Personality Disorders Notes

Introduction to Personality Disorders

Every individual possesses a unique personality, characterized by their distinctive ways of thinking, feeling, behaving, and relating to others. Personality traits, evident from childhood and prominent in adulthood, shape a person's sense of self, influencing their values, thoughts, feelings, and preferences.

The Five-Factor Model

The Five-Factor Model organizes countless personality traits into five broad domains, encompassing all aspects of personality. These domains are:

  • Neuroticism: Includes traits like anxiousness, self-consciousness, and apprehension.

  • Extraversion: Includes traits like being outgoing, active, and talkative.

  • Openness: Includes traits like imagination, feelings, actions, and ideas.

  • Agreeableness: Includes traits like being appreciative, forgiving, generous, and trusting.

  • Conscientiousness: Includes traits like being efficient, organized, and prudent.

DSM-5 Personality Disorders

Personality disorders arise when personality traits cause significant distress, social impairment, or occupational impairment. The DSM-5 (Diagnostic and Statistical Manual of Mental Disorders) provides a standard for classifying and diagnosing mental disorders.

The DSM-5 includes 10 personality disorders:

  • Antisocial

  • Avoidant

  • Borderline

  • Dependent

  • Histrionic

  • Narcissistic

  • Obsessive-Compulsive

  • Paranoid

  • Schizoid

  • Schizotypal

The DSM-5 also includes "other specified personality disorder" (OSPD) and "unspecified personality disorder" (UPD) diagnoses for cases not fully covered by the existing 10 disorders.

Each personality disorder is a syndrome, combining multiple maladaptive personality traits. For instance:

  • Avoidant Personality Disorder: Combines introversion (social withdrawal) and neuroticism (self-consciousness).

  • Dependent Personality Disorder: Combines neuroticism (anxiety) and maladaptive agreeableness (submissiveness).

  • Antisocial Personality Disorder: Combines antagonism (dishonesty) and low conscientiousness (irresponsibility).

Some personality disorders are primarily related to one of the basic domains of personality:

  • Obsessive-Compulsive Personality Disorder: Maladaptive conscientiousness.

  • Schizoid Personality Disorder: Introversion.

  • Borderline Personality Disorder: Neuroticism.

  • Histrionic Personality Disorder: Maladaptive extraversion.

However, a complete description of each DSM-5 personality disorder typically includes traits from multiple domains.

  • Antisocial Personality Disorder: May also include low neuroticism (fearlessness) and extraversion (excitement-seeking).

  • Borderline Personality Disorder: May also include antagonism (manipulation) and low conscientiousness (rashness).

  • Histrionic Personality Disorder: May also include antagonism (vanity) and low conscientiousness (impressionistic).

  • Narcissistic Personality Disorder: Includes traits from neuroticism (reactive anger), extraversion (exhibitionism), antagonism (arrogance), and conscientiousness (acclaim-seeking).

  • Schizotypal Personality Disorder: Includes traits from neuroticism (social anxiousness), introversion (social withdrawal), unconventionality (odd ideas), and antagonism (suspiciousness).

While the APA conceptualizes personality disorders as distinct from normal personality functioning and each other, an alternative view suggests they are extreme variants of normal personality traits.

Many researchers, however, believe that personality disorders involve a unique pathology in self and interpersonal relatedness, distinct from personality traits.

Validity of Personality Disorders

Future DSM revisions may exclude some currently included personality disorders due to limited empirical support. Histrionic, schizoid, paranoid, and dependent personality disorders were considered for deletion in DSM-5.

Antisocial, borderline, and schizotypal personality disorders have strong empirical support. The etiology of DSM-5 personality disorders is complex, involving interactions between neurobiological vulnerabilities and environmental factors.

  • Antisocial Personality Disorder: Genetic dispositions for low anxiousness and impulsivity, combined with a tough environment and poor parenting.

  • Borderline Personality Disorder: Genetic disposition to negative affectivity, combined with an abusive family environment.

Viewing personality disorders as maladaptive variants of general personality structure, supported by the Five-Factor Model, provides validity for all personality disorders.

Treatment of Personality Disorders

Personality disorders are often ego-syntonic, meaning individuals are comfortable with their behaviors and rarely seek treatment. Borderline and avoidant personality disorders are exceptions due to high neuroticism.

High levels of neuroticism and emotional pain, as experienced in borderline personality disorder, can motivate individuals to seek help. People with avoidant personality disorder may seek treatment due to high neuroticism (anxiousness and self-consciousness) and introversion (social isolation).

Maladaptive personality traits are often evident in individuals seeking treatment for other mental disorders, such as anxiety, mood, or substance use disorders. The prevalence of personality disorders in clinical settings is estimated to be above 50%.

The presence of a personality disorder can impact the treatment of other mental disorders. While challenging, personality disorders can be treated with psychosocial and pharmacologic interventions.

Moderate adjustments in personality functioning can yield significant improvements, especially for disorders like antisocial and borderline personality disorder.

Manualized treatment protocols exist for borderline personality disorder, including dialectical behavior therapy and mentalization therapy.

Treatment of Borderline Personality Disorder

Dialectical Behavior Therapy

Dialectical behavior therapy (DBT) combines cognitive-behavioral techniques with principles from Zen Buddhism, dialectical philosophy, and behavioral science. DBT includes individual therapy, group skills training, telephone coaching, and a therapist consultation team, typically lasting a year. It is an expensive treatment, but research suggests its benefits outweigh the costs.

Mentalization Therapy

Mentalization therapy (MT) is another treatment approach used for borderline personality disorder.

Specific treatment manuals have not been developed for other personality disorders, possibly due to the assumption that they are unresponsive to treatment or the complexity of their treatment. Each DSM-5 disorder is a heterogeneous constellation of maladaptive personality traits, with significant diagnostic overlap and heterogeneity hindering the identification of specific treatments.

A lack of treatment-seeking behavior among individuals with personality disorders also impedes treatment development.

Conclusions

Personality traits can result in distress and impairment, leading to personality disorders. Research has focused on understanding the etiology, pathology, and treatment of certain personality disorders (antisocial, schizotypal, borderline, dependent, and narcissistic).

A dimensional understanding of personality disorders is emerging, viewing them as maladaptive variants of general personality structure.

Vocabulary

  • Antisocial: A pervasive pattern of disregard and violation of the rights of others.

  • Avoidant: A pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation.

  • Borderline: A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity.

  • Dependent: A pervasive and excessive need to be taken care of that leads to submissive and clinging behavior and fears of separation.

  • Five-Factor Model: Five broad domains or dimensions that are used to describe human personality.

  • Histrionic: A pervasive pattern of excessive emotionality and attention seeking.

  • Narcissistic: A pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy.

  • Obsessive-compulsive: A pervasive pattern of preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness, and efficiency.

  • Paranoid: A pervasive distrust and suspiciousness of others such that their motives are interpreted as malevolent.

  • Personality: Characteristic, routine ways of thinking, feeling, and relating to others.

  • Personality disorders: When personality traits result in significant distress, social impairment, and/or occupational impairment.

  • Schizoid: A pervasive pattern of detachment from social relationships and a restricted range of expression of emotions in interpersonal settings.

  • Schizotypal: A pervasive pattern of social and interpersonal deficits marked by acute discomfort with, and reduced capacity for, close relationships as well as perceptual distortions and eccentricities of behavior.