Personality disorder
A personality disorder is a mental disorder characterized by an enduring and pervasive maladaptive pattern of behavior, emotions, cognition, and inner experience. This definition appears in the sixth chapter of the International Classification of Diseases and the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders. The patterns deviate from social norms and manifest as significant impairment in interpersonal relationships. They also affect various aspects of functioning of the self, such as self-concept. These patterns develop early in life and are inflexible. They are associated with significant distress or disability for the individual. Official criteria for diagnosing these disorders remain a matter of controversy among experts. For psychiatric patients, the prevalence of personality disorders is estimated between 40 and 60%. The behavior patterns are typically recognized by adolescence, the beginning of adulthood, or sometimes even childhood.
There are two main approaches to the classification of personality disorders: the dimensional and the categorical. The categorical approach views personality disorders as discrete entities that are distinct from each other as well as from normal personality. In contrast, the dimensional approach suggests that personality disorders exist on a continuum, with traits varying in degree rather than kind. The DSM-5-TR standard model retains the categorical approach, while the ICD-11 implements the latter. There has been a sustained movement toward replacing categorical models with dimensional approaches. The categorical model has been criticized for not being sufficiently evidence-based. It suffers from issues such as undue prevalence of comorbidity, where the majority of people with a PD are eligible for another PD diagnosis. Heterogeneity within categories and stigmatization are also major criticisms. In response, dimensional models have been developed that assess personality disorders in terms of severity of impairment and maladaptive personality traits. Emerging research indicates that dimensional models may facilitate the personalization of psychotherapy by aligning treatment strategies with underlying trait dimensions rather than diagnostic categories. The shift towards a dimensional approach is reflected in the inclusion of the AMPD in Section III of the DSM-5 and in the ICD-11's adoption of a dimensional system.
Personality disorders are complex conditions influenced by a combination of genetic, environmental, and experiential factors. These disorders emerge from the interaction of multiple determinants, making the precise causes difficult to identify. Environmental factors play a significant role in development. They include prenatal conditions, childhood trauma, abuse, neglect, and other adverse childhood experiences. Possible genetic and neurobiological causes have also been identified. Twin studies allow scientists to assess the influence of genes and environment. Researcher Svenn Torgersen explained this in a 2009 review regarding how much variation in a trait is attributed to shared or unshared environments. Childhood and parenting early experiences shape personality traits significantly. Psychoanalytic theories suggest that childhood trauma and early relationships are critical to personality development. Child abuse and neglect consistently show up as risk factors for developing personality disorders in adulthood. A study of 793 mothers and children found that children who experienced verbal abuse were three times as likely 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 behavior.
Establishing a formal diagnosis of a personality disorder is an issue for specialist psychiatry. The patient history must cover the life perspective to understand the current clinical landscape. General and permanent problems in work, studies, and relationships are often primary observations. Difficulties in interpersonal relations are often visible already at the first patient encounter. There is substantial social stigma and discrimination related to the diagnosis. An individual with a personality disorder may not consider themselves to have a mental health problem. This perspective may be caused by the patient's ignorance or lack of insight into their own condition. Psychoanalytic theory has been used to explain treatment-resistant tendencies as egosyntonic. Patients do not experience the pathology as being in conflict with their goals and self-image. Of those who have a personality disorder, many lack recognition of any abnormality and defend valiantly their continued occupancy of their personality role. They have been termed the Type R, or treatment-resisting personality disorders. This is in opposition to the Type S or treatment-seeking ones. In treatment, it can take several months of sessions to begin to develop a trusting relationship that can meaningfully address a client's issues. Community mental health services may view individuals with personality disorders as too complex or difficult.
The management of personality disorders involves a combination of psychotherapeutic, behavioral, and occasionally pharmacological interventions. Treatment approaches are often tailored to the individual's specific diagnosis, severity, and co-occurring conditions. Individual psychotherapy has been a mainstay of treatment. The American Psychiatric Association and Cochrane both found that psychotherapy was effective in treating borderline personality disorder. Cognitive behavioral therapy focuses on challenging and changing cognitive distortions and their associated behaviors. It is evidence-based and commonly used for avoidant, obsessive-compulsive, and dependent personality disorders. Dialectical behavior therapy evolved into a process where the therapist and client work with acceptance and change-oriented strategies. The NICE review for BPD recommended DBT in the treatment of BPD symptoms. Psychiatric medications are not a primary treatment for personality disorders. Their use for this purpose lacks sufficient evidence. They may however be prescribed to address co-occurring symptoms such as anxiety, depression, or impulsivity. No medication has been approved by the U.S. Food and Drug Administration for the purpose of treating personality disorders. NICE guidelines discourage the use of medication to treat antisocial personality disorder and borderline personality disorder.
Personality disorder is a term with a distinctly modern meaning owing in part to its clinical usage and the institutional character of modern psychiatry. Some have suggested similarities to other concepts going back to at least the ancient Greeks. The Greek philosopher Theophrastus described 29 'character' types that he saw as deviations from the norm. A long-standing influence in the Western world was Galen's concept of personality types linked to the four humours proposed by Hippocrates. In ancient India, the concept of temperament was closely related to ideas in Ayurvedic medicine which categorized individuals according to three doshas. Physicians in the early nineteenth century started to diagnose forms of insanity involving disturbed emotions but seemingly without significant intellectual impairment. Philippe Pinel referred to this as manie sans délire. James Cowles Prichard advanced a similar concept called moral insanity. This would be used to diagnose patients for some decades. Richard von Krafft-Ebing popularized the terms sadism and masochism as psychiatric issues. The German psychiatrist Koch sought to make the moral insanity concept more scientific. In 1891 he suggested the phrase psychopathic inferiority theorized to be a congenital disorder. Emil Kraepelin included a chapter on psychopathic inferiority in his influential work on clinical psychiatry for students and physicians.
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 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 8% for the more common varieties such as obsessive-compulsive, schizotypal, antisocial, borderline, and histrionic. It drops to 0.5, 1% for the least common such as narcissistic and avoidant. A screening survey across 13 countries by the World Health Organization reported in 2009 a prevalence estimate of around 6%. Personality disorders are found more commonly among homeless people. There are some sex differences in the frequency of personality disorders which are shown in various tables. Antisocial personality disorder is about three times more common in men with rates substantially higher in prison populations up to almost 50% in some prison populations. Borderline personality disorder diagnosis rates vary from about three times more common in women to only a minor predominance of women over men.
Common questions
What is the definition of personality disorder according to medical standards?
A personality disorder is a mental disorder characterized by an enduring and pervasive maladaptive pattern of behavior, emotions, cognition, and inner experience. This definition appears in the sixth chapter of the International Classification of Diseases and the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders.
When do personality disorder patterns typically develop and become recognized?
These patterns develop early in life and are inflexible. The behavior patterns are typically recognized by adolescence, the beginning of adulthood, or sometimes even childhood.
How does the dimensional approach differ from the categorical model for classifying personality disorders?
The categorical approach views personality disorders as discrete entities that are distinct from each other as well as from normal personality. In contrast, the dimensional approach suggests that personality disorders exist on a continuum, with traits varying in degree rather than kind.
What environmental factors contribute to the development of personality disorders?
Environmental factors play a significant role in development and include prenatal conditions, childhood trauma, abuse, neglect, and other adverse childhood experiences. A study of 793 mothers and children found that children who experienced verbal abuse were three times as likely to have borderline, narcissistic, obsessive-compulsive, or paranoid personality disorders in adulthood.
Which treatments are considered effective for managing personality disorders according to guidelines?
Individual psychotherapy has been a mainstay of treatment and is evidence-based for various types such as avoidant, obsessive-compulsive, and dependent personality disorders. Dialectical behavior therapy evolved into a process where the therapist and client work with acceptance and change-oriented strategies and was recommended by the NICE review for BPD symptoms.