Personality disorder

Personality disorders, formerly referred to as character disorders, are a class of personality types and behaviors that the American Psychiatric Association (APA) defines as "an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the culture of the individual who exhibits it".^[1][2] Personality disorders are noted on Axis II of the Diagnostic and Statistical Manual of Mental Disorders, or DSM-IV-TR (fourth edition, text revision) of the American Psychiatric Association.

Personality disorders are also defined by the International Statistical Classification of Diseases and Related Health Problems (ICD-10), which is published by the World Health Organization. Personality disorders are categorized in ICD-10 Chapter V: Mental and behavioural disorders, specifically under Mental and behavioral disorders: 28F60-F69.29 Disorders of adult personality and behavior.^[3]

These behavioral patterns in personality disorders are typically associated with severe disturbances in the behavioral tendencies of an individual, usually involving several areas of the personality, and are nearly always associated with considerable personal and social disruption. Additionally, personality disorders are inflexible and pervasive across many situations, due in large part to the fact that such behavior is 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.

The onset of these patterns of behavior can typically be traced back to late adolescence and the beginning of adulthood and, in rarer instances, childhood.^[1] It is therefore unlikely that a diagnosis of personality disorder will be appropriate before the age of 16 or 17 years. General diagnostic guidelines applying to all personality disorders are presented below; supplementary descriptions are provided with each of the subtypes.

Diagnosis of personality disorders can be very subjective; however, inflexible and pervasive behavioral patterns often cause serious personal and social difficulties, as well as a general functional impairment. Rigid and ongoing patterns of feeling, thinking and behavior are said to be caused by underlying belief systems and these systems are referred to as fixed fantasies or "dysfunctional schemata" (Cognitive modules).

Classification

World Health Organization

• (F60.) Specific personality disorders
  • (F60.0) Paranoid personality disorder
  • (F60.1) Schizoid personality disorder
  • (F60.2) Dissocial personality disorder
  • (F60.3) Borderline personality disorder
  • (F60.4) Histrionic personality disorder
  • (F60.5) Anankastic personality disorder
  • (F60.6) Anxious (avoidant) personality disorder
  • (F60.7) Dependent personality disorder
  • (F60.8) Other specific personality disorders
    • Narcissistic personality disorder
    • Passive-aggressive personality disorder
  • (F60.9) Personality disorder, unspecified
• (F61.) Mixed and other personality disorders

DSM

The DSM-IV lists ten personality disorders, grouped into three clusters in Axis II. The DSM also contains a category for behavioral patterns that do not match these ten disorders, but nevertheless exhibit characteristics of a personality disorder. This category is labeled Personality disorder not otherwise specified.

Cluster A (odd or eccentric disorders)

• Paranoid personality disorder (DSM-IV code 301.0): characterized by irrational suspicions and mistrust of others.
• Schizoid personality disorder (DSM-IV code 301.20): lack of interest in social relationships, seeing no point in sharing time with others, anhedonia, introspection.
• Schizotypal personality disorder (DSM-IV code 301.22): characterized by odd behavior or thinking.

Cluster B (dramatic, emotional or erratic disorders)

• Antisocial personality disorder (DSM-IV code 301.7): a pervasive disregard for the law and the rights of others.
• Borderline personality disorder (DSM-IV code 301.83): extreme "black and white" thinking, instability in relationships, self-image, identity and behavior.
• Histrionic personality disorder (DSM-IV code 301.50): pervasive attention-seeking behavior including inappropriate sexual seductiveness and shallow or exaggerated emotions.
• Narcissistic personality disorder (DSM-IV code 301.81): a pervasive pattern of grandiosity, need for admiration, and a lack of empathy.

Cluster C (anxious or fearful disorders)

• Avoidant personality disorder (DSM-IV code 301.82): social inhibition, feelings of inadequacy, extreme sensitivity to negative evaluation and avoidance of social interaction.
• Dependent personality disorder (DSM-IV code 301.6): pervasive psychological dependence on other people.
• Obsessive-compulsive personality disorder (not the same as obsessive-compulsive disorder) (DSM-IV code 301.4): characterized by rigid conformity to rules, moral codes and excessive orderliness.

Appendix B: Criteria Sets and Axes Provided for Further Study

Appendix B contains the following disorders^[4]. They are still widely considered amongst psychiatrists as being valid disorders, for example by Theodore Millon.^[5]

• Depressive personality disorder - is a pervasive pattern of depressive cognitions and behaviors beginning by early adulthood.
• Passive-aggressive personality disorder (negativististic personality disorder) - is a pattern of negative attitudes and passive resistance in interpersonal situations.

Deleted

The following disorders are still considered to be valid disorders by Millon.^[5] They were in DSM-III-R but were deleted from DSM-IV. Both appeared in an appendix entitled “Proposed diagnostic categories needing further study”,^[6] and so did not have any concrete diagnostic criteria.

• Sadistic personality disorder - is a pervasive pattern of cruel, demeaning and aggressive behavior.
• Self-defeating personality disorder (masochistic personality disorder) - is characterised by behaviour consequently undermining the person's pleasure and goals.

Cause

A study of almost 600 male college students, averaging almost 30 years of age and who were not drawn from a clinical sample, examined the relationship between childhood experiences of sexual and physical abuse and currently reported personality disorder symptoms. Childhood abuse histories were found to be definitively associated with greater levels of symptomatology. Severity of abuse was found to be statistically significant, but clinically negligible, in symptomatology variance spread over Cluster A, B and C scales ^[7]

Child abuse and neglect consistently evidence themselves as antecedent risks to the development of personality disorders in adulthood.^[8] In the following study, efforts were taken to match retrospective reports of abuse with a clinical population that had demonstrated psychopathology from childhood to adulthood who were later found to have experienced abuse and neglect. The sexually abused group demonstrated the most consistently elevated patterns of psychopathology. Officially verified physical abuse showed an extremely strong role in the development of antisocial and impulsive behavior. 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.^[8]

Diagnosis

According to ICD-10, the diagnosis of a personality disorder must satisfy the following general criteria, in addition to the specific criteria listed under the specific personality disorder under consideration:

1. There is evidence that the individual's characteristic and enduring patterns of inner experience and behaviour as a whole deviate markedly from the culturally expected and accepted range (or "norm"). Such deviation must be manifest in more than one of the following areas:
   1. cognition (i.e., ways of perceiving and interpreting things, people, and events; forming attitudes and images of self and others);
   2. affectivity (range, intensity, and appropriateness of emotional arousal and response);
   3. control over impulses and gratification of needs;
   4. manner of relating to others and of handling interpersonal situations.
2. The deviation must manifest itself pervasively as behaviour that is inflexible, maladaptive, or otherwise dysfunctional across a broad range of personal and social situations (i.e., not being limited to one specific "triggering" stimulus or situation).
3. There is personal distress, or adverse impact on the social environment, or both, clearly attributable to the behaviour referred to in criterion 2.
4. There must be evidence that the deviation is stable and of long duration, having its onset in late childhood or adolescence.
5. The deviation cannot be explained as a manifestation or consequence of other adult mental disorders, although episodic or chronic conditions from sections F00-F59 or F70-F79 of this classification may coexist with, or be superimposed upon, the deviation.
6. Organic brain disease, injury, or dysfunction must be excluded as the possible cause of the deviation. (If an organic causation is demonstrable, category F07.- should be used.)

In children and adolescents

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 executives

In 2005, 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, they were:

• 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.^[9]

History

The concept of personality disorders goes back to at least the ancient Greeks.^[3]

References

Further reading

• American Psychiatric Association. (2000). Diagnostic and Statistical Manual of Mental Disorders. 4th ed. (text revision). (DSM-IV-TR). Arlington, VA.
• Häcker, H. O. Stapf (2004). Dorsch Psychologisches Wörterbuch, Verlag Hans Huber, Bern
• Marshall, W. & Serin, R. (1997) Personality Disorders. In Sm.M. Turner & R. Hersen (Eds.) Adult Psychopathology and Diagnosis. New York: Wiley. 508-541
• Murphy, N. & McVey, D. (2010) Treating Severe Personality Disorder: Creating Robust Services for Clients with Complex Mental Health Needs. London: Routledge
• Millon, Theodore (and Roger D. Davis, contributor) - Disorders of Personality: DSM IV and Beyond - 2nd ed. - New York, John Wiley and Sons, 1995 ISBN 0-471-01186-X
• Yudofsky, Stuart C. M.D. (2005) Fatal Flaws: Navigating Destructive Relationships With People With Disorders of Personality and Character, by ISBN 1-58562-214-1

External links

• The Institute for Advanced Studies in Personology and Psychopathology the official website for Theodore Millon, Ph.D., D.Sc.
• Personality Disorders Foundation
• National Personality Disorder website for England
• Dangerous severe personality disorder
• National Mental Health Association Personality Disorder Fact Sheet
• Personality Diagnostic Questionnaire (PDQ) web site
• Personality Disorders information leaflet from mental health charity The Royal College of Psychiatrists