What is Personality Disorder?
The concept of classifying temperament or behavior types has a long history, going back to ancient Greece when the philosopher Hippocrates first suggested his theory. The four basic temperaments he identified were sanguine, choleric, melancholic, and phlegmatic, and these were still being used as a way to categorize human behavior up until the 20th century.
In later years, Emil Kraepelin, a well-known psychiatrist, categorized patients with manic-depression according to depressive, hypomanic, or irritable mood types, which related to melancholic, sanguine, or choleric temperaments respectively. These temperaments eventually developed into seven recognized personality disturbances in 1952’s DSM-1, the official manual for psychiatric diagnosis.
Progressing through time, the 1968’s DSM II expanded on this to clearly differentiate personality disruptions from neurotic disorders. The focus in psychiatry then shifted away from psychoanalytics towards a model more aligned with traditional medical diagnoses, as initially proposed by Kraepelin. This revised approach was represented in the DSM III in 1980, where 11 distinct personality disorders were identified. This number was slightly reduced to ten in the DSM IV version released in 1994.
While making the 2013’s DSM 5, experts considered merging a new five-factor model of behavior with older models of personality, but eventually decided to leave the categorization as it was.
Today, the ten personality disorders are grouped into three clusters. Cluster A includes paranoid, schizoid, and schizotypal disorders. Cluster B encompasses antisocial, borderline, histrionic, and narcissistic disorders, and Cluster C comprises avoidant, dependent, and obsessive-compulsive disorders. These disorders are currently defined as deep-rooted and unhelpful patterns of behavior, thought, and emotion causing distress and dysfunction.
People diagnosed with personality disorders usually struggle with distorted reality perceptions and abnormal emotional responses, resulting in unhelpful coping strategies and personal distress.
What Causes Personality Disorder?
The exact cause of personality disorders is still a mystery, leading to a variety of theories. Psychoanalysts believe these disorders might stem from interruptions in the normal process of personality development related to our sexual drive, as described by famous psychologist, Freud. According to this view, personality disorders like dependent, obsessive-compulsive, and histrionic disorders could be caused by getting ‘stuck’ in different stages of development: the oral, anal, and phallic stages, specifically.
Another theory suggests childhood trauma might play a role. For example, people with borderline and antisocial disorders often struggle with intimacy and trust, issues which could be linked to early life abuse or trauma.
Recent research has started to reveal a potential genetic component to personality disorders, especially in the cases of schizotypal, borderline and antisocial disorders. Certain genes that help control the way our brain cells communicate, specifically those related to the chemicals serotonin, dopamine, and norepinephrine, seem to be of particular interest.
Culture also seems to influence personality disorders. This is suggested by the fact that the frequency of certain disorders varies by country. An example of this is the much lower number of cases of antisocial personality disorders seen in Taiwan, China, and Japan when compared to a higher occurrence of cluster C personality disorders.
Risk Factors and Frequency for Personality Disorder
According to the World Health Organization, about 6.1% of people have a personality disorder. These disorders can be divided into three main groups (A, B, and C), with respective prevalence rates of 3.6%, 1.5%, and 2.7%. Among people with mental health problems, about 30% have a personality disorder, with a higher percentage found in prisons. Research shows that people with personality disorders are generally younger, unmarried, male, have a lower income, and less education. Some personality disorders occur more commonly in certain genders; men are more likely to have antisocial personality disorder, whereas women are more likely to have borderline, histrionic, or dependent personality disorder.
- About 6.1% of people have a personality disorder according to the World Health Organization.
- This includes Cluster A, B, and C disorders, affecting around 3.6%, 1.5%, and 2.7% of the population respectively.
- In the mental health patient population, about 30% have a personality disorder. This rate is even higher among the prison population.
- People with personality disorders are typically younger, unmarried, male, belong to a lower socioeconomic group, and have lower education levels.
- Men are more likely to show antisocial personality disorder, while women are more likely to have borderline, histrionic, or dependent personality disorder.
Signs and Symptoms of Personality Disorder
People who suffer from personality disorders often don’t fully understand, or have insight into, their abnormal behavior. As a result, they rarely seek treatment for these issues directly. Rather, they often see a doctor because of problems related to their disorder, like ongoing depression, difficulties in their relationships or struggles with school or work. Information from family members or close friends who know the patient well is often very helpful. They can provide a clearer picture of the patient’s usual behavior patterns, and they may be the ones who finally encourage the patient to seek help.
There are different categories, or clusters, of personality disorders. Each cluster and specific disorder within it has unique characteristics. For example, Cluster A, which is the “odd or eccentric” group, includes Paranoid, Schizoid and Schizotypal personality disorders. People with these issues are often suspicious, withdrawn, and display strange behavior. Paranoid people are excessively distrustful, while Schizoid individuals tend to be notably antisocial and emotionally cold. The Schizotypal disorder, on the other hand, manifests with strange behavior, thoughts, and perceptions, alongside emotional instability.
- Cluster A: Eccentric or odd behaviors
- Paranoid: Excessive distrust
- Schizoid: Antisocial, emotionally cold
- Schizotypal: Strange behavior, thoughts, and perceptions, and emotional instability
In contrast, Cluster B personality disorders are characterized by dramatic, unpredictable behavior. These include Antisocial, Borderline, Histrionic and Narcissistic personality disorders. People with these disorders often violate social norms and act impulsively, which can lead to criminal activity. They may also struggle with impulsive aggression and may be pathological liars. For instance, those with Borderline Personality Disorder typically experience high emotional instability, intense relationships, frequent anger, and a sense of emptiness, with recurrent self-harm. Patients struggling with Narcissistic Personality Disorder experience grandiosity, lack empathy, and are excessively sensitive to the evaluations of others, making themselves the center of attention.
- Cluster B: Dramatic, impulsive behaviors
- Antisocial: Violates social norms, acts impulsively
- Borderline: Emotional instability, intense relationships
- Histrionic: Attention seeking, shallow emotions
- Narcissistic: Excessive love of self, need for admiration
Finally, Cluster C disorders are characterized by intense anxiety and fear. Avoidant, Dependent and Obsessive-Compulsive personality disorders fall into this category. People with these disorders may feel inadequacy in social situations leading to isolation, depend on others for emotional validation. They might also obsess over perfection, leading to inflexibility in their routine. Such quirks and behaviors often lead to difficulty in forming and maintaining relationships.
- Cluster C: High levels of anxiety and fear
- Avoidant: Sensitivity to criticism, social inhibition
- Dependent: Strong need to be taken of
- Obsessive-Compulsive: Obsessed with orderliness and control
Testing for Personality Disorder
Diagnosing personality disorders is a delicate process. It’s important to start gently, with broad, non-confrontational questions. This approach helps avoid causing the patient to become defensive or hostile. You might want to ask about their past relationships, work experiences, their grasp on reality, emotional nature, and self-control.
What’s really crucial, though, is gathering extra information from sources other than the patient. This is because patients often lack self-awareness regarding their condition. Good sources for this information can be family members, police officers, or parole officers.
As personality disorders often share similarities, collecting as much information as possible is crucial to establishing an accurate diagnosis. Once all the data is collected, the healthcare provider will refer to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), which is a guide that defines and classifies mental disorders, to determine which disorder the patient’s condition lines up with best.
Treatment Options for Personality Disorder
Personality disorders are among the trickiest mental health conditions to treat. Often, individuals with these disorders don’t recognize that their behavior is causing problems. In addition, even if they’re willing to get help, there are no specific medications for personality disorders. This can make treatment quite challenging. The most effective approach usually comes down to managing behaviors and emotions in difficult situations.
Depending on the type of personality disorder, care givers employ different strategies. For instance, people with cluster A disorders, who often have trouble trusting others, may benefit more from one-on-one social skills training rather than group therapy. In certain cases, treatment may also involve medications known as second-generation antipsychotics.
Contrarily, group therapy can be helpful for those with cluster B disorders. The main aim of therapy for people with antisocial personality disorder is to reduce aggressive behavior. This can sometimes be aided by medications such as lithium, valproic acid, and antipsychotics. Individuals with histrionic personality disorder, who frequently seek attention, may benefit from cognitive-behavioral therapy (CBT), which helps them focus on their behavior patterns.
Narcissistic individuals are especially hard to treat, as they often resist feedback and seldom seek help. However, with intensive psychodynamic psychotherapy, there can be noticeable improvement. For people with borderline personality disorder, the treatment often involves dialectical behavior therapy (DBT), proven to be effective through various studies.
Lastly, for cluster C personality disorders, CBT can be beneficial. It helps in addressing issues like assertiveness, independence, and attitude, while certain medications called selective serotonin reuptake inhibitors (SSRIs) can help manage anxiety. In case of avoidant personality disorder, a range of methods from supportive psychotherapy to assertiveness training are found useful. Those with obsessive-compulsive personality disorder often respond well to psychoanalytic psychotherapy.
What else can Personality Disorder be?
Personality disorders often look like or occur simultaneously with other mental health conditions. A common confusion lies in differentiating between borderline personality disorder and bipolar disorder. Borderline personality disorder typically involves mood swings related to relationship issues, while bipolar disorder is characterized by longer periods of mood changes.
Confusion can also arise between schizotypal personality disorders and schizophrenia. The former can seem like a less severe, or early stage of schizophrenia. Social anxiety disorder and avoidant personality disorder also have similar traits and can be hard to distinguish. Both involve higher-than-normal anxiety levels, but social anxiety tends to indicate a less severe mental issue, while avoidant personality disorder suggests a more serious mental illness.
These conditions all have different outcomes and respond uniquely to treatments. Therefore, it’s crucial for doctors to understand the small differences that make each disorder stand out. On most occasions, due to the nature of the disorder, patients are likely to have other conditions like depression or anxiety. It’s equally essential to distinguish between unique personal qualities and personality disorders. The latter are rigid, distressing, and unhealthy, while the former are part of a spectrum of normal behaviors.
Cultural differences can sometimes seem to resemble these conditions. Some cultures and religions believe in magic and spiritual worlds, but these beliefs aren’t the same as having unfounded or unrealistic thoughts, also known as delusions.
Finally, because many personality disorders share common traits, it can often lead to inaccurate diagnoses. All these factors contribute to the complexity of diagnosing and treating such conditions.
What to expect with Personality Disorder
Personality disorders can cause significant distress for the affected individual and can also be a societal burden. Studies have shown that these disorders are often linked with disability benefits. Since many people with personality disorders lack self-awareness, they may not seek the necessary medical help, which results in a generally poor outlook.
The severity of the symptoms can fluctuate over time. Fortunately, some disorders can “burn out” as a person gets older, meaning that they become less intense and less disabling with age.
Possible Complications When Diagnosed with Personality Disorder
People with personality disorders often face many troubles, including conflicts in personal relationships and difficulties in their jobs. These challenges can result in poor social skills and regular interpersonal problems. Research has shown that these individuals have higher chances of experiencing unemployment, divorce, domestic abuse, substance use, and even homelessness.
Such disorders also impact the wider society, particularly in terms of healthcare costs. For instance, these individuals are more likely to visit emergency departments, have traumatic accidents, and may tragically lose their lives to suicide earlier than others.
A major issue is that these people usually have depression or anxiety that is difficult to treat. Due to misdiagnosis or lack of accurate diagnosis, medication meant to manage their mental health problems often do not result in any significant improvement.
Personality disorders therefore carry a significant burden, not just for the individuals affected, but also for society and countries at large. Their widespread nature, coupled with lack of accurate diagnosis and effective treatment, create ongoing issues. The situation is further complicated by the fact that people suffering from such disorders might not recognise the need for treatment.
Preventing Personality Disorder
Because of a patient’s inability to fully understand their condition, it’s crucial for family and friends to stay alert and encourage the patient to get help. It’s also recommended for those close to the patient to learn about the specific disorder they’re dealing with. Having knowledge about the illness not only helps the patient, but is also beneficial to those around them.
Research has shown that factors like being married, having a job, and getting a higher education can reduce the negative impacts of disability. On the other hand, those who are unmarried, jobless, and have received less education are more likely to be seriously affected by their disorders. These factors may prevent personality disorders from developing into more severe mental health conditions.
