable to make decisions

• Lack self confidence and don’t believe they can care for themselves

• Without others near them, feel despondent and abandoned

2021 ICD-10-CM Diagnosis Code: F60.7 — Learn more

Obsessive-Compulsive Personality Disorder:

Pervasive pattern of preoccupation with orderliness, perfectionism, and control as reflected by:

• Obsessed with orderliness, perfectionism, control, rules, details, and schedules

• Inflexible, easily stressed, and surprisingly inefficient

• Manifested in worrying, indecisiveness, and rigidity

• Sense of self and self-worth in terms of work productivity

• Do not experience obsessions and compulsions

2021 ICD-10-CM Diagnosis Code: F60.5 — Learn more

Relation to College Students:

Personality disorders may not be at the forefront of potential mental health issues for college students; but, they are still very relevant to college students and it’s a good idea for college students to be aware of them. A “normal” personality is a combination of different personality traits which contribute to individual patterns of thinking, feeling, and behaving. Individuals with a “normal” personality also have the ability to be adaptable, flexible, problem solve, and observe and self-correct mistakes. On the other hand, a personality disorder is a combination of luster of different personality traits and behavioral patterns that represent inflexible, long-standing, and deeply-rooted ways of thinking, feeling, and acting about/toward oneself and others. While personality disorders, like all other mental disorders, exist on a spectrum, individuals with personality disorders are not flexible, they are not very adaptable, and they do not tend to take responsibility for their mistakes, for their part in fights, nor any facet of wrongdoing. For example, individuals with borderline personality disorder deeply fear abandonment. Nobody wants to be abandoned and, on some level, fear it to a degree. However, individuals with borderline personality disorder can fear abandonment so much that it affects every facet of their lives—emotional, behavioral, interpersonal, and their sense of self. Furthermore, certain types of personality disorders are characterized as being very manipulative and skillful liars, making it hard to treat them. Remember, personality disorders are on a spectrum. One person’s manifestation of borderline personality disorder may not be as extreme as compared to another individual. No two people are the same and everyone is unique—meaning, everyone’s needs are unique as well. Even though treating personality disorders may present a unique set of difficulties, many of them are treatable. The biggest barrier to treating personality disorders is the individual themselves. Remember, people with personality disorders do not generally take responsibility for their mistakes so it can be a big hurdle to get someone with a personality disorder see how they contribute to the not-so-positive aspects of their lives.