Personality disorder

More about Personality Disorders: Causes and symptoms Diagnosis Treatment Prognosis Prevention Resources

Definition

Personality disorders are a group of mental disturbances defined by the fourth (1994) edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) as "enduring pattern[s] of inner experience and behavior" that are sufficiently rigid and deep-seated to bring a person into repeated conflicts with his or her social and occupational environment. DSM-IV specifies that these dysfunctional patterns must be regarded as non-conforming or deviant by the person's culture, and cause significant emotional pain and/or difficulties in relationships and occupational performance. In addition, the patient usually sees the disorder as being consistent with his or her self image (ego-syntonic) and may blame others.

Description

To meet the diagnosis of personality disorder, which is sometimes called character disorder, the patient's problematic behaviors must appear in two or more of the following areas:

• perception and interpretation of the self and other people
• intensity and duration of feelings and their appropriateness to situations
• relationships with others
• ability to control impulses

Personality disorders have their onset in late adolescence or early adulthood. Doctors rarely give a diagnosis of personality disorder to children on the grounds that children's personalities are still in the process of formation and may change considerably by the time they are in their late teens. But, in retrospect, many individuals with personality disorders could be judged to have shown evidence of the problems in childhood.

It is difficult to give close estimates of the percentage of the population that has personality disorders. Patients with certain personality disorders, including antisocial and borderline disorders, are more likely to get into trouble with the law or otherwise attract attention than are patients whose disorders chiefly affect their capacity for intimacy. On the other hand, some patients, such as those with narcissistic or obsessive-compulsive personality disorders, may be outwardly successful because their symptoms are useful within their particular occupations. It has, however, been estimated that about 15% of the general population of the United States has a personality disorder, with higher rates in poor or troubled neighborhoods. The rate of personality disorders among patients in psychiatric treatment is between 30% and 50%. It is possible for patients to have a so-called dual diagnosis; for example, they may have more than one personality disorder, or a personality disorder together with a substance-abuse problem.

By contrast, DSM-IV classifies personality disorders into three clusters based on symptom similarities:

• Cluster A (paranoid, schizoid, schizotypal): Patients appear odd or eccentric to others.
• Cluster B (antisocial, borderline, histrionic, narcissistic): Patients appear overly emotional, unstable, or self-dramatizing to others.
• Cluster C (avoidant, dependent, obsessive-compulsive): Patients appear tense and anxiety-ridden to others.

The DSM-IV clustering system does not mean that all patients can be fitted neatly into one of the three clusters. It is possible for patients to have symptoms of more than one personality disorder or to have symptoms from different clusters.

Since the criteria for personality disorders include friction or conflict between the patient and his or her social environment, these syndromes are open to redefinition as societies change. Successive editions of DSM have tried to be sensitive to cultural differences, including changes over time, when defining personality disorders. One category that had been proposed for DSM-IIIR, self-defeating personality disorder, was excluded from DSM-IV on the grounds that its definition reflected prejudice against women. DSM-IV recommends that doctors take a patient's background, especially recent immigration, into account before deciding that he or she has a personality disorder. One criticism that has been made of the general category of personality disorder is that it is based on Western notions of individual uniqueness. Its applicability to people from cultures with different definitions of human personhood is thus open to question. Furthermore, even within a culture, it can be difficult to define the limits of "normalcy."

The personality disorders defined by DSM-IV are as follows:

Paranoid

Patients with paranoid personality disorder are characterized by suspiciousness and a belief that others are out to harm or cheat them. They have problems with intimacy and may join cults or groups with paranoid belief systems. Some are litigious, bringing lawsuits against those they believe have wronged them. Although not ordinarily delusional, these patients may develop psychotic symptoms under severe stress. It is estimated that0.5–2.5% of the general population meet the criteria for paranoid personality disorder.

Schizoid

Schizoid patients are perceived by others as "loners" without close family relationships or social contacts. Indeed, they are aloof and really do prefer to be alone. They may appear cold to others because they rarely display strong emotions. They may, however, be successful in occupations that do not require personal interaction. About 2% of the general population has this disorder. It is slightly more common in men than in women.

Schizotypal

Patients diagnosed as schizotypal are often considered odd or eccentric because they pay little attention to their clothing and sometimes have peculiar speech mannerisms. They are socially isolated and uncomfortable in parties or other social gatherings. In addition, people with schizotypal personality disorder often have oddities of thought, including "magical" beliefs or peculiar ideas (for example, a belief in telepathy) that are outside of their cultural norms. It is thought that 3% of the general population has schizotypal personality disorder. It is slightly more common in males. Schizotypal disorder should not be confused with schizophrenia, although there is some evidence that the disorders are genetically related.

Antisocial

Patients with antisocial personality disorder are sometimes referred to as sociopaths or psychopaths. They are characterized by lying, manipulativeness, and a selfish disregard for the rights of others; some may act impulsively. People with antisocial personality disorder are frequently chemically dependent and sexually promiscuous. It is estimated that 3% of males in the general population and 1% of females have antisocial personality disorder.

Borderline

Patients with borderline personality disorder (BPD) are highly unstable, with wide mood swings, a history of intense but stormy relationships, impulsive behavior, and confusion about career goals, personal values, or sexual orientation. These often highly conflictual ideas may correspond to an even deeper confusion about their sense of self (identity). People with BPD frequently cut or burn themselves, or threaten or attempt suicide. Many of these patients have histories of severe childhood abuse or neglect. About 2% of the general population have BPD; 75% of these patients are female.

Histrionic

Patients diagnosed with this disorder impress others as overly emotional, overly dramatic, and hungry for attention. They may be flirtatious or seductive as a way of drawing attention to themselves, yet they are emotionally shallow. Histrionic patients often live in a romantic fantasy world and are easily bored with routine. About 2–3% of the population is thought to have this disorder. Although historically, in clinical settings, the disorder has been more associated with women, there may be bias toward diagnosing women with the histrionic personality disorder.

Narcissistic

Narcissistic patients are characterized by self-importance, a craving for admiration, and exploitative attitudes toward others. They have unrealistically inflated views of their talents and accomplishments, and may become extremely angry if they are criticized or outshone by others. Narcissists may be professionally successful but rarely have long-lasting intimate relationships. Fewer than 1% of the population has this disorder; about 75% of those diagnosed with it are male.

Avoidant

Patients with avoidant personality disorder are fearful of rejection and shy away from situations or occupations that might expose their supposed inadequacy. They may reject opportunities to develop close relationships because of their fears of criticism or humiliation. Patients with this personality disorder are often diagnosed with dependent personality disorder as well. Many also fit the criteria for social phobia. Between 0.5–1.0% of the population have avoidant personality disorder.

Dependent

Dependent patients are afraid of being on their own and typically develop submissive or compliant behaviors in order to avoid displeasing people. They are afraid to question authority and often ask others for guidance or direction. Dependent personality disorder is diagnosed more often in women, but it has been suggested that this finding reflects social pressures on women to conform to gender stereotyping or bias on the part of clinicians.

Obsessive-compulsive

Patients diagnosed with this disorder are preoccupied with keeping order, attaining perfection, and maintaining mental and interpersonal control. They may spend a great deal of time adhering to plans, schedules, or rules from which they will not deviate, even at the expense of openness, flexibility, and efficiency. These patients are often unable to relax and may become "workaholics." They may have problems in employment as well as in intimate relationships because they are very "stiff" and formal, and insist on doing everything their way. About 1% of the population has obsessive-compulsive personality disorder; the male/female ratio is about 2:1.

— Rebecca J. Frey

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(′pərs·ən′al·əd·ē dis′örd·ər)

(psychology) Any of various disorders characterized by abnormal behavior rather than by neurotic, psychotic, or mental disturbances.

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For more information on personality disorder, visit Britannica.com.

n

A disruption in relatedness manifested in any of a large group of mental disorders characterized by rigid, inflexible, and maladaptive behavior patterns that impair a person’s ability to function in society.

Definition

Personality disorders (PD) are a group of psychiatric conditions characterized by experience and behavior patterns that cause serious problems with respect to any two of the following: thinking, mood, personal relations, and the control of impulses.

Description

Most personality disorders are associated with problems in personal development and character which peak during adolescence and are then defined as personality disorders. Children and adolescents with a personality disorder have great difficulty dealing with others. They tend to be inflexible, rigid, with inadequate response to the changes and demands of life. They have a narrow view of the world and find it hard to participate in social activities. There are many formally identified personality disorders, each with its own types of associated behaviors. Most PDs, however, fall into three distinct categories or clusters, namely: cluster A, which includes disorders characterized by odd or eccentric behavior; cluster B, which includes disorders marked by dramatic, emotional or erratic behavior; and cluster C, which includes disorders accompanied by anxious and fearful behavior. The most common disorders in each cluster are given below.

Cluster a Disorders

These disorders include the following:

• Schizoid personality disorder. Schizoid personalities are introverted, withdrawn, solitary, emotionally cold, and distant. Often absorbed with their own thoughts and feelings, they fear closeness and intimacy with others. People suffering from schizoid personality tend to be more daydreamers than practical action takers, often living "in a world of their own."
• Paranoid personality disorder. Paranoid personalities interpret the actions of others as deliberately threatening or demeaning. People with paranoid personality disorder are untrusting, unforgiving, and often resort to angry or aggressive outbursts without justification because they see others as unfaithful, disloyal, or dishonest. Paranoid personalities are often jealous, guarded, secretive, and scheming, and may appear to be emotionally "cold" or excessively serious.
• Schizotypal personality disorder. Schizotypal personalities tend to have odd or eccentric manners of speaking or dressing. They often have strange, outlandish, or paranoid beliefs and thoughts. People with schizotypal personality disorder have difficulties bonding with others and experience extreme anxiety in social situations. They tend to react inappropriately or not react at all during a conversation, or they may talk to themselves. They also have delusions characterized by "magical thinking," for example, by saying that they can foretell the future or read other people's minds.

Cluster B Disorders

Cluster B disorders include the following:

• Antisocial personality disorder. Antisocial personalities typically ignore the normal rules of social behavior. These individuals are impulsive, irresponsible, and callous. They often have a history of violent and irresponsible behavior, aggressive and even violent relationships. They have no respect for other people and feel no remorse about the effects of their behavior on others. Antisocial personalities are at high risk for substance abuse, since it helps them to relieve tension, irritability, and boredom.
• Borderline personality disorder. Borderline personalities are unstable in interpersonal relationships, behavior, mood, and self-image. They are prone to sudden and extreme mood changes, stormy relationships, unpredictable and often self-destructive behavior. These personalities have great difficulty with their own sense of identity and often experience the world in extremes, viewing experiences and others as either "black" or "white." They often form intense personal attachments only to quickly dissolve them over a perceived offense. Fears of abandonment and rejection often lead to an excessive dependency on others. Self-mutilation or suicidal threats may be used to get attention or manipulate others. Impulsive actions, persistent feelings of boredom or emptiness, and intense anger outbursts are other traits of this disorder.
• Narcissistic personality disorder. Narcissistic personalities tend to have an exaggerated sense of self-importance, and are absorbed by fantasies of unlimited success. They also seek constant attention, and are oversensitive to failure, often complaining about multiple physical disorders. They also tend to be prone to extreme mood swings between self-admiration and insecurity, and tend to exploit interpersonal relationships.

Cluster C Disorders

Cluster C disorders include the following:

• Avoidant personality disorder. Avoidant personalities are often fearful of rejection and unwilling to become involved with others. They are characterized by excessive social discomfort, shyness, fear of criticism, and avoidance of social activities that involve interpersonal contact. They are afraid of saying something considered foolish by others and are deeply hurt by any disapproval from others. They tend to have no close relationships outside the family circle and are upset at their inability to form meaningful relationships.
• Dependent personality disorder. As the name implies, dependent personalities exhibit a pattern of dependent and submissive behavior, relying on others to make decisions for them. They fear rejection, need constant reassurance and advice, and are oversensitive to criticism or disapproval. They feel uncomfortable and helpless if they are alone and can be devastated when a close relationship ends. Typically lacking in self-confidence, the dependent personality rarely initiates projects or does things independently.
• Compulsive personality disorder. Compulsive personalities are conscientious, reliable, dependable, orderly, and methodical, but with an inflexibility that often makes them incapable of adapting to changing circumstances. They have such high standards of achievement that they constantly strive for perfection. Never satisfied with their performance or with that of others, they take on more and more responsibilities. They also pay excessive attention to detail, which makes it very hard for them to make decisions and complete tasks. When their feelings are not under strict control, when events are unpredictable, or when they must rely on others, compulsive personalities often feel a sense of isolation and helplessness.

Demographics

In 2001 to 2002, fully 16.4 million Americans (7.9% of all adults) had obsessive-compulsive personality disorder; 9.2 million (4.4%) had paranoid personality disorder; 7.6 million (3.6%) had antisocial personality disorder; 6.5 million (3.1%) had schizoid personality disorder; 4.9 million (2.4%) had avoidant personality disorder; and 1.0 million (0.5%) had dependent personality disorder. According to the National Institutes of Health, nearly 31 million Americans meet criteria for at least one personality disorder. A 2004 survey showed that nearly 14.8 percent of adult Americans met diagnostic criteria for personality disorders as defined by the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders. The risk of having avoidant, dependent, and paranoid personality disorders is greater for females than males, whereas risk of having antisocial personality disorder is greater for males than females. There are no gender differences in the risk of having compulsive or schizoid personality disorders. In general, other risk factors contributing to the emergence of personality disorders include being Native American or African American; being a young adult; having a low socioeconomic status; and having any other status than married.

Causes and Symptoms

The exact cause of personality disorders is unknown. However, evidence points to genetic and environmental factors such as a history of personality disorders in the family. Some experts believe that traumatic events occurring in early childhood exert a crucial influence upon behavior later in life. Others propose that people are genetically predisposed to personality disorders or that they have an underlying biological disturbance (anatomical, electrical, or neurochemical).

Symptoms vary widely depending on the specific type of PD, but according to the American Psychiatric Association, individuals with personality disorders have most of the following symptoms in common:

• self-centeredness that manifests itself through a "me-first," self-preoccupied attitude
• lack of individual accountability that results in a "victim mentality" and blaming others for their problems
• lack of empathy and caring
• manipulative and exploitative behavior
• unhappiness, suffering from depression, and other mood and anxiety disorders
• vulnerability to other mental disorders
• distorted or superficial understanding of self and others' perceptions that results in being unable to see how objectionable, unacceptable, and disagreeable their behavior is
• self-destructive behavior
• socially maladaptive, changing the "rules of the game," or otherwise influencing the external world to conform to their own needs

When to Call the Doctor

An appointment should be made with a healthcare provider or a mental health professional if a child has persistent symptoms of a personality disorder. Parents are often concerned about their child's emotional health or behavior, but they do not know where to start to get help. The mental health system can also be complicated and difficult for parents to understand. When worried about their child's behavior, parents can start by talking to the child's pediatrician or family physician about their concerns. Personality disorders require treatment and parents should try to find a mental health professional with advanced training and experience with children, adolescents, and families. Parents should always ask about the professional's training and experience. It is also very important to find a good match between child, family, and the mental health professional.

Diagnosis

The character of a person is shown through his or her personality, by the way the person thinks, feels, and behaves. When the behavior is inflexible, maladaptive, and antisocial, then that individual is diagnosed with a personality disorder. Personality disorders are diagnosed following a psychological evaluation that records the history and severity of the symptoms. A personality disorder must fulfill several criteria. A deeply ingrained, inflexible pattern of relating, perceiving, and thinking that is serious enough to cause distress or impaired functioning defines a personality disorder. Personality disorders are usually recognizable by adolescence or earlier, continue throughout adulthood, and become less obvious in middle age.

Treatment

There are many types of help available for the different personality disorders. Treatment may include individual, group, or family psychotherapy. Medications, prescribed by a patient's physician, may also be helpful in relieving some of the symptoms of personality disorders, such as problems with anxiety and delusions. Psychotherapy is a form of treatment designed to help children and families understand and resolve the problems due to PD and modify the inappropriate behavior. In some cases a combination of medication with psychotherapy may be more effective. PD psychotherapy focuses on helping patients see the unconscious conflicts that are causing their disorder. It also helps them become more flexible and is aimed at reducing the behavior patterns that interfere with everyday living. In psychotherapy, patients have the opportunity to learn to recognize the effects of their behavior on others. The different types of psychotherapies available to children and adolescents include the following:

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• Cognitive behavior therapy (CBT). CBT is focused on improving a child's moods and behavior by examining confused or distorted patterns of thinking. With CBT, the child learns that thoughts cause feelings and moods that can influence behavior. For example, if a child has problematic behavior patterns, the therapist seeks to identify the underlying thinking that is causing them. The therapist then helps the child replace this thinking with thoughts that result in more appropriate feelings and behaviors.
• Dialectical behavior therapy (DBT). DBT is used to treat older adolescents with suicidal thoughts or who intentionally engage in self-destructive behavior or who have borderline personality disorder. DBT teaches how to take responsibility for one's problems and how to deal with conflict and negative feelings. DBT often involves a combination of group and individual sessions.
• Family therapy. This therapy approach is designed to help the family unit function in more positive and constructive ways by exploring patterns of communication and providing support and education. Family therapy sessions can include the child or adolescent along with parents and siblings.
• Group therapy (GT). GT uses group dynamics and peer interactions to increase understanding, communication, and improve social skills.
• Play therapy. This type of therapy is directed at helping younger children. It involves the use of toys, blocks, dolls, puppets, drawings, and games to help the child recognize, identify, and verbalize feelings. The psychotherapist observes how the child uses play materials and identifies themes or patterns to understand the child's problems. Through a combination of talk and play the child has an opportunity to better understand conflicts, feelings, and behavior.

Alternative Treatment

Alternative treatments are available for personality disorders and most are complementary to conventional psychotherapy. They include the following:

• Coloring therapy. CT uses the activity of coloring as a self-help medium. While a person colors (with felt tipped markers, colored pens, pencils, etc.) a state of consciousness similar to meditation occurs. The approach is based on how people speak to themselves on the "inside." During a coloring session, people are asked to listen to the thoughts going on in their minds so as to become aware of where their thoughts, feelings, and opinions come from.
• Creative arts therapies. These therapies include art therapy, dance/movement therapy, drama therapy, music therapy, poetry therapy, and psychodrama. They use arts and creative processes to promote health, communication, and expression; they encourage the integration of physical, emotional, cognitive, and social functioning while enhancing self-awareness and facilitating change.
• Neurolinguistic programming. NLP is a method of examining the way a person thinks and acts through language and using this knowledge to effect change.

Nutritional Concerns

The notion that foods and nutrients influence brain function and behavior generated in the early 2000s widespread interest in the general public and in the scientific community. However, the evaluation data are still ambiguous when it comes to establishing a direct link between personality disorders and diet, aside from recommending the avoidance of alcoholic and stimulant beverages.

Prognosis

The PD outlook varies. Some personality disorders diminish during middle age without any treatment, while others persist throughout life despite treatment.

Prevention

The prevention of personality disorders is an area surrounded with pessimism and controversy. Many mental health specialists believe that these disorders are untreatable, that individuals with personality disorder have little capacity for change; therefore not surprisingly, they remain skeptical about prevention prospects. However, even though the innate temperament of a person cannot be modified, understanding the factors that influence the development of personality disorders (such as genetic risks and environmental factors) may help prevention. Accordingly, some mental health professionals advocate primary prevention steps, which should include education of parents and primary healthcare workers, as well as early psychotherapy and protection of traumatized children, which can be carried out by child developing services. Some evidence suggests that traditional doctor-patient relationships are of much less value than programs which enable parents to see their own role as crucial and their own actions as able to bring changes for the better in their child's behavior. High quality parenting plays a critical role in child development and, thus, in the prevention of personality disorders.

Parental Concerns

Understanding personality disorders can be challenging for parents as well as for children. During the last third of the twentieth century, great advances were made in the areas of diagnosis and treatment of personality disorders. Parents can help children understand that these are real illnesses that can be treated. In order for parents to talk with a child about a personality disorder, they must be knowledgeable of the subject. Parents may have to do some homework to become better informed. They should have a basic understanding and answers to questions such as what are personality disorders, who gets them, what causes them, how are diagnoses made, and what treatments are available. When explaining to a child about how personality disorders affect a person, it may be helpful to explain that feelings of anxiety, worry, and irritability are common for most people. However, when these feelings get very intense, last for a long period of time, and begin to interfere with school and relationships, it may be a sign of a personality disorder that can, however, be treated.

A child's personality disorder often causes disruption to both the parents' and the child's world. Parents may have difficulty being objective. They may blame themselves or worry that others such as teachers or family members will blame them. Recognizing these feelings and seeking the help of professional care providers and support groups is the best way to cope with this issue.

Medication can also be an effective part of the treatment for several personality disorders in childhood and adolescence. A doctor's recommendation to use medication often raises many concerns and questions in both the parents and the child. The physician who recommends medication should be experienced in treating psychiatric illnesses in children and adolescents. He or she should fully explain the reasons for medication use, what benefits the medication should provide, as well as the possible negative side-effects or dangers and other treatment alternatives.

See also Antisocial behavior; Antisocial personality disorder; Anxiety.

Resources

Books

Moskovitz, Richard, A. Lost in the Mirror: An Inside Look atBorderline Personality Disorder. Lanham, MD: Taylor Trade Publishing, 2001.

Kantor, Martin. Distancing: Avoidant Personality Disorder. Westport, CT: Praeger Publishers, 2003.

Periodicals

Chiesa, M. et al. "Residential versus community treatment of personality disorders: a comparative study of three treatment programs." American Journal of Psychiatry 161, no. 8 (August, 2004): 1463–70.

Gothelf, D., et al. "Life events and personality factors in children and adolescents with obsessive-compulsive disorder and other anxiety disorders." Comprehensive Psychiatry 45, no. 3 (May-June, 2004): 192–98.

Haugaard, J. J. "Recognizing and treating uncommon behavioral and emotional disorders in children and adolescents who have been severely maltreated: borderline personality disorder." Child Maltreatment 9, no. 2 (May, 2004): 139–45.

Krueger, R. F., and S. R. Carlson. "Personality disorders in children and adolescents." Current Psychiatry Reports 3, no. 1 (February, 2001): 46–51.

Organizations

American Academy of Child & Adolescent Psychiatry(AACAP). 3615 Wisconsin Ave., NW, Washington, DC 20016–3007. Web site: www.aacap.org.

American Psychiatric Association. 1000 Wilson Boulevard, Suite 1825, Arlington, Va. 22209–3901. Web site: www.psych.org.

Federation of Families for Children's Mental Health. 1101 King Street, Suite 420, Alexandria, VA 22314. Web site: www.ffcmh.org.

National Mental Health Association (NMHA). 2001 N. Beauregard Street, 12th Floor, Alexandria, VA 22311. Web site: www.nmha.org.

Web Sites

Lebelle, Linda. "Personality Disorders." Focus Adolescent Services. Available online at www.focusas.com/PersonalityDisorders.html (accessed October 13, 2004).

[Article by: Monique Laberge, Ph.D.]

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Personality disorder is present when a persistent trait of personality, possessed by the individual to an abnormal extent, causes that person or others to suffer over time. Personality, in this context, implies the unique quality of the individual, his feelings and personal goals; this leads to a characteristic pattern of behaviour which allows us, to some extent, to predict his future actions and which makes this individual different from other people.

This clinical description of personality is purely descriptive, based upon persistent traits of normal personality such as ambition, anxiety, assertiveness, conventionality, dutifulness, energy, and so on; these tend to conglomerate in personality types, clusters of traits that frequently occur together. When one or more of these clinically significant features of personality are present to an extent that is statistically deviant from the expected or normal range (significantly more or less), then the individual may be considered to have abnormality of personality. Only when this abnormality causes suffering to the individual himself or to other people is personality disorder present.

Personality disorder is an important concept for psychiatry, and hence for medicine, and is recognized as a generic category of mental and behavioural disorders. In the internationally used International Classification of Diseases, 10th revision (ICD-10) (WHO 1992), these conditions are considered to be clinically significant, persistent, and the expression of an individual's characteristic lifestyle and mode of relating to self and to others. The generic category of 'Disorders of adult personality and behaviour' includes specific personality disorders, enduring personality change after catastrophic experience or psychiatric illness, habit and impulse disorder, gender identity disorder such as transsexualism, disorders of sexual preference, and psychological and behavioural disorders associated with sexual development and orientation. These are varied groups, but they all have abnormality of personality and its expression in common.

Both of the psychiatric classifications currently in regular use are based upon a categorical rather than a dimensional model for the description of personality disorder. That is, personality is classified according to the presence or absence of items from a list of criteria rather than being measured according to the amount of a quality demonstrated. The latter, dimensional, method for assessment of personality has been used by Hans Eysenck, and others, with a quantitative measure of such lifelong qualities as extroversion and neuroticism. The categorical method is used both in ICD-10 and in the American Diagnostic and Statistical Manual of Mental Disorders, 4th edn. (DSM-IV — APA 1994), with general diagnostic criteria for personality disorder, and specific diagnostic criteria for each type of personality disorder. There is a detailed list of criteria, all of which are described as enduring or persistent, that must be fulfilled for the diagnosis to be made.

DSM-IV makes an important distinction between personality disorders and other categories of mental disorder with its application of multi-axial diagnosis. In this scheme, with five axes for clinical and research use, Axis I refers to clinical disorders and conditions that may be a focus of clinical attention. The implication is that the condition has an onset that interferes with the otherwise healthy mental state of the individual. Axis II refers to personality disorders or mental retardation, conditions that are considered to have no distinct onset and are innate to the individual.

In the same way that personality characteristics tend to occur together to form the commonly described personality types, so DSM-IV considers that the different types of personality disorder tend to occur in three distinct clusters. Cluster A includes paranoid, schizoid, and schizotypal personality disorders; Cluster B, antisocial, borderline, histrionic, and narcissistic personality disorders; and Cluster C avoidant, dependent, and obsessive–compulsive personality disorders. However, many mixed types of personality disorder are found, and many mixtures of personality types from different clusters also occur.

There has been considerable confusion in the United Kingdom, especially at the interface between the law and psychiatry, concerning the meaning and the use of the term 'personality disorder', as two senses of the term have been used with significantly different meanings. Most psychiatrists use it, as above, to include those cases where persistent abnormality of personality causes suffering to the individual or to others. However, some people have used the term solely to refer to the antisocial consequences of abnormal personality. This latter dates back to Prichard's concept (1835) of 'moral insanity', denoting the loss of feeling, of control and of ethical sense in certain criminals. This was the forerunner of the term 'psychopathic personality', included as a condition meriting detention in hospital in the 1959 and 1983 England and Wales Mental Health Acts.

Psychopathic personality is there defined as 'a persistent disorder or disability of the mind ... which results in abnormally aggressive or seriously irresponsible conduct on the part of the patient and requires or is susceptible to medical treatment'. Thus, if the condition of the patient is considered, in the view of the treating psychiatrist, to require and be amenable to treatment, the patient may be admitted under the Act. As most psychiatrists working in general psychiatric, as opposed to specialist forensic, units regard most of those with psychopathic personality as not being treatable, this clause has often been a reason for excluding these people from admission to psychiatric hospital or unit.

Whereas, according to correct psychiatric classification, psychopathic personality should be regarded as synonymous with dissocial personality disorder (ICD-10), the term personality disorder has been used interchangeably with psychopathic personality by some people, and the stigma of psychopathy has been attached thereby to all those suffering from personality disorders. A precise use of terms is recommended, so that those with the features of psychopathic personality should be diagnosed as suffering from dissocial personality disorder. The generic term personality disorder should also include those, such as those suffering from anankastic personality disorder, whose abnormalities of personality cause themselves to suffer but in no way predispose them to criminality.

This area of confusion has been further compounded over recent years with discussion, initiated by government, concerning 'dangerous people with severe personality disorder' (DSPD), and whether such people should be placed compulsorily in hospital even if they have not committed an offence. Again, the type of personality disorder is not stipulated, but whilst only those with certain types of personality disorder are ever likely to be 'dangerous', any of the types described below may be 'severe'. Because a few of those suffering from certain categories of personality disorder may be dangerous, the reputation of all those with the condition has been unjustifiably tarnished as having a propensity for violence with consequent stigmatization.

Personality types are the landmarks scattered across the map of human variation. Real people, with real personalities, approximate more or less closely to one or more type, so those with personality disorder may show the classical features of one type or mixed features of two or more different personality disorders. Simply stating that an individual has a disorder of personality is not enough; the features of his personality, the type of personality disorder must always be described. Personality type predicts, to some extent, behaviour and cognition, and is thus always significant.

For diagnosing type of personality disorder, a recognized scheme or classification should be used and, because of its widespread, international application, ICD-10 is recommended. This lists eight specific personality disorders and allows for the recording of 'mixed', 'other', and 'unspecified' personality disorders. Although the specific types described below appear to be discrete and differentiated from each other, the description is only a guide and individuals are likely to show mixtures of different types.

With paranoid personality disorder there is a pattern of mistrust and suspiciousness so that other people's motives are interpreted as malevolent. Personality characteristics may be 'active', resulting in hostility, quarrels, litigation, and even violence or destructive behaviour on occasions, or 'passive', with the individual facing the world from a position of submission and humiliation. He believes that others dislike him and will do him down but is not able to do much about it.

There is enduring detachment from social relationships and a restricted range of emotional expression with schizoid personality disorder. Such individuals are disinclined to mix — 'loners' who hold themselves aloof from others, more interested in things than humans. They are emotionally cool and detached and indifferent to the feelings of other people.

In dissocial personality disorder there is a defect in the capacity to appreciate the feelings of others, especially how others feel about the consequences of their behaviour. There is disregard for and violation of the rights of other people. Synonyms are antisocial, psychopathic, and sociopathic personality disorder.

Emotionally unstable personality disorder has two types — impulsive and borderline. With impulsive personality there is liability to intemperate and uncontrolled outbursts of mood — violent anger, inconsolable grief, and so on. Borderline personality shows a pattern of instability in personal relationships, self-image, and mood with marked impulsivity.

Theatrical behaviour, craving for attention and excitement, excessive reaction to minor events, and outbursts of mood characterizes histrionic, previously known as hysterical, personality disorder. There is a shallowness of feelings and relationships, seen by others as lack in genuineness, and producing difficulty in long-term partnership.

Perfectionism, rigidity, sensitivity, indecisiveness, a lack of capacity to express deeply felt emotion, and conscientiousness occur with anankastic (obsessive–compulsive) personality disorder. There is preoccupation with orderliness, control, and excessive attention to detail. This personality characteristic within normal limits is socially useful, but causes distress to the sufferer in excess.

Those considered to be 'born worriers', anxious in public situations, as at work, but comfortable at home may suffer from anxious (avoidant) personality disorder. There are persistent, pervasive feelings of apprehension, a belief that one is inept or inferior, and a consequent restriction of lifestyle, avoiding those situations that might provoke disapproval.

In dependent personality disorder there are feelings of inadequacy concerning oneself and emotional dependence upon others. This clinging, submissive stance may become manifest when the object of dependence is removed through death, divorce, or loss of job.

The causes of personality disorder may lie either in heredity or in the environment. In practice, there is good evidence for both. There is a consistent finding of a genetic contribution to antisocial, anxious/avoidant, and cschizoid personality. However, environmental causes are usually given for most personality disorders and these are particularly related to early upbringing within the family.

For management or treatment of personality disorder, personality type entirely dictates the nature of treatment and differs for each type. Thus, for anankastic personality disorder, for example, pharmacological treatment may be used for the component of anxiety associated with doubts, indecisiveness, and scruples. Psychological treatment, especially cognitive–behavioural treatment, concentrates upon perfectionism, rigidity, scrupulousness, and intolerance of failure. Psychodynamic psychotherapy was formerly extensively used.

For dissocial personality disorder, drugs have been used to control impulsivity and aggression. In-patient small self-help groups and the larger group therapeutic community have proved beneficial to a limited extent. Personality is regarded as relatively fixed during adult life and the aim of treatment is to enable patients to live more comfortably and safely with themselves.

Frequently personality disorder overlaps with other psychiatric disorder and this makes the other condition more difficult to treat and exacerbates the prognosis. Co-morbidity is especially frequent with substance misuse but also quite often occurs with schizophrenia, depressive illness, and neurotic disorders such as anxiety, dissociative, and obsessive–compulsive disorders.

(Published 2004)

— Andrew Sims

Bibliography
• American Psychiatric Association (1994). Diagnostic and Statistical Manual of Mental Disorders (4th edn.).
• Gelder, M., López-Ibor, J. J., and Andreasen, N. C. (2000). New Oxford Textbook of Psychiatry.
• Sims, A. (2002). Symptoms in the Mind: An Introduction to Descriptive Psychopathology (3rd edn.).
• Tyrer, P., and Stein, G. (1993). Personality Disorder Reviewed.
• World Health Organization (1992). International Classification of Diseases (10th revision).

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