DSM5577 - SECTION 16: ADDRESSING THE COMPLEXITIES - PERSONALITY DISORDERS
Section XVI: Addressing the Complexities – Personality Disorders
Personality Disorders are pervasive, inflexible and enduring patterns of behavior and inner sense of self that deviate greatly from an individual’s cultural expectations. All personality disorders can be traced back at least to early adolescence or young adulthood. Any person diagnosed with a personality disorder will show a great deal of impairment and/or distress in social, occupational and every significant area of functioning. All these patterns are very stable and last a long time, and cannot be related to any medical condition. The personality patterns must be pervasive and inflexible in two or more of the following patterns:
- Thinking and perception with others, self and daily events and interactions;
- Interpersonal functioning in any situation;
- Impulse control; and
- Emotional presentation (the person’s intensity, range and lability of emotion with others)
The DSM 5 lists 10 specific personality disorders. They are grouped into three categories called clusters. Each cluster is grouped around specific behavior or interactive typologies.
Cluster A includes persons who present as odd or eccentric in their lifestyle and/or interactions with others. These three personality disorders are paranoid, schizoid and schizotypal.
Cluster B personality disorders are used to describe persons who are dramatic, erratic or emotional in their interactions and behavior. The four cluster B disorders are antisocial, borderline, histrionic and narcissistic.
Cluster C includes the three personality disorders that describe persons who show consistent anxious or fearful traits.
The 10 personality disorders with ICD-10 codes (listed by clusters) are as follows:
- Paranoid personality disorder 0
- Schizoid personality disorder 1
- Schizotypal personality disorder F21
- Antisocial personality disorder 2
- Borderline personality disorder 3
- Histrionic personality disorder 4
- Narcissistic personality disorder 81
- Avoidant personality disorder 6
- Dependent personality disorder 7
- Obsessive-Compulsive personality disorder 5
Personality Change Due to Another Medical Condition F07.0
The diagnosis of any of the 10 personality disorders is in addition to a person’s mental health or substance use diagnosis. Personality disorders can begin to emerge based on developmental, traumatic and detrimental life experiences in childhood or adolescence. An isolated traumatic experience or any combination of traumatic events may lay the foundation for a personality disorder but does not guarantee an automatic personality disorder.
The cluster A personality disorders are marked by eccentric and/or odd behaviors. Paranoid personality disorders are marked by suspiciousness and distrust. Four or more of the following traits must be present:
- Bears persistent grudges of often long ago (real or perceived) insults
- Consistently doubts that friends or associates are faithful to them
- Suspects that everyone will cheat, deceive or harm them (with no experience of that)
- Doubts the faithfulness of friends, associates or life partners
- Reacts with anger without provocation to any perceived threat or harm
- Refuses to trust or confide in others for fear of betrayal of that trust
Persons with paranoid personality disorders are very difficult to get along with as they are suspicious of everyone’s motives. They can be aloof or argumentative, all in the service of keeping other persons at a distance.
Schizoid personality disorder presents with a restricted emotional range and consistent detachment from others. Four or more of the following must be present:
- Finds little pleasure in most activities
- Shows little reaction to the praise or criticism of others
- Displays flat affect and detachment in most situations
- No interest in sexual relationships with others
- Prefers solitary activities
- Isolates self from close relationships, including being part of a family
- Has no close friends other than first degree family members
Schizotypal personality disorder is listed with schizophrenia spectrum disorders due to marked interpersonal deficits in social interactions that result in cognitive and perceptual distortions and strange behaviors. These persons are extremely uncomfortable in relating to other people. The pattern is fully developed by early adulthood and is manifested by five or more of the following:
- Paranoid ideations
- Magical or odd beliefs not consistent with cultural norms
- Strange or odd thinking or speech
- Constricted affect
- Lack of confidants or close friends other than first degree family
- Peculiar, odd or eccentric behaviors
- Extreme social anxiety related to paranoid thoughts rather than negative thinking
- Ideas of reference but not delusions
Persons diagnosed with an Antisocial personality disorder show a prevalent pattern of total disregard for the rights of others. They violate the rights of others consistently and the pattern starts around age 15. The following behaviors are consistent with antisocial personality disorder:
- No regard for the safety of self or others
- No regret or remorse for damage or harm done to anyone that they hurt or steal from
- Failure to plan ahead with consistent impulsivity in behavior
- Repeated lying with no awareness or acknowledgment of the disregard for other rights; focus is on the individual’s pleasure
- Inability to comply with societal standards which results in a history of unlawful acts or behaviors that may result in frequent arrests. No accountability is taken for any of these behaviors
- Cannot conform to social norms or follow lawful behavior
- Constant fights or assaults of others
Deceit and manipulation are central components of antisocial personality disorder so a thorough assessment and review of the individual’s history from collaborative resources, in addition to treatment history, is necessary for an accurate diagnosis. Psychopathy and sociopathy are additional terms used to describe this personality disorder. No empathy, a total disregard for the rights of others, and putting their needs/wants first with cynicism and a self-inflated sense of self are the primary characteristics of avoidant personality disorder.
Borderline personality disorder is a diagnosis that can bring chills to the spine of the clinician. An absolute fear of abandonment or the creation of situation where the significant other will abandon the person living with borderline personality disorder is a core characteristic. There is a consistent pattern of emotional volatility, unstable relationships, poor self-image and excessive impulsivity. To receive this diagnosis, an individual must show five of the nine patterns consistently, starting in early adulthood. These patterns are:
- Repeated pattern of suicidal gestures, attempts or threats
- Intense and unstable interpersonal relationships
- Consistent, reported feelings of emptiness
- Unstable self-image
- Anxious attempts to avoid imagined or real abandonment
- Dissociative symptoms and intermittent paranoid ideation in stressful situations
- Consistent impulsive or self-damaging behaviors such as substance abuse, over-spending, sex, binge-eating
- Intense emotional instability from overreaction of mood with irritableness, or anxiety for several minutes or hours that disappears as quickly as it starts
- Intense anger or inability to manage angry feelings and possible physical fights
Histrionic personality disorder will show extreme emotionality and attention seeking behavior. It will begin in early adulthood and exhibit five of the following:
- Excessively impressionistic speech
- Extremely theatrical and exaggerated emotional expression
- Shows great discomfort when not the center of attention
- Sexually seductive and provocative interactions with others
- Labile and shallow emotional expression
- Always uses physical appearance to draw attention to self
- Easily influenced by other persons or situations
- Acts as if interpersonal relationships are more familiar than they are
Persons with a histrionic personality disorder must be the center of attention. They are often flamboyant and sexually provocative, they are energetic and dramatic and often seductive. This disorder may limit a person’s ability to form lasting, intimate relationships. Suicidal gestures and threats may be another way of being the center of attention.
Narcissistic personality disorder is marked by a constant need for attention and lack of concern or interest in others. A tremendous sense of self-importance and consistent amplification of successes, talents and abilities have persons with narcissistic personality disorder presenting as boastful, ostentatious and showy at the expense of everyone else. Five or more of the following must be present for this diagnosis.
- Need for excessive admiration
- Belief in the person’s ‘specialness’ or high status
- Sense of entitlement at the expense of others
- Convinced of her/his unlimited power, success or brilliance
- Extreme sense of self-importance
- Exploits others to meet her/his personal goals
Persons with this disorder require constant attention, and excessive admiration. No one equals their ‘specialness’ or ‘uniqueness’ and they regularly compare themselves to famous people. They have no understanding, comprehension or
Persons diagnosed with a cluster C personality disorders consistently appear anxious or fearful when interacting with others.
Avoidant personality disorder diagnosis is given when a person shows a hypersensitivity to negative evaluation, intense social hesitancy and consistently inadequate feelings. Four of the following must be noted.
- Constant fear of rejection or criticism in social situations
- Feelings of inferiority compared to others and social ineptness
- Hesitancy in trying new activities or taking personal risks due to fear of embarrassment
- Declines interactions with others without a guarantee of being liked
- Avoids any activities or interactions with others due to fear of rejection or criticism
- Holds back in intimate relationships for fear of ridicule or shame
Dependent personality disorder shows a pervasive need to be cared for by others with submissive and clinging behaviors in all interpersonal relationships. Five or more of the following are needed for this diagnosis.
- Preoccupied with fear of having to care for self
- Must be in a significant relationship that is a source of support and care
- Will do anything (even unpleasant activities) to insure cure and nurture
- Requires that others are responsible for most areas of the person life
- Seeks constant feedback and advice to make any decisions
- Unable to initiate activities due to lack of self-confidence or motivation
- Will not disagree with others for fear of rejection
Obsessive-compulsive personality disorder manifests in a severe and persistent need for order and perfection in all interactions and activities. Four or more of the following must be present for this diagnosis.
- Stubbornness and inflexibility
- Inability to throw away objects that no longer have any practical or emotional value
- Obsessed with work and effectiveness at the expense of any interpersonal activities or relationships
- Perfectionism interferes the completion of any activity
- Morality, ethics and personal values are very inflexible
- Hoarding objects for possible use in the future is important
- Trusts no one to complete any task as perfectly as she or he can
Personality change due to another medical condition is used when a personality
Disturbance is evident but not pervasive enough to meet the criteria for any of the 10 personality disorders previously defined.
There are seven specifiers to use to document any personality change due to a medical condition. They are:
- Labile type
- Disinhibited type
- Aggressive type
- Apathetic type
- Paranoid type
- Other type
- Combined type
- Unspecified type
To summarize personality disorders, remember that these behavior patterns are pervasive, consistent and evident in all areas of the individual’s life, work and interpersonal relationships (to the level that they can interact comfortably and confidently with others. All personality disorder characteristics begin to manifest in late adolescence and are set by early adulthood. Cultural patterns and practices must not be confused with personality disorders. Any possible medical condition must be ruled out before diagnosing any of the ten accepted personality disorders.
Personality Disorder Not Otherwise Specified
This category is used when Personality Disorder criteria are partially met under several Disorder categories, but do not meet full criteria for any one Personality Disorder.
Criteria must create clinically significant distress for the individual in at least one important area of functioning (work, social, etc.).
Because personality disorders can present with such a variety of extreme and severe symptoms, it is often difficult to distinguish between certain personality disorders and certain serious thought disorders. This section will provide some key information about how to distinguish between personality disorders and thought disorders, as well as guidelines for distinguishing between different kinds of personality disorders.
Paranoid Personality Disorder (PD) versus Schizophrenia
Paranoid personality disorders are distinguished from Schizophrenia in that Schizophrenia is characterized by a period of persistent psychotic symptoms (delusions / hallucinations). Paranoid personality disorders present with longer term suspiciousness without the presence of clear delusional or hallucinogenic breakthroughs.
Schizoid versus Schizotypal Personality Disorder (PD)
Schizoid PD is differentiated from Schizotypal PD by the lack of perceptual and cognitive distortions. Schizoid PD is differentiated from Paranoid PD by lack of suspicion and paranoia. Although they share social isolation as a symptom, Schizoid PD is different from Avoidant PD in that social isolation in Avoidant PD is due to fear of embarrassment or rejection. Schizoid PD includes social isolation due to detachment and lack of desire for social intimacy.
Borderline PD versus Dependent PD
Borderline PD differs from Dependent PD primarily in the reaction to abandonment. An individual with Borderline PD reacts to rejection and abandonment with rage, demands, and emotional emptiness. An individual with Dependent PD, on the other hand, reacts with greater submissiveness, and seeks to immediately replace the relationship with another in order to gain further support and care-giving. The fear of loss and abandonment outweighs the anger at rejection.
In addition, a person with Borderline PD has a typical pattern of intense, unstable relationships. Patients with Dependent PD, on the other hand, will frequently be engaged in somewhat more stable - albeit still dysfunctional - relationships over extended periods of time.
Borderline PD versus Histrionic PD
Histrionic PD and Borderline PD are different in that Borderline PD includes more immediately visible self-destructive behaviors, angry disruptions in intimate relationships, feelings of extreme emptiness and identity disturbance.
Histrionic PD versus Dependent PD
Histrionic PD is distinguished from Dependent PD in that while they both include dependence upon others for praise; Histrionic PD also includes exaggerated and dramatic emotionality. Patients with Dependent PD are more likely to suffer in silence, fearing the abandonment that will follow dramatic emotional expressions of need.
Obsessive-Compulsive PD versus Obsessive-Compulsive Disorder
Obsessive-Compulsive Disorder differs from Obsessive-Compulsive Personality Disorder in that an individual with Obsessive-Compulsive Disorder has true obsessions and compulsions, especially when hoarding is extreme.
The etiology of OCD is not fully understood, but the basis appears to be related to predisposing factors combined with the presence of environmental stresses. The patient with OCD may be more inclined to view his or her symptoms as ego-dystonic. The patient with OCD is therefore more likely to experience the symptoms as occurring as a war with the self, in which the intruding symptoms feel somewhat foreign or alien to the personality structure of the individual involved.
Obsessive-Compulsive Personality Disorder, on the other hand, typically shows less acute symptomatology, but with the signs and symptoms more fully integrated into the personality structure of the individual. The presentation of the obsessive and compulsive features are therefore typically more ego-syntonic for the OCPD, and wrapped up somewhat in the person's overall sense of self.
Sometimes, criteria for both OCD and OCPD are met, and both should be recorded.
Key Knowledge Point to Follow:
Differential Diagnosis Schizophrenia, Schizophreniform, and Schizoaffective Disorders are psychotic disorders. The array of problems will have a basis in some form of neurochemical dysfunction.
Schizoid and Schizotypal Disorders are personality disorders. The suspiciousness and inappropriate affect/behavior will have a basis in poor personality organization, usually due to some combination of pre-disposing personality fragility and environmental/family stresses experienced during early developmental periods.