Tag: AvPD: Avoidant Personality Disorder

Introduction

Personality disorders (PD) are a class of mental disorders characterised by enduring maladaptive patterns of behaviour, cognition, and inner experience, exhibited across many contexts and deviating 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 somewhat, according to source, and remain a matter of controversy. Official criteria for diagnosing personality disorders are listed in the fifth chapter of the International Classification of Diseases (ICD) and in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM).

Personality, defined psychologically, is the set of enduring behavioural and mental traits that distinguish individual humans. Hence, PDs are defined by experiences and behaviours that deviate from social norms and expectations. Those diagnosed with a PD may experience difficulties in cognition, emotiveness, interpersonal functioning, or impulse control. In general, PDs are diagnosed in 40-60% of psychiatric patients, making them the most frequent of psychiatric diagnoses.

PDs are characterised by an enduring collection of behavioural patterns often associated with considerable personal, social, and occupational disruption. PDs are also inflexible and pervasive across many situations, largely due to the fact that such behaviour 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. In addition, people with personality disorders often lack insight into their condition and so refrain from seeking treatment. This behaviour can result in maladaptive coping skills and may lead to personal problems that induce extreme anxiety, distress, or depression and result in impaired psychosocial functioning. These behaviour patterns are typically recognised by adolescence, the beginning of adulthood or sometimes even childhood and often have a pervasive negative impact on the quality of life.

While emerging treatments, such as dialectical behaviour therapy, have demonstrated efficacy in treating PDs, such as borderline personality disorder, PDs are associated with considerable stigma in popular and clinical discourse alike. Despite various methodological schemas designed to categorise PDs, many issues occur with classifying a personality disorder because the theory and diagnosis of such disorders occur within prevailing cultural expectations; thus, their validity is contested by some experts on the basis of inevitable subjectivity. They argue that the theory and diagnosis of PDs are based strictly on social, or even sociopolitical and economic considerations.

Refer to Personality Disorder Not Otherwise Specified.

Brief History

Before the 20th Century

Personality disorder is a term with a distinctly modern meaning, owing in part to its clinical usage and the institutional character of modern psychiatry. The currently accepted meaning must be understood in the context of historical changing classification systems such as DSM-IV and its predecessors. Although highly anachronistic, and ignoring radical differences in the character of subjectivity and social relations, some have suggested similarities to other concepts going back to at least the ancient Greeks.  For example, the Greek philosopher Theophrastus described 29 ‘character’ types that he saw as deviations from the norm, and similar views have been found in Asian, Arabic and Celtic cultures. A long-standing influence in the Western world was Galen’s concept of personality types, which he linked to the four humours proposed by Hippocrates.

Such views lasted into the eighteenth century, when experiments began to question the supposed biologically based humours and ‘temperaments’. Psychological concepts of character and ‘self’ became widespread. In the nineteenth century, ‘personality’ referred to a person’s conscious awareness of their behaviour, a disorder of which could be linked to altered states such as dissociation. This sense of the term has been compared to the use of the term ‘multiple personality disorder’ in the first versions of the DSM.

Physicians in the early nineteenth century started to diagnose forms of insanity involving disturbed emotions and behaviours but seemingly without significant intellectual impairment or delusions or hallucinations. Philippe Pinel referred to this as ‘ manie sans délire ‘ – mania without delusions – and described a number of cases mainly involving excessive or inexplicable anger or rage. James Cowles Prichard advanced a similar concept he called moral insanity, which would be used to diagnose patients for some decades. ‘Moral’ in this sense referred to affect (emotion or mood) rather than ethics, but it was arguably based in part on religious, social and moral beliefs, with a pessimism about medical intervention so social control should take precedence. These categories were much different and broader than later definitions of personality disorder, while also being developed by some into a more specific meaning of moral degeneracy akin to later ideas about ‘psychopaths’. Separately, Richard von Krafft-Ebing popularised the terms sadism and masochism, as well as homosexuality, as psychiatric issues.

The German psychiatrist Koch sought to make the moral insanity concept more scientific, and in 1891 suggested the phrase ‘psychopathic inferiority’, theorised to be a congenital disorder. This referred to continual and rigid patterns of misconduct or dysfunction in the absence of apparent mental retardation or illness, supposedly without a moral judgement. Described as deeply rooted in his Christian faith, his work established the concept of personality disorder as used today.

20th century

In the early 20th century, another German psychiatrist, Emil Kraepelin, included a chapter on psychopathic inferiority in his influential work on clinical psychiatry for students and physicians. He suggested six types:

• Excitable;
• Unstable;
• Eccentric;
• Liar;
• Swindler; and
• Quarrelsome.

The categories were essentially defined by the most disordered criminal offenders observed, distinguished between criminals by impulse, professional criminals, and morbid vagabonds who wandered through life. Kraepelin also described three paranoid (meaning then delusional) disorders, resembling later concepts of schizophrenia, delusional disorder and paranoid personality disorder. A diagnostic term for the latter concept would be included in the DSM from 1952, and from 1980 the DSM would also include schizoid, schizotypal; interpretations of earlier (1921) theories of Ernst Kretschmer led to a distinction between these and another type later included in the DSM, avoidant personality disorder.

In 1933 Russian psychiatrist Pyotr Borisovich Gannushkin published his book Manifestations of Psychopathies: Statics, Dynamics, Systematic Aspects, which was one of the first attempts to develop a detailed typology of psychopathies. Regarding maladaptation, ubiquity, and stability as the three main symptoms of behavioural pathology, he distinguished nine clusters of psychopaths: cycloids (including constitutionally depressive, constitutionally excitable, cyclothymics, and emotionally labile), asthenics (including psychasthenics), schizoids (including dreamers), paranoiacs (including fanatics), epileptoids, hysterical personalities (including pathological liars), unstable psychopaths, antisocial psychopaths, and constitutionally stupid. Some elements of Gannushkin’s typology were later incorporated into the theory developed by a Russian adolescent psychiatrist, Andrey Yevgenyevich Lichko, who was also interested in psychopathies along with their milder forms, the so-called accentuations of character.

In 1939, psychiatrist David Henderson published a theory of ‘psychopathic states’ that contributed to popularly linking the term to anti-social behaviour. Hervey M. Cleckley’s 1941 text, The Mask of Sanity, based on his personal categorisation of similarities he noted in some prisoners, marked the start of the modern clinical conception of psychopathy and its popularist usage.

Towards the mid 20th century, psychoanalytic theories were coming to the fore based on work from the turn of the century being popularized by Sigmund Freud and others. This included the concept of character disorders, which were seen as enduring problems linked not to specific symptoms but to pervasive internal conflicts or derailments of normal childhood development. These were often understood as weaknesses of character or wilful deviance, and were distinguished from neurosis or psychosis. The term ‘borderline’ stems from a belief some individuals were functioning on the edge of those two categories, and a number of the other personality disorder categories were also heavily influenced by this approach, including dependent, obsessive-compulsive and histrionic, the latter starting off as a conversion symptom of hysteria particularly associated with women, then a hysterical personality, then renamed histrionic personality disorder in later versions of the DSM. A passive aggressive style was defined clinically by Colonel William Menninger during World War II in the context of men’s reactions to military compliance, which would later be referenced as a personality disorder in the DSM. Otto Kernberg was influential with regard to the concepts of borderline and narcissistic personalities later incorporated in 1980 as disorders into the DSM.

Meanwhile, a more general personality psychology had been developing in academia and to some extent clinically. Gordon Allport published theories of personality traits from the 1920s – and Henry Murray advanced a theory called personology, which influenced a later key advocate of personality disorders, Theodore Millon. Tests were developing or being applied for personality evaluation, including projective tests such as the Rorshach, as well as questionnaires such as the Minnesota Multiphasic Personality Inventory. Around mid-century, Hans Eysenck was analysing traits and personality types, and psychiatrist Kurt Schneider was popularising a clinical use in place of the previously more usual terms ‘character’, ‘temperament’ or ‘constitution’.

American psychiatrists officially recognised concepts of enduring personality disturbances in the first Diagnostic and Statistical Manual of Mental Disorders in the 1950s, which relied heavily on psychoanalytic concepts. Somewhat more neutral language was employed in the DSM-II in 1968, though the terms and descriptions had only a slight resemblance to current definitions. The DSM-III published in 1980 made some major changes, notably putting all personality disorders onto a second separate ‘axis’ along with mental retardation, intended to signify more enduring patterns, distinct from what were considered axis one mental disorders. ‘Inadequate’ and ‘asthenic’ personality disorder’ categories were deleted, and others were expanded into more types, or changed from being personality disorders to regular disorders. Sociopathic personality disorder, which had been the term for psychopathy, was renamed Antisocial Personality Disorder. Most categories were given more specific ‘operationalised’ definitions, with standard criteria psychiatrists could agree on to conduct research and diagnose patients. In the DSM-III revision, self-defeating personality disorder and sadistic personality disorder were included as provisional diagnoses requiring further study. They were dropped in the DSM-IV, though a proposed ‘depressive personality disorder’ was added; in addition, the official diagnosis of passive-aggressive personality disorder was dropped, tentatively renamed ‘negativistic personality disorder.’

International differences have been noted in how attitudes have developed towards the diagnosis of personality disorder. Kurt Schneider argued they were ‘abnormal varieties of psychic life’ and therefore not necessarily the domain of psychiatry, a view said to still have influence in Germany today. British psychiatrists have also been reluctant to address such disorders or consider them on par with other mental disorders, which has been attributed partly to resource pressures within the National Health Service, as well as to negative medical attitudes towards behaviours associated with personality disorders. In the US, the prevailing healthcare system and psychanalytic tradition has been said to provide a rationale for private therapists to diagnose some personality disorders more broadly and provide ongoing treatment for them.

Epidemiology

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 WHO 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.

Personality disorders (especially Cluster A) are also very common among homeless people.

There are some sex differences in the frequency of personality disorders which are shown below (type of PD/predominant gender):

•  Paranoid personality disorder: Male.
• Schizoid personality disorder: Male.
• Schizotypal personality disorder: Male.
• Antisocial personality disorder: Male.
• Borderline personality disorder: Female.
• Histrionic personality disorder: Female.
• Narcissistic personality disorder: Male.
• Avoidant personality disorder: Male.
• Dependent personality disorder: Female.
• Depressive personality disorder: Female.
• Passive–aggressive personality disorder: Male.
• Obsessive-compulsive personality disorder: Male.
• Self-defeating personality disorder: Female.
• Sadistic personality disorder: Male.

Classification

The two relevant major systems of classification are:

• The International Classification of Diseases (11th revision, ICD-11) published by the World Health Organisation (WHO); and
• The Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition, DSM-5) by the American Psychiatric Association.

The ICD system is a collection of numerical codes that have been assigned to all known clinical disease states, which provides uniform terminology for medical records, billing, and research purposes. The DSM defines psychiatric diagnoses based on research and expert consensus, and its content informs the ICD-10 classifications. Both 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.

General Criteria

Both diagnostic systems provide a definition and six criteria for a general personality disorder. These criteria should be met by all personality disorder cases before a more specific diagnosis can be made.

The ICD-10 lists these general guideline criteria:

• Markedly disharmonious attitudes and behaviour, 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 behaviour pattern is enduring, of long standing, and not limited to episodes of mental illness;
• The abnormal behaviour 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 DSM-5, any personality disorder diagnosis must meet the following criteria:

• An enduring pattern of inner experience and behaviour that deviates markedly from the expectations of the individual’s culture. This pattern is manifested in two (or more) of the following areas:
  • Cognition (i.e. ways of perceiving and interpreting self, other people, and events).
  • Affectivity (i.e. the range, intensity, lability, and appropriateness of emotional response).
  • Interpersonal functioning.
  • Impulse control.
• The enduring pattern is inflexible and pervasive across a broad range of personal and social situations.
• The enduring pattern leads to clinically significant distress or impairment in social, occupational, or other important areas of functioning.
• The pattern is stable and of long duration, and its onset can be traced back at least to adolescence or early adulthood.
• The enduring pattern is not better explained as a manifestation or consequence of another mental disorder.
• The enduring pattern is not attributable to the physiological effects of a substance (e.g. a drug of abuse, a medication) or another medical condition (e.g. head trauma).

In ICD-10

Chapter V in the ICD-10 contains the mental and behavioural disorders and 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.

Besides the ten specific PD, there are the following categories:

• Other specific personality disorders (involves PD characterised as eccentric, haltlose, immature, narcissistic, passive-aggressive, or psychoneurotic).
• Personality disorder, unspecified (includes “character neurosis” and “pathological personality”).
• 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).
• 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).

In ICD-11

In the proposed revision of ICD-11, all discrete personality disorder diagnoses will be removed and replaced by the single diagnosis “personality disorder”. Instead, there will be specifiers called “prominent personality traits” and the possibility to classify degrees of severity ranging from “mild”, “moderate”, and “severe” based on the dysfunction in interpersonal relationships and everyday life of the patient.

There are six prominent personality traits/patterns categorised by the ICD-11:

• Negative affectivity (“tendency to experience a broad range of negative emotions.”).
• Detachment (“tendency to maintain interpersonal distance (social detachment) and emotional distance (emotional detachment).”).
• Dissociality (“disregard for the rights and feelings of others, encompassing both self-centredness and lack of empathy.” Equivalent to the DSM-5 classification of antisocial personality disorder.).
• Disinhibition (“tendency to act rashly based on immediate external or internal stimuli (i.e., sensations, emotions, thoughts), without consideration of potential negative consequences.”).
• Anankastia (“narrow focus on one’s rigid standard of perfection and of right and wrong, and on controlling one’s own and others’ behaviour and controlling situations to ensure conformity to these standards.” Equivalent to the DSM-5 classification of obsessive-compulsive personality disorder.),
• Borderline pattern (“pattern of personality disturbance is characterised by a pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity”. Equivalent to the DSM-5 classification of borderline personality disorder.),

In DSM-5

The most recent fifth edition of the Diagnostic and Statistical Manual of Mental Disorders stresses that a personality disorder is an enduring and inflexible pattern of long duration leading to significant distress or impairment and is not due to use of substances or another medical condition. The DSM-5 lists personality disorders in the same way as other mental disorders, rather than on a separate ‘axis’, as previously.

DSM-5 lists ten specific personality disorders: paranoid, schizoid, schizotypal, antisocial, borderline, histrionic, narcissistic, avoidant, dependent and obsessive-compulsive personality disorder.

The DSM-5 also contains three diagnoses for personality patterns not matching these ten disorders, but nevertheless exhibit characteristics of a personality disorder:

• Personality change due to another medical condition – personality disturbance due to the direct effects of a medical condition.
• Other specified personality disorder – general criteria for a personality disorder are met but fails to meet the criteria for a specific disorder, with the reason given.
• Unspecified personality disorder – general criteria for a personality disorder are met but the personality disorder is not included in the DSM-5 classification.

Personality Clusters

The specific personality disorders are grouped into the following three clusters based on descriptive similarities:

Cluster A (Odd or Eccentric Disorders)

Cluster A personality disorders are often associated with schizophrenia: in particular, schizotypal personality disorder shares some of its hallmark symptoms with schizophrenia, e.g., acute discomfort in close relationships, cognitive or perceptual distortions, and eccentricities of behaviour. However, people diagnosed with odd-eccentric personality disorders tend to have a greater grasp on reality than those with schizophrenia. Patients suffering from these disorders can be paranoid and have difficulty being understood by others, as they often have odd or eccentric modes of speaking and an unwillingness and inability to form and maintain close relationships. Though their perceptions may be unusual, these anomalies are distinguished from delusions or hallucinations as people suffering from these would be diagnosed with other conditions. Significant evidence suggests a small proportion of people with Cluster A personality disorders, especially schizotypal personality disorder, have the potential to develop schizophrenia and other psychotic disorders. These disorders also have a higher probability of occurring among individuals whose first-degree relatives have either schizophrenia or a Cluster A personality disorder.

• Paranoid personality disorder: characterised 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, apathy, and restricted emotional expression.
• Schizotypal personality disorder: pattern of extreme discomfort interacting socially, and distorted cognition and perceptions.

Cluster B (Dramatic, Emotional or Erratic Disorders)

• Antisocial personality disorder: pervasive pattern of disregard for and violation of the rights of others, lack of empathy, bloated self-image, manipulative and impulsive behaviour.
• Borderline personality disorder: pervasive pattern of abrupt emotional outbursts, altered empathy, instability in relationships, self-image, identity, behaviour and affect, often leading to self-harm and impulsivity.
• Histrionic personality disorder: pervasive pattern of attention-seeking behaviour, excessive emotions, and egocentrism.
• Narcissistic personality disorder: pervasive pattern of superior grandiosity, need for admiration, and a perceived or real lack of empathy. In a more severe expression, narcissistic personality disorder may show evidence of paranoia, aggression, psychopathy, and sadistic personality disorder, which is known as malignant narcissism.

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: characterised by rigid conformity to rules, perfectionism, and control to the point of satisfaction and exclusion of leisurely activities and friendships (distinct from obsessive-compulsive disorder).

Other Personality Types

Some types of personality disorder were in previous versions of the diagnostic manuals but have been deleted. Examples include sadistic personality disorder (pervasive pattern of cruel, demeaning, and aggressive behaviour) and self-defeating personality disorder or masochistic personality disorder (characterised by behaviour consequently undermining the person’s pleasure and goals). They were listed in the DSM-III-R appendix as “Proposed diagnostic categories needing further study” without specific criteria. 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.

Millon’s Description

Psychologist Theodore Millon, who has written numerous popular works on personality, proposed the following description of personality disorders:

Type of Personality Disorder	Description
Paranoid	Guarded, defensive, distrustful and suspicious. Hypervigilant to the motives of others to undermine or do harm. Always seeking confirmatory evidence of hidden schemes. Feel righteous, but persecuted. Experience a pattern of pervasive distrust and suspicion of others that lasts a long time. They are generally difficult to work with and are very hard to form relationships with. They are also known to be somewhat short-tempered.
Schizoid	Apathetic, indifferent, remote, solitary, distant, humourless, contempt, odd fantasies. Neither desire nor need human attachments. Withdrawn from relationships and prefer to be alone. Little interest in others, often seen as a loner. Minimal awareness of the feelings of themselves or others. Few drives or ambitions, if any. Is an uncommon condition in which people avoid social activities and consistently shy away from interaction with others. It affects more males than females. To others, they may appear somewhat dull or humourless. Because they don’t tend to show emotion, they may appear as though they don’t care about what’s going on around them.
Schizotypal	Eccentric, self-estranged, bizarre, absent. Exhibit peculiar mannerisms and behaviours. Think they can read thoughts of others. Preoccupied with odd daydreams and beliefs. Blur line between reality and fantasy. Magical thinking and strange beliefs. People with schizotypal personality disorder are often described as odd or eccentric and usually have few, if any, close relationships. They think others think negatively of them.
Antisocial	Impulsive, irresponsible, deviant, unruly. Act without due consideration. Meet social obligations only when self-serving. Disrespect societal customs, rules, and standards. See themselves as free and independent. People with antisocial personality disorder depict a long pattern of disregard for other people’s rights. They often cross the line and violate these rights.
Borderline	Unpredictable, egocentric, emotionally unstable. Frantically fears abandonment and isolation. Experience rapidly fluctuating moods. Shift rapidly between loving and hating. See themselves and others alternatively as all-good and all-bad. Unstable and frequently changing moods. People with borderline personality disorder have a pervasive pattern of instability in interpersonal relationships.
Histrionic	Hysteria, dramatic, seductive, shallow, egocentric, attention-seeking, vain. Overreact to minor events. Exhibitionistic as a means of securing attention and favours. See themselves as attractive and charming. Constantly seeking others’ attention. Disorder is characterised by constant attention-seeking, emotional overreaction, and suggestibility. Their tendency to over-dramatise may impair relationships and lead to depression, but they are often high-functioning.
Narcissistic	Egotistical, arrogant, grandiose, insouciant. Preoccupied with fantasies of success, beauty, or achievement. See themselves as admirable and superior, and therefore entitled to special treatment. Is a mental disorder in which people have an inflated sense of their own importance and a deep need for admiration. Those with narcissistic personality disorder believe that they are superior to others and have little regard for other people’s feelings.
Avoidant	Hesitant, self-conscious, embarrassed, anxious. Tense in social situations due to fear of rejection. Plagued by constant performance anxiety. See themselves as inept, inferior, or unappealing. They experience long-standing feelings of inadequacy and are very sensitive of what others think about them.
Dependent	Helpless, incompetent, submissive, immature. Withdrawn from adult responsibilities. See themselves as weak or fragile. Seek constant reassurance from stronger figures. They have the need to be taken care of by a person. They fear being abandoned or separated from important people in their life.
Obsessive-Compulsive	Restrained, conscientious, respectful, rigid. Maintain a rule-bound lifestyle. Adhere closely to social conventions. See the world in terms of regulations and hierarchies. See themselves as devoted, reliable, efficient, and productive.
Depressive	Sombre, discouraged, pessimistic, brooding, fatalistic. Present themselves as vulnerable and abandoned. Feel valueless, guilty, and impotent. Judge themselves as worthy only of criticism and contempt. Hopeless, suicidal, restless. This disorder can lead to aggressive acts and hallucinations.
Passive-Aggressive (Negativistic)	Resentful, contrary, sceptical, discontented. Resist fulfilling others’ expectations. Deliberately inefficient. Vent anger indirectly by undermining others’ goals. Alternately moody and irritable, then sullen and withdrawn. Withhold emotions. Will not communicate when there is something problematic to discuss.
Sadistic	Explosively hostile, abrasive, cruel, dogmatic. Liable to sudden outbursts of rage. Gain satisfaction through dominating, intimidating and humiliating others. They are opinionated and closed-minded. Enjoy performing brutal acts on others. Find pleasure in abusing others. Would likely engage in a sadomasochist relationship, but will not play the role of a masochist.
Self-Defeating (Masochistic)	Deferential, pleasure-phobic, servile, blameful, self-effacing. Encourage others to take advantage of them. Deliberately defeat own achievements. Seek condemning or mistreatful partners. They are suspicious of people who treat them well. Would likely engage in a sadomasochist relationship.

Additional Factors

In addition to classifying by category and cluster, it is possible to classify personality disorders using additional factors such as severity, impact on social functioning, and attribution.

Severity

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.

Dimensional System of Classifying Personality Disorders

Level of Severity	Description	Definition by Categorical System
0	No personality disorder	Does not meet actual or subthreshold criteria for any personality disorder.
1	Personality difficulty	Meets sub-threshold criteria for one or several personality disorders.
2	Simple personality disorder	Meets actual criteria for one or more personality disorders within the same cluster.
3	Complex (diffuse) personality disorder	Meets actual criteria for one or more personality disorders within more than one cluster.
4	Severe personality disorder	Meets criteria for creation of severe disruption to both individual and to many in society.

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 disorder versus personality disorder.
• This system accommodates the new diagnosis of severe personality disorder, particularly “dangerous and severe personality disorder” (DSPD).

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.

Attribution

Many who have a personality disorder do not recognise 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 clamour 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.

Presentation

Comorbidity

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.

Impact on Functioning

It is generally assumed that all personality disorders are linked to impaired functioning and a reduced quality of life (QoL) because that is a basic diagnostic requirement. But research shows that this may be true only for some types of personality disorder.

In several studies, higher disability and lower QoL were predicted by avoidant, dependent, schizoid, paranoid, schizotypal and antisocial personality disorder. This link is particularly strong for avoidant, schizotypal and borderline PD. However, obsessive-compulsive PD was not related to a compromised QoL or dysfunction. A prospective study reported that all PD were associated with significant impairment 15 years later, except for obsessive compulsive and narcissistic personality disorder.

One study investigated some aspects of “life success” (status, wealth and successful intimate relationships). It showed somewhat poor functioning for schizotypal, antisocial, borderline and dependent PD, schizoid PD had the lowest scores regarding these variables. Paranoid, histrionic and avoidant PD were average. Narcissistic and obsessive-compulsive PD, however, had high functioning and appeared to contribute rather positively to these aspects of life success.

There is also a direct relationship between the number of diagnostic criteria and quality of life. For each additional personality disorder criterion that a person meets there is an even reduction in quality of life.

Issues

In the Workplace

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 disorders, 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 and again in 2009, 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 leadership academic Manfred F.R. Kets de Vries, it seems almost inevitable that some personality disorders will be present in a senior management team.

In Children

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 personality 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.

Versus Mental Disorders

The disorders in each of the three clusters may share with each other underlying common vulnerability factors involving cognition, affect and impulse control, and behavioural maintenance or inhibition, respectively. But they may also have a spectrum relationship to certain syndromal mental disorders:

• Paranoid, schizoid 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, with impulse-control disorders, eating disorders, ADHD, or a substance use disorder.
• Avoidant personality disorder is seen with social anxiety disorder.

Versus Normal Personality

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-5 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 the Five Factor Model of personality as an 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 DSM-5.

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.

As of 2002, there were over fifty published studies relating the five factor model (FFM) to personality disorders. Since that time, quite a number of additional studies have expanded on this research base and provided further empirical support for understanding the DSM personality disorders in terms of the FFM domains. In her seminal review of the personality disorder literature published in 2007, Lee Anna Clark asserted that “the five-factor model of personality is widely accepted as representing the higher-order structure of both normal and abnormal personality traits”.

The five factor model has been shown to significantly predict all 10 personality disorder symptoms and outperform the Minnesota Multiphasic Personality Inventory (MMPI) in the prediction of borderline, avoidant, and dependent personality disorder symptoms.

Research results examining the relationships between the FFM and each of the ten DSM personality disorder diagnostic categories are widely available. For example, in a study published in 2003 titled “The five-factor model and personality disorder empirical literature: A meta-analytic review”, the authors analysed data from 15 other studies to determine how personality disorders are different and similar, respectively, with regard to underlying personality traits. In terms of how personality disorders differ, the results showed that each disorder displays a FFM profile that is meaningful and predictable given its unique diagnostic criteria. With regard to their similarities, the findings revealed that the most prominent and consistent personality dimensions underlying a large number of the personality disorders are positive associations with neuroticism and negative associations with agreeableness.

Openness to Experience

At least three aspects of openness to experience are relevant to understanding personality disorders: cognitive distortions, lack of insight (means the ability to recognise one’s own mental illness here) and impulsivity. Problems related to high openness that can cause problems with social or professional functioning are excessive fantasising, peculiar thinking, diffuse identity, unstable goals and nonconformity with the demands of the society.

High openness is characteristic to schizotypal personality disorder (odd and fragmented thinking), narcissistic personality disorder (excessive self-valuation) and paranoid personality disorder (sensitivity to external hostility). Lack of insight (shows low openness) is characteristic to all personality disorders and could help explain the persistence of maladaptive behavioural patterns.

The problems associated with low openness are difficulties adapting to change, low tolerance for different worldviews or lifestyles, emotional flattening, alexithymia and a narrow range of interests. Rigidity is the most obvious aspect of (low) openness among personality disorders and that shows lack of knowledge of one’s emotional experiences. It is most characteristic of obsessive-compulsive personality disorder; the opposite of it known as impulsivity (here: an aspect of openness that shows a tendency to behave unusually or autistically) is characteristic of schizotypal and borderline personality disorders.

Causes

Currently, there are no definitive proven causes for personality disorders. However, there are numerous possible causes and known risk factors supported by scientific research that vary depending on the disorder, the individual, and the circumstance. Overall, findings show that genetic disposition and life experiences, such as trauma and abuse, play a key role in the development of personality disorders.

Child Abuse

Child abuse and neglect consistently show up as risk factors to the development of personality disorders in adulthood. A study looked at retrospective reports of abuse of participants that had demonstrated psychopathology throughout their life and were later found to have past experience with abuse. In a study of 793 mothers and children, researchers asked mothers if they had screamed at their children, and told them that they did not love them or threatened to send them away. Children who had experienced such verbal abuse were three times as likely as other children (who did not 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 behaviour. 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.

Socioeconomic Status

Socioeconomic status has also been looked at as a potential cause for personality disorders. There is a strong association with low parental/neighbourhood socioeconomic status and personality disorder symptoms. In a 2015 publication from Bonn, Germany, which compared parental socioeconomic status and a child’s personality, it was seen that children who were from higher socioeconomic backgrounds were more altruistic, less risk seeking, and had overall higher IQs. These traits correlate with a low risk of developing personality disorders later on in life. In a study looking at female children who were detained for disciplinary actions found that psychological problems were most negatively associated with socioeconomic problems. Furthermore, social disorganisation was found to be inversely correlated with personality disorder symptoms.

Parenting

Evidence shows personality disorders may begin with parental personality issues. These cause the child to have their own difficulties in adulthood, such as difficulties reaching higher education, obtaining jobs, and securing dependable relationships. By either genetic or modelling mechanisms, children can pick up these traits. Additionally, poor parenting appears to have symptom elevating effects on personality disorders. More specifically, lack of maternal bonding has also been correlated with personality disorders. In a study comparing 100 healthy individuals to 100 borderline personality disorder patients, analysis showed that BPD patients were significantly more likely not to have been breastfed as a baby (42.4% in BPD vs. 9.2% in healthy controls). These researchers suggested this act may be essential in fostering maternal relationships. Additionally, findings suggest personality disorders show a negative correlation with two attachment variables: maternal availability and dependability. When left unfostered, other attachment and interpersonal problems occur later in life ultimately leading to development of personality disorders.

Genetics

Currently, genetic research for the understanding of the development of personality disorders is severely lacking. However, there are a few possible risk factors currently in discovery. Researchers are currently looking into genetic mechanisms for traits such as aggression, fear and anxiety, which are associated with diagnosed individuals. More research is being conducted into disorder specific mechanisms.

Malfunctioning Inner Brain – Hippocampus, Amygdala

Research shows a malfunctioning inner brain: hippocampus up to 18% smaller, a smaller amygdala, malfunctions in the striatum-nucleus accumbens and the cingulum neural pathways connecting them and taking care of the feedback loops on what to do with all the incoming information from the multiple senses; so what comes out is anti-social – not according to what is the social norm, socially acceptable and appropriate.

Management

Specific Approaches

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.
• The practice of mindfulness that includes developing the ability to be non-judgementally aware of unpleasant emotions appears to be a promising clinical tool for managing different types of personality disorders.

There are different specific theories or schools of therapy within many of these modalities. They may, for example, emphasize psychodynamic techniques, or cognitive or behavioural 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).

Response of Patients with Personality Disorders to Biological and Psychosocial Treatments

Cluster	Evidence for Brain Dysfunction	Response to Biological Treatments	Response to Psychosocial Treatments
A	Evidence for relationship to schizophrenia; otherwise none known.	Schizotypal patients may improve on antipsychotic medication; otherwise not indicated.	Poor. Supportive psychotherapy may help.
B	Evidence for relationship to bipolar disorder; otherwise none known.	Antidepressants, antipsychotics, or mood stabilizers may help for borderline personality; otherwise not indicated.	Poor in antisocial personality. Variable in borderline, narcissistic, and histrionic personalities.
C	Evidence for relationship to generalized anxiety disorder; otherwise none known.	No direct response. Medications may help with comorbid anxiety and depression.	Most common treatment for these disorders. Response variable.

Challenges

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 organisations 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 behaviours. The disruptiveness that 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. There is substantial social stigma and discrimination related to the diagnosis.

The term ‘personality disorder’ encompasses a wide range of issues, each with a different 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 characterised 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 behavioural addictions. A person may meet the criteria for dissociative identity disorder (formerly “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 perceived 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 judgments or the need to consider underlying motivations for specific behaviours or conflicts. The vulnerabilities of a client, and indeed a 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 views that both the 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 of one extreme, people who may have been exposed to hostility, deceptiveness, rejection, aggression or abuse in their lives, 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 a client’s issues.