Personality Disorders – Causes, Signs and Symptoms

Personality Disorders

Also called: Cluster C Personality Disorders, Cluster A Personality Disorders, Cluster B Personality Disorders

Summary

Personality disorders are conditions in which a person struggles to deal with other people and acts in a manner that is inflexible and not well-suited to coping with the demands and changes of life. Personality disorders typically begin during adolescence or early adulthood, remain stable over time and create distress or impairment in a person’s life.

Patients with personality disorders have a long pattern of inner experience and behavior that differs significantly from what is expected in their culture. This causes them to think and behave in ways that are considered socially distressing. Despite these difficulties, patients usually believe their thoughts and actions are correct and are unable to recognize their disorder.

There are 10 major types of personality disorders including paranoid personality disorder,borderline personality disorder(BPD)and avoidant personality disorder(APD). In many cases, personality disorders are not diagnosed until years after they begin. They often continue through adulthood, and in some cases become less prominent as a person reaches middle age. However, in other cases, they may become more prominent.

There are no specific tests that are used to diagnose personality disorders. A physician will instead ask questions about a patient’s well-being and perform a complete physical examination, including a thorough medical history. In many cases, a physician will need to talk to a patient and/or their friends and relatives several times over a period of time before a diagnosis of personality disorder can be made. If a primary care physician suspects the presence of a personality disorder, the patient will likely be referred to a mental health professional, such as a psychiatrist or psychologist.

Personality disorders can be especially difficult to treat, as patients with these conditions often struggle to trust and confide in a therapist. They may react angrily to perceived criticism and suddenly discontinue treatment. Nonetheless, treatments such as psychotherapy can have a significant impact in improving a patient’s quality of life.

About personality disorders

Personality disorders are conditions in which a person has a lasting pattern of inner experience and behavior that is significantly different from the expectations of the individual’s culture. In addition, the disorder is pervasive and inflexible, begins in adolescence or early adulthood and remains stable over time, leading to some form of distress or impairment.

A person’s personality is made up of lasting patterns of perceiving, relating to and thinking about oneself and the surrounding environment. It is formed by a combination of heredity and early life experiences and involves distinctive traits, behavior styles, attitudes, thoughts and feelings. 

A person with a healthy personality is able to form relationships with family, friends and co-workers and to cope with everyday stresses that arise. However, those with personality disorders have traits that cause them to think and behave in ways that are socially distressing. They struggle to get along with other people and to have successful careers, tend to be inflexible, and are unable to respond to life’s changes and demands. Despite these difficulties, people with personality disorders usually believe their thoughts and behaviors are correct and are unable to recognize the mental health disorder.

A person’s ethnic, cultural and social backgrounds also play a role in determining whether a personality disorder exists. For example, the habits, customs, religious and political values that appear inappropriate in one culture may be entirely appropriate in another.

The onset of personality disorders usually takes place no later than early adulthood. However, in many cases the disorder is not diagnosed until years later. In addition, personality disorders are rarely diagnosed in childhood and adolescence, because symptoms that appear similar to those of a personality disorder are frequently examples of temporary conditions that pass when the child enters adulthood. Personality disorders often continue through adulthood, but in many cases they become less prominent as a person reaches middle age. In other cases, a personality disorder may become more prominent as a patient ages. There is no cure for these disorders, but treatments can be effective in helping patients to live more fulfilling lives.

Types and differences of personality disorders

There are 10 major types of personality disorders. Each is categorized in one of three different “clusters” based on its characteristic symptoms. The American Psychiatric Association (APA) cautions that these categories have significant limitations, and that individuals often have a combination of the different personality disorders.

Cluster A disorders are characterized by odd or eccentric behavior. They often become less prominent with age and include:

  • Paranoid personality disorder. Patients with this disorder frequently view the actions of others as intentionally threatening or demeaning, and suspect others of lying or trying to exploit them. People with paranoid personality disorder tend to be distrustful, unforgiving, emotionally detached, jealous and prone to outbursts.
  • Schizoid personality disorder. Marked by introverted, withdrawn, solitary and emotionally detached behaviors. People with this disorder are often self-absorbed and tend to disregard others’ opinions. They fear intimacy with others, including members of their own family.
  • Schizotypal personality disorder. Characterized by a pattern of peculiarities, such as odd or eccentric ways of speaking and dressing. People with this disorder may have trouble forming relationships and may have extreme anxiety in social situations. They may have trouble conversing appropriately with others and may talk to themselves. They may also display magical thinking, believing they can influence people and events with their thoughts.

Cluster B disorders are marked by dramatic, emotional or erratic behavior. They often become less prominent with age and include:

  • Antisocial personality disorder. Patients typically act out conflicts while ignoring rules of acceptable social conduct. They tend to be impulsive, irresponsible, belligerent and callous, and may have violent, aggressive relationships. They often lack respect for others, persistently steal or lie, and feel no remorse about the effects of their behavior on others. People with antisocial personality disorder tend to be at high risk for substance abuse problems.
  • Borderline personality disorder(BPD). Characterized by instability in several areas of a person’s life, including relationships, behavior, mood and self-image. Patients have difficulty controlling emotions and impulses. They may also have a great fear of abandonment that leads to an excessive dependency on others, while at the same time their behavior tends to push people away.
  • Histrionic personality disorder. Characterized by an excessive need for others’ approval and constant, sudden shifts in emotions. Patients are fixated on their physical appearance and may use provocative clothing and behavior to gain attention. In many cases, these behaviors result in little more than a false sense of intimacy with others.
  • Narcissistic personality disorder. Marked by an inflated sense of self-importance, intense focus on achievements and talents and fantasies of success. Despite feelings of grandiosity, patients often fear failure and may complain of multiple physical symptoms. People with narcissistic personality disorder seek constant attention and engage in attention-getting behavior, but tend to exploit others.

Cluster C disorders are distinguished by anxious, fearful behavior. These disorders often become more prominent with age and include:

  • Avoidant personality disorder(APD). Marked by a patient’s hypersensitivity to rejection or criticism and fear of becoming involved with others. Symptoms associated with this condition include excessive social discomfort, timidity and avoidance of social and work activities that involve interpersonal contact. Patients are usually upset by an inability to form close relationships outside the family circle.
  • Dependent personality disorder. Patients often exhibit a pattern of dependent and submissive behavior and rely on others to make major decisions. They lack self-confidence, are easily hurt by criticism and disapproval, and seek constant reassurance and advice. They will frequently tolerate poor treatment from other people in order to maintain relationships.
  • Obsessive-compulsive personality disorder. Marked by levels of perfectionism and aspiration that are so high that they may struggle to make decisions or complete tasks. Patients with this disorder are never satisfied with their achievements and tend to take on increasing levels of responsibility. Although conscientious and dependable people, they are usually inflexible, which makes it difficult to share responsibility with others or to adapt to changed circumstances. They may feel isolated or helpless when their feelings are not under strict control or when events are unpredictable. This condition should not be confused with obsessive-compulsive disorder (OCD), which is an anxiety disorder that shares some of the same symptoms but is considered more disabling.  

Patients who have some symptoms of various personality disorders but not enough symptoms of any one disorder to warrant a specific diagnosis may be diagnosed with a personality disorder not otherwise specified. This designation also includes passive aggressive behavior – a personality trait that no longer is officially recognized as a disorder by the APA.

Potential causes of personality disorders

The exact cause of personality disorders is not known. Many mental health experts believe that early childhood trauma such as physical, sexual or emotional abuse may lead to the eventual development of some personality disorders. For example, patients with borderline personality disorder(BPD) report high rates of childhood sexual abuse. Other stressors that can trigger these conditions include combat, natural disasters, kidnapping, torture and invasive medical procedures.

In addition, studies have shown that some people may be genetically predisposed to developing personality disorders. For example, patients with a family history of schizophrenia are at higher risk of developing schizotypal, schizoid and paranoid personality disorders. Obsessive-compulsive disorder and antisocial personality disorder also appear to have a genetic component.

Other potential risk factors for developing personality disorders include an unstable family life and a childhood head injury.

Avoidant, borderline, dependent and paranoid personality disorders are more likely to occur in women, whereas antisocial personality disorder and obsessive-compulsive disorder are more likely in men.

Signs and symptoms of personality disorders

The signs and symptoms associated with personality disorders differ depending on the nature of the disorder. For more information, see Types and differences.

Personality disorders also raise the risk of several related behaviors and conditions. Patients may become socially disconnected and find themselves both lacking the desire for close relationships and having an inability to forge such relationships. They are also at greater risk for developing depression, anxiety and eating disorders.

Other behaviors and conditions associated with personality disorders include:

  • Crime. People with antisocial personality disorder are at increased risk of committing crimes that lead to incarceration.
  • Homicide and other violence. People with paranoid and antisocial personality disorders are more likely to engage in aggressive behavior.
  • Self-destructive behavior. People with borderline personality disorder often engage in destabilizing behaviors such as gambling or risky sex. People with dependent personality disorder are so desperate to remain in relationships that they may place themselves at risk of physical, emotional and sexual abuse.
  • Substance abuse. The risk is highest among people with personality disorders in cluster B.
  • Suicide. The risk is highest among people with personality disorders in cluster B, especially if they also suffer from major depression and alcoholism.

Diagnosis methods for personality disorders

In most cases, patients with personality disorders do not recognize that they need treatment. It is more likely that patients will be diagnosed with a personality disorder while seeking treatment for a related mental health condition, such as substance abuse or depression. In some cases, patients will seek this help on their own whereas in others, family or friends may ask them to seek help.

There are no specific tests that are used to diagnose personality disorders. A physician will instead ask questions about the patient’s well-being and perform a complete physical examination that includes a medical history. Questions that a physician may ask patients include:

  • Are they experiencing any relationship difficulties?
  • Are they having any problems in the workplace?
  • What types of behaviors are contributing to such difficulties?

In addition, a physician may request to talk to relatives and friends about a patient’s behavior to get perspectives separate from that of the patient. If a primary care physician suspects the presence of a personality disorder, the patient may be referred to a psychiatrist, psychologist or other mental health professional.

The criteria for diagnosing a personality disorder depend on the disorder that is present. However, there are some criteria that are common to all personality disorders. A personality disorder is diagnosed when there is an enduring pattern of personal experience and behavior that sharply differs from the expectations within an individual’s culture. This pattern must appear in two or more of the following areas:

  • Cognition (ways of perceiving and interpreting the self, other people and events)
  • Affectivity (the range, intensity, and appropriateness of emotional response)
  • Interpersonal functioning
  • Impulse control

In addition, the enduring pattern of the patient’s experience and behavior must be inflexible and widely spread across a range of personal and social situations, and must lead to significant distress or impairment in social, occupational or other areas of functioning.

The behavior pattern must be stable and must date back to at least adolescence or early adulthood. Other mental illnesses must also be ruled out prior to diagnosis. In addition, the enduring pattern cannot be due to the direct physiological effect of a substance or a general medical condition.

The following are examples of criteria for individual disorders established by the American Psychiatric Association (APA). Unless otherwise noted, these criteria must be present by early adulthood and in several contexts:

Cluster A disorders:

ConditionCriteria
Paranoid personality disorderDistrust and suspicion of others such that motives are interpreted as sinister. Symptoms may include: Suspects others are exploiting or harming the patient despite lacking supporting evidence

Unjustified doubts about others’ loyalty and trustworthiness

Reluctant to confide in others due to unwarranted fear of how information may be used

Reads negative meanings into others’ remarks

Persists in bearing grudges

Perceives attacks on character

Suspects spouse’s infidelity
Schizoid personality disorderPattern of detachment from social relationships and restricted expression of emotions in interpersonal settings. Symptoms may include: Neither desires nor enjoys close relationships, even with family

Almost always chooses solitary activities

Has little desire for sexual experiences with another person

Takes pleasure in few activities

Lacks close friends

Indifferent to others’ praise or criticism

Emotionally cold
Schizotypal personality disorderPattern of acute discomfort with close relationships, distorted thinking and perceiving or eccentric behavior. Symptoms may include: Personalizing external events

Odd beliefs or magical thinking that influences behavior

Unusual perceived experiences, including bodily illusions

Odd thinking and speech

Suspiciousness or paranoid ideas

Inappropriate, odd, stiff behavior

Lack of close friends

Excessive and lasting social anxiety

 Cluster B disorders:

ConditionCriteria
Antisocial personality disorderDisregard for and violation of the rights of others that has occurred since age 15. Individual must currently be at least 18 years of age. Symptoms may include: Failure to conform to social norms and laws

Deceitfulness including repeated lying, use of aliases or conning others for personal profit or pleasure

Impulsiveness or failure to plan ahead

Irritability and aggressiveness

Reckless disregard for safety

Consistent irresponsibility

Lack of remorse
Borderline personality disorderPattern of instability in interpersonal relationships and self-image. Symptoms may include: Frantic efforts to avoid real or imagined abandonment

Pattern of unstable and intense interpersonal relationships

Unstable self-image with impulsive behavior in at least two areas that are potentially self-damaging (spending, sex, binge eating)

Recurrent suicidal thoughts or behavior and/or self-injury (e.g., cutting)

Unstable moods

Feelings of emptiness, loneliness

Inappropriate, intense anger

Stress-related paranoid ideas
Histrionic personality disorderExcessive emotions and attention-seeking behavior. Symptoms may include: Discomfort in situations in which the patient is not the center of attention

Interactions characterized by inappropriate sexually seductive or provocative behavior

Rapidly shifting and shallow expression of emotions

Draws attention to self with physical appearance

Emotionally intense speech

Tendency to be dramatic and theatrical

Easily influenced by others/circumstances

Considers relationships to be more intimate than they are
Narcissistic personality disorderPattern of inflated concept of identity, need for admiration and lack of empathy. Symptoms may include: Grandiose sense of self-importance

Preoccupation with fantasies of unlimited success, power, brilliance, beauty or ideal love

Belief that patient is “special” and can only be understood by high-status people

Need for excessive admiration

Sense of entitlement

Takes advantage of others

Lacks empathy

Envious of others, or believes others are jealous of patient

Arrogance and haughty behaviors

Cluster C disorders:

ConditionCriteria
Avoidant personality disorder(APD)Patterned social inhibition, feelings of inadequacy and hypersensitivity to criticism. Symptoms may include: Avoiding work/school activities that involve significant interpersonal contact

Unwillingness to get involved with people unless certain of being liked

Restraint in intimate relationships because of the fear of being shamed or ridiculed

Preoccupation with being criticized/rejected in social situations

Inhibited in new relationships by fear of inadequacy

Views self as socially inept or inferior

Reluctant to take personal risks for fear of embarrassment
Dependent personality disorderExcessive need to be taken care of that leads to submissive, clinging behavior and fears of separation. Symptoms may include: Difficulty making everyday decisions without excessive advice and reassurance from others

Need for others to assume responsibility for most major areas of the patient’s life

Difficulty expressing disagreement with others for fear of loss of support or approval

Difficulty initiating things by oneself

Goes to great lengths to get support

Feels helpless when alone

Seeks a relationship quickly when another relationships ends

Preoccupied with fears of being left alone
Obsessive-compulsive personality disorderPreoccupation with orderliness, perfectionism and mental and interpersonal control. Symptoms may include: Preoccupation with details, rules, lists, order, organization or schedules to the extent that the major point of the activity is lost

Perfectionism that interferes with finishing tasks

Devoted to work and productivity to the exclusion of leisure activities and friendships

Overconscientious and inflexible about morality and ethics

Unable to discard worn-out objects

Reluctant to delegate tasks

Adopts miserly spending patterns

Rigid and stubborn

In teenagers, many of the signs and symptoms of personality disorders are merely part of a phase of life that will disappear with maturity. Therefore, special caution should be taken when the diagnosis of one of these disorders is being considered for a teenage patient.

Treatment options for personality disorders

Treatment of personality disorders can be very difficult, as patients often have difficulty trusting and confiding in a therapist. In addition, they may react angrily to perceived criticism and may be at risk for suddenly discontinuing treatment. Nonetheless, treatments can have a significant impact in improving a patient’s quality of life, particularly in patients who are highly motivated and willing to commit to therapy over the long term.

Psychotherapy is the major form of treatment for individuals with personality disorders and may take the form of individual therapy, group therapy or family therapy. It is aimed at trying to reduce the behavior patterns associated with personality disorders that may interfere with day-to-day living. Patients are encouraged to focus on the unconscious conflicts that may be contributing to symptoms. They also are encouraged to examine the impact of their behavior on others and to use cognitive behavior therapy(CBT) to become more flexible in thinking and behavior patterns.

Through all of these techniques, patients can learn to overcome difficulties such as an inability to make important life decisions or to form relationships. Medications such as antidepressants, anticonvulsants, antipsychotics, anti-anxiety medications and mood stabilizers may also be used to treat personality disorders.

Questions for your doctor 

Preparing questions in advance can help patients have more meaningful discussions with their mental healthcare physician regarding their conditions. Patients may wish to ask their doctor the following questions related to personality disorders:

  1. What makes you suspect I may have a personality disorder?
  2. What type of personality disorder do you suspect I have?
  3. How will you diagnose my suspected personality disorder?
  4. I don’t feel like I have a personality disorder – is that normal?
  5. What are my treatment options?
  6. Are there medications that may help me? Which do you recommend? What are the benefits and risks?
  7. What type of therapy should I consider? Can you recommend a qualified therapist?
  8. Might other members of my family benefit from counseling?
  9. Will I ever be cured of my personality disorder?
  10. How soon after beginning treatment will I notice improvement in my behavior?
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