What Are Personality Disorders in the DSM-5?

What Are Personality Disorders?

Personality disorders include 10 diagnosable psychiatric conditions that are recognized and described in the fifth and most recent version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).

Each is a distinct mental illness defined by personality traits that can be troubling enough to create problems with relating to other people in healthy ways, and can lead to significant distress or impairment in important areas of functioning.

Types

The DSM-5 organizes personality disorders into three groups, or clusters, based on shared key features.

Cluster A

These personality disorders are characterized by odd or eccentric behavior. People with cluster A personality disorders tend to experience major disruptions in relationships because their behavior may be perceived as peculiar, suspicious, or detached.

Cluster A personality disorders include:

• Paranoid personality disorder, which affects between 2.3% to 4.4% of adults in the U.S. Symptoms include chronic, pervasive distrust of other people; suspicion of being deceived or exploited by others, including friends, family, and partners.
• Schizoid personality disorder, which is characterized by social isolation and indifference toward other people. It affects slightly more men than women. People with this disorder often are described as cold or withdrawn, rarely have close relationships with other people, and may be preoccupied with introspection and fantasy.
• Schizotypal personality disorder, which features odd speech, behavior, and appearance, as well as strange beliefs and difficulty forming relationships.

Cluster B

The cluster B personality disorders are characterized by dramatic or erratic behavior. People who have a personality disorder from this cluster tend to either experience very intense emotions or engage in extremely impulsive, theatrical, promiscuous, or law-breaking behaviors.

Cluster B personality disorders include:

• Antisocial personality disorder, which tends to show up in childhood, unlike most other personality disorders (most don't become apparent until adolescence or young adulthood). Symptoms include a disregard for rules and social norms and a lack of remorse for other people.
• Borderline personality disorder, which is characterized by instability in interpersonal relationships, emotions, self-image, and impulsive behaviors.
• Histrionic personality disorder, which features excessive emotionality and attention seeking that often leads to socially inappropriate behavior in order to get attention.
• Narcissistic personality disorder, which is associated with self-centeredness, exaggerated self-image, and lack of empathy for others and is often driven by an underlying fragility in the sense of self.

Cluster C 

Cluster C personality disorders are characterized by anxiety. People with personality disorders in this cluster tend to experience pervasive anxiety and/or fearfulness.

Cluster C personality disorders include:

• Avoidant personality disorder is a pattern of social inhibition and avoidance fueled by fears of inadequacy and criticism by others.
• Dependent personality disorder, which involves fear of being alone and often causes those who have the disorder to do things to try to get other people to take care of them.
• Obsessive-compulsive personality disorder, which is characterized by a preoccupation with orderliness, perfection, and control of relationships. Though similarly named, it is not the same as obsessive-compulsive disorder (OCD).

Symptoms

Personality disorders tend to appear in adolescence or early adulthood, continue over many years, and can cause a great deal of distress. They can potentially cause enormous conflict with other people, impacting relationships, social situations, and life goals. People with personality disorders often don't recognize that they have problems and are often confusing and frustrating to people around them (including clinicians).

Certain symptoms of personality disorders can fall into two categories: self-identity and interpersonal functioning.

Self-identity problems include:

• Unstable self-image
• Inconsistencies in values, goals, and appearance

Interpersonal problems include:

• Being insensitive to others (unable to empathize)
• Difficulty knowing boundaries between themselves and others
• Inconsistent, detached, overemotional, abusive, or irresponsible styles of relating

Diagnosis

According to the DMS-5, a person must meet the following criteria to be diagnosed with a personality disorder:

• Chronic and pervasive patterns of behavior that affect social functioning, work, school, and close relationships
• Symptoms that affect two or more of the following four areas: thoughts, emotions, interpersonal functioning, impulse control
• Onset of patterns of behavior that can be traced back to adolescence or early adulthood
• Patterns of behaviors that cannot be explained by any other mental disorders, substance use, or medical conditions

Differential Diagnosis

Before a clinician can diagnose a personality disorder, they must make a differential diagnosis to rule out other disorders or medical conditions that may be causing the symptoms.

A differential diagnosis is very important but can be difficult since personality disorders also commonly co-occur with other mental illnesses. A person who meets the criteria for one personality disorder will often also meet criteria for one or more additional personality disorders.

Causes

Personality disorders don’t discriminate. Roughly 10% of the general population and up to half of psychiatric patients in clinical settings have a personality disorder.

Although experts are yet to fully understand the causes of personality disorders, they believe that both genetic and environmental factors play a role.

Roughly 50% of personality disorders are attributed to genetic factors and family history. Genetic vulnerabilities may make people more susceptible to these conditions, while experiences and other environmental factors may act as a trigger in the development of a personality disorder.

There is also a significant association between a history of childhood trauma as well as verbal abuse. One study found that children who experience verbal abuse were three times more likely to have borderline, narcissistic, obsessive-compulsive or paranoid personality disorders in adulthood.

High reactivity in children, including sensitivity to light, noise, texture, and other stimuli, has also been linked to certain personality disorders.

Treatment 

Compared to mood disorders such as clinical depression and bipolar disorder, there have historically been relatively few studies on how to effectively treat personality disorders. Many experts believe that personality disorders are difficult to treat because they are, by definition, long-standing patterns of personality. However, there are an increasing number of evidence-based treatments that are being found effective for personality disorders.

In general, the goal of personality disorder treatment includes the following:

• Reducing subjective distress and symptoms such as anxiety and depression
• Helping people to understand the aspect of their problems that are internal to themselves
• Changing maladaptive and socially undesirable behaviors, including recklessness, social isolation, lack of assertiveness, and temper outbursts
• Modifying problematic personality traits like dependency, distrust, arrogance, and manipulativeness

Psychotherapy

The National Alliance on Mental Illness (NAMI) lists several types of psychotherapy that may be useful in the treatment of personality disorders:

• Dialectical behavior therapy (DBT), which teaches coping skills and strategies for dealing with urges related to self-harm and suicide, regulating emotions, and improving relationships.
• Cognitive behavior therapy (CBT), the goal of which as stated by NAMI is "to recognize negative thoughts and learn effective coping strategies."
• Mentalization-based therapy (MBT), which teaches people to notice and reflect on their internal states of mind and those of others.
• Psychodynamic therapy, which places a large emphasis on the unconscious mind, where upsetting feelings, urges, and thoughts that are too painful for us to directly look at are housed.
• Family therapy, during which family members learn to change unhealthy reactions to each other and learn effective communication skills.

Medication

Medication can be useful to treat associated or co-morbid depression or anxiety. Depending on your symptoms, your healthcare provider may prescribe one or more of the following:

• Anti-anxiety medication
• Antidepressant
• Antipsychotic
• Mood stabilizer

Coping

Learning how to cope with a personality disorder is key to functioning at your best. In addition to seeking professional support, it's important to reach out to a supportive friend or family member who can help when you are struggling with strong emotions. If you don’t have someone in mind that is supportive and you are in a crisis, call a helpline.

• Become an expert. The more you know about your condition, the better able you’ll be to understand and cope with symptoms. Education about your condition can also help motivate you to stay the treatment course.
• Play an active role in your treatment. Take time to think about your treatment goals during and after therapy sessions. Even if you’re not feeling well, don’t skip your sessions or stop taking your medications without talking to your healthcare professional. Similarly, be sure to stick with regular appointments.
• Practice self-care strategies. Regular exercise and consistent eating and sleeping schedules can help prevent mood swings and manage anxiety, stress, and depression. It’s also important to avoid drugs and alcohol, which can worsen symptoms and interact with medications.

For Loved Ones

If you have a loved one with a personality disorder, you may also find it helpful to talk to a mental health professional. A professional can help you learn coping skills and how to set boundaries and practice self-care strategies. Group therapy and support groups may also be helpful resources of support and information.