Personality Disorders: Diagnostic Criteria, Causes, Treatment, and More

Personality disorders are highly distinctive and unique from other mental health disorders. These disorders involve highly ingrained, negative, and maladaptive behaviors that can have serious implications in relationships, work, and overall functioning.

According to the American Psychiatric Association (2013), personality disorders are, “An enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment.”

Personality disorders are so different from other disorders that at one point they were diagnosed separately and viewed differently from all other mental illness. These disorders are often apparent, and frequently involve traits that are not always pleasant to be around. Some of the traits can involve arrogance, instability, anger, and violence.

Symptoms of Personality Disorders

The array of symptoms will vary greatly, so looking at each disorder independently will be important. Just like all disorders, there is a continuum of severity of mental health disorders. Often, symptoms will manifest through relationships with other people including, family, romantic, and occupational.

Some of the following symptoms are common, but again symptoms will vary significantly between disorders:

• Difficulty dealing with people. This can be in rigidity, stubbornness, irrationality, serious communication problems, dependence, inconsistency, and more.
• Feeling like they are right and everyone else is wrong. Consistently feeling that it is everyone else who is wrong, crazy, or off, not them. Deflecting blame to others for internal issues.
• Unstable relationships. Often viewing relationships in extremes between love and hate and often view people in a very polarizing manner.
• Inaccurate view of self. This can be inflated and elevated, or overly negative, but the view of self is often off from reality.
• Impulsivity. Frequently, people will act very quickly and make rash decisions, which can have negative side effects and results.
• Self destructive tendencies.  This can manifest in a wide array of capacities, as can the severity. But making decisions, often impulsively, that will have major negative consequences to the person and often others.
• Extreme emotional swings. Much like in bipolar disorder, but less chemically based, people will often have a “short fuse” and have rapid shifts in emotional states.
• Having abnormal affect. Affect is a term used for how one presents emotionally. Usually it is fairly apparent how a person feels based on how she or he looks physically. Often people with personality disorders will have unique affects, or affects that are not appropriate for the situation.
• Emotional numbness. With some disorders, people will feel numb or emotionless and present as such.
• Specific symptoms to each disorder. Reiterating the deviation between symptoms within personality disorders is essential. See below for specific symptoms for each disorder and cluster of disorders. 

Causes of Personality Disorders

Unlike depressive, anxiety, or eating disorders, there is very little known about the causes of personality disorders. With most disorders, certain brain chemicals and biology lend a good explanation. Genetics and personality disorders are not as strongly linked, however, with advances in technology, more information is being gathered about potential genetic links. There is believed to be “malfunctioning” genes in people that could cause the development of a p.d.

There are many factors that are influential in the development of certain personality disorders. These nurture based influences include:

• Trauma, abuse, and neglect. Particularly childhood trauma can increase the chances of developing certain personality disorders. Having serious traumatic events can shape the way that people view themselves, relationships, and the world around them.
• Difficult upbringing. Being raised in difficult circumstances, being forced to do whatever it takes to survive, and exposure to negative behaviors can all increase the chances of developing a personality disorder.
• Learned behaviors. Watching maladaptive people and relationships can lead people to act that way. If a person grows up poor and sees dad stealing and swindling to make money this is something that can be learned, like other negative behavioral and relationship patterns.
• High reactivity. People who in childhood and into adulthood are “over reactors” can often develop personality disorders. Over sensitivity to emotions, stimulus (like light and noise) can lead to a problem.

Treatments for Personality Disorders

Much like causes, the treatment of personality disorders is unique. With no “anti-personality disorder medication” like anti-depressents or anti-anxiety meds, this category of disorders does not generally respond well to medications. Usually talk therapy and other forms of counseling are used.

Of all categories of diagnosis, personality disorders respond the least to treatment. While progress can be made, it is often in smaller amounts than other categories of disorders. Each specific disorder will respond differently to treatment with some disorders having better success in treatment. Behavioral modification, cognitive-behavioral, and other forms of counseling are often implemented.

Diagnosis of Personality Disorders

Personality disorders fall into three clusters, each having similarities of traits. The clusters are:

Cluster A: Excessive worry and anxiety

• Paranoid Personality Disorder
• Schizoid Personality Disorder
• Schizotypal Personality Disorder

Cluster B: Dramatic, emotional, and erratic behavior

• Anti-Social Personality Disorder
• Histrionic Personality Disorder
• Narcissistic Personality Disorder
• Borderline Personality Disorder

Cluster C:  Anxious and fearful

• Avoidant Personality Disorder
• Dependent Personality Disorder
• Obsessive Compulsive Personality Disorder

Cluster A: Excessive Worry and Anxiety

The Personality Disorders (all criteria according to the DSM5 written by the American Psychiatric Association)

Paranoid personality disorder is a pattern of distrust and suspiciousness such that others’ motives are interpreted as malevolent.

1. A pervasive distrust and suspiciousness of others such that their motives are interpreted as malevolent, beginning by early adulthood and present in a variety of contexts as indicated by four (or more) of the following:

Criteria

1. Suspects, without sufficient basis, that others are exploiting, harming, or deceiving him or her.
2. Is preoccupied with unjustified doubts about the loyalty of trustworthiness of friends and associates.
3. Is reluctant to confide in others because of unwarranted fear that the information will be used maliciously against him or her.
4. Reads hidden demeaning or threatening meanings into benign remarks or events.
5. Persistently bears grudges
6. Perceives attacks on his or her character or reputation that are not apparent to others and is quick to react angrily or to counterattack.
7. Has recurrent suspicions, without justification, regarding fidelity of spouse or sexual partner.
8. Does not occur exclusively during the course of schizophrenia, a bipolar disorder or depressive disorder with psychotic features, or another psychotic disorder and is not attributed to the physiological effects of another medical condition.

Schizoid personality disorder is a pattern of detachment from social relationships and a restricted range of emotional expression. Minimal range of emotion.

1. A pervasive pattern of detachment from social relationships and a restricted range of expression of emotions in interpersonal settings, beginning by early adulthood and present in a variety of contexts, as indicated for four (or more) of the following:

Criteria

1. Neither desires nor enjoys close relationships, including being part of a family.
2. Almost always chooses solitary activities
3. Has little, if any, interest in have sexual experiences with another person.
4. Takes pleasure in few, if any, activities.
5. Lacks close friends or confidants other than first- degree relatives.
6. Appears indifferent to the praise or criticism of others.
7. Shows emotional coldness, detachment, or flattened affectivity.
8. Does not occur exclusively during the course of schizophrenia, a bipolar disorder or depressive disorder with psychotic features, another psychotic disorder, or autism spectrum disorder and is not attributable to the physiological effects of another medical condition.

Schizotypal personality disorder is a pattern of acute discomfort in close relationships, cognitive or perceptual distortions, and eccentricities of behavior.

1. A pervasive pattern of social and interpersonal deficits marked by acute discomfort with, and reduced capacity for, close relationships as well as by cognitive or perceptual distortions and eccentricities of behavior, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

Criteria

1. Ideas of reference (excluding delusions of reference).
2. Odd beliefs or magical thinking that influences behavior and is inconsistent with subcultural norms (i.e. superstitiousness, belief in clairvoyance, telepathy, or “sixth sense”; in children and adolescents, bizarre fantasies or preoccupations).
3. Unusual perceptual experiences, including bodily illusions.
4. Odd thinking and speech (i.e. vague, circumstantial, metaphorical, over elaborate, or stereotyped).
5. Suspiciousness or paranoid ideation.
6. Inappropriate or constricted affect.
7. Behavior or appearance that is odd, eccentric, or peculiar.
8. Lack of close friends or confidants other than first- degree relatives.
9. Excessive social anxiety that does not diminish with familiarity and tends to be associated with paranoid fears rather than negative judgements about self.

Cluster B Personality Disorders

Antisocial personality disorder is a pattern of disregard for, and violation of, the rights of others. CMI – Charming, Manipulation, Intimidation. Against social norms.

1. A pervasive pattern of disregard for violation of the rights of others, occurring since age 15 years, as indicated by three (or more) of the following:

Criteria

1. Failure to conform to social norms with respect to lawful behaviors, as indicated by repeatedly performing acts that are grounds for arrest.
2. Deceitfulness, as indicated by repeated lying, use of aliases, or conning others for personal profit or pleasure.
3. Impulsivity or failure to plan ahead.
4. Irritability and aggressiveness, as indicated by repeated physical fights or assaults.
5. Reckless disregard for safety of self or others.
6. Consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or honor financial obligations.
7. Lack of remorse, as indicated by being indifferent to or rationalizing have hurt, mistreated, or stolen from another.

1. The individual is at least age 18 years.
2. There is evidence of conduct disorder with onset before age 15 years.

D The Occurrence of antisocial behavior is not exclusively during the course of schizophrenia or bipolar disorder.

Borderline personality disorder is a pattern of instability in interpersonal relationships, self- image, and affects, and marked impulsivity.

1. A pervasive pattern of instability of interpersonal relationships, self- image, and affects, and marked impulsivity, beginning by early adulthood and present in a variety of contexts, as indicated by 5 or more of the following:

Criteria

1. Frantic efforts to avoid real or imagined abandonment.
2. A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation.
3. Identity disturbance: markedly and persistently unstable self- image or sense of self
4. Impulsivity in at least two areas that are potentially self- damaging (spending, sex, substance abuse, reckless driving, binge eating)
5. Recurrent suicidal behavior, gestures, or threats, or self- mutilating behavior.
6. Affective instability due to a marked reactivity of mood (intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days).
7. Chronic feelings of emptiness.
8. inappropriate, intense anger or difficulty controlling anger (frequent displays of temper, constant anger, recurrent physical fights).
9. Transient, stress-related paranoid ideation or severe dissociative symptoms.

Histrionic personality disorder is a pattern of excessive emotionality and attention seeking.

1. A pervasive pattern of excessive emotionality and attention seeking, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

1. Is uncomfortable in situations in which he or she is not the center of attention.
2. Interaction with others is often characterized by inappropriate sexually seductive or provocative behavior.
3. Displays rapidly shifting and shallow expression of emotion.
4. Consistently uses physical appearance to draw attention to self.
5. Has a style of speech that is excessively impressionistic and lacking in detail.
6. Shows self- dramatization, theatricality, and exaggerated expression of emotion.
7. Is suggestible (i.e. easily influenced by others or circumstances).
8. Considers relationships to be more intimate than they actually are.

Narcissistic Personality Disorder is a pattern of grandiosity, need for admiration, and lack of empathy. A pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

1. Has a grandiose sense of self- importance (ie. exaggerates achievements and talents, expects to be recognized as superior without commensurate achievements).
2. Is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love.
3. Believes that he or she is “special” and unique and can only be understood by, or shoulder associate with, other special or high- status people (or institutions).
4. Requires excessive admiration.
5. Has a sense of entitlement (ie unreasonable expectations of especially favorable treatment or automatic compliance with his or her expectations.
6. Is interpersonally exploitative (ie. takes advantage of others to achieve his or her own ends).
7. Lacks empathy: is unwilling to recognize or identify with the feelings and needs of others.
8. Is often envious of others or believes that others are envious of him or her.
9. Shows arrogant, haughty behaviors or attitudes.
   

Cluster C Personality Disorders

Avoidant Personality Disorder is a pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation. Beginning of early adulthood and present in a variety of contexts, as indicated by four or more of the following:

1. Avoids occupational activities that involve significant interpersonal contact because of fears of criticism, disapproval, or rejection.
2. Is unwilling to get involved with people unless certain of being liked.
3. Shows restraint within intimate relationships because of the fear of being shamed or ridiculed.
4. Is preoccupied with being criticized or rejected in social situations.
5. Is inhibited in  interpersonal situations because of feelings of inadequacy.
6. Views self as socially inept, personally unappealing, or inferior to others
7. Is unusually reluctant to take personal risks or to engage in any new activities because they may prove embarrassing.

Dependent Personality Disorder is a pattern of submissive and clinging behavior related to an excessive need to be taken care of. Beginning in early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

1. Has difficulty making everyday decisions without an excessive amount of advice and reassurance from others.
2. Needs others to assume responsibility for most major areas of his or her life.
3. Has difficulty expressing disagreement with others because of fear of loss of support or approval. (Note: do not include realistic fears of retribution.)
4. Has difficulty initiating projects or doing things on his or her own (because of a lack of self- confidence in judgement or abilities rather than a lack of motivation or energy).
5. Goes to excessive lengths to obtain nurturance and support from others, to the point of volunteering to do things that are unpleasant.
6. Feels uncomfortable or helpless when alone because of exaggerated fears of being unable to care for himself or herself.
7. Urgently seeks another relationship as a source of care and support when a close relationship ends.
8. Is unrealistically preoccupied with fears of being left to take care of himself or herself.

Obsessive-compulsive Personality Disorder is a pattern of preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness, and efficiency, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following:

1. Is preoccupied with details, rules, lists, order, organization, or schedules to the extent that the major point of the activity is lost.
2. Shows perfectionism ther interferes with task completion (e.g. is unable to complete a project because his or her own overly strict standards are not met).
3. Is excessively devoted to work and productivity to the exclusion of leisure activities and friendships (not accounted for by obvious economic necessity).
4. Is over conscientious, scrupulous, and inflexible about matters of morality, ethics, or values (not accounted for by cultural or religious identification).
5. Is unable to discard worn- out or worthless objects even when they have no sentimental value.
6. Is reluctant to delegate tasks or to work with others unless they submit to exactly his or her way of doing things.
7. Adopts a miserly spending style toward both self and others; money is viewed as something to be hoarded for future catastrophes.
8. Shows rigidity and stubbornness.

Personality change due to another medical condition

1. A persistent personality disturbance that represents a change from the individual’s previous characteristic personality pattern.

Note: In children, the disturbance involves a marked deviation from normal development or significant change in the child’s usual behavior patterns, lasting at least 1 year.

1. There is evidence from the history, physical examination, or laboratory findings that the disturbance is the direct pathophysiology consequence of another medical condition.
2. The disturbance is not better explained by another mental disorder (including another mental disorder due to another medical condition.)
3. The disturbance does not occur exclusively during the course of a delirium.
4. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.