Clinical: Understanding Personality Disorders: A helpful guide for health professionals

Our personalities are an integral part of who we are. They impact how we interact with others, our moods and behaviors, and how we respond to everyday events and crises. At some point, you've probably taken a quiz to learn more about your personality and how it shapes you. However, it's likely that personality disorders weren't included in the results.

According to the Diagnostic Statistical Manual on Mental Disorders (DSM), a personality disorder is defined as "an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual's culture." Personality disorders lead to impairment and frequent difficulties for those who have them. These disorders tend to affect two or more of the following areas:

Self-perception and perception of others
Emotional responses to others
Approach to engaging with others
Ability to regulate behavior

There are ten types of personality disorders organized into three clusters: Cluster A, Cluster B, and Cluster C. Recognizing personality disorder symptoms is crucial for health professionals because patients do not usually present with concerns about these symptoms. Their worries center around difficulty excelling at work, depression, poor academic performance, and issues with interpersonal relationships. These concerns are typically consequences of the underlying personality disorder due to their maladaptive, inflexible, and persistent nature. Patients view their behavior patterns as ego-syntonic, meaning they align with their values and self-image, which may cause difficulty accepting treatment. Clinicians often have difficulty diagnosing personality disorders due to the overlapping presentation with other mental health disorders.

Keep reading to gain more insight and confidence about managing personality disorders in your clinical practice!

Understanding Personality Disorders

Let's begin understanding personality disorders by learning which ones fall under each Cluster.

Starting with Cluster A, this group includes Paranoid, Schizoid, and Schizotypal personality disorders. Patients with Cluster A personality disorders tend to be perceived as strange or eccentric by others and often have a lack of interest or distrust of those around them. The World Health Organization (WHO) estimates that 3.6% of people worldwide have a Cluster A personality disorder.

Cluster B personality disorders are characterized by dramatic, impulsive, and emotional behaviors. This Cluster includes Antisocial, Borderline, Histrionic, and Narcissistic personality disorders with an international prevalence of 1.5%.

Lastly, there are Cluster C personality disorders, which include Avoidant, Dependent, and Obsessive-compulsive personality disorders. Patients with these disorders tend to be very fearful and anxious. About 2.7% of the population worldwide fall under this cluster.

Before learning more about each personality disorder, let's dispel some common misconceptions. One myth is that evidence of a personality disorder must be present from an early age. These disorders typically develop around the late adolescent years or early adulthood, but they can also present later in life following an overwhelming life event. Another misconception is that patients with personality disorders are inherently manipulative. Manipulative behavior is not a feature of all personality disorders. For patients who exhibit those characteristics, it isn't a conscious behavior. Instead, it's often a response to a lack of safety and control as a child and an attempt to gain control now. Also, many people believe that personality disorders are untreatable when, in fact, various psychotherapy techniques are helpful in the treatment process. You'll learn more about these options as you progress through this guide for health professionals!

Types of Personality Disorders

Now, let's take a closer look at each disorder, discuss key features, and understand the diagnostic criteria for personality disorders.

Woman looking afraid and suspicious of her surroundings.

Cluster A Personality Disorders

Paranoid personality disorder is characterized by a widespread distrust and suspicion of others. Patients also believe that the intentions of others are malicious and harmful. Patients with this disorder may also have one or more additional diagnoses, such as post-traumatic stress disorder (PTSD), anxiety disorder, schizophrenia, or another personality disorder. In terms of diagnosis, patients must present with four or more of the following:

Suspicion of others without evidence that they are being deceived or exploited
Constant worry about the loyalty and trustworthiness of friends/acquaintances
Reluctance to share personal details
Misinterpreting unassuming statements as belittling or threatening
Holding on to grudges
Perception of attacks on character that are not apparent to others, with a readiness to counterattack or react angrily
Constant and unjustified suspicions that their partner or spouse is unfaithful

Next, let's discuss Schizoid personality disorder. Remember not to confuse this with schizophrenia, although the names sound similar. Those with Schizoid personality disorder have a limited range of emotions, prefer to be alone, and have no desire for close interpersonal relationships. While this may sound lonely, these patients have a lifelong pattern of reclusion. Diagnostically, patients must present with four or more of the following:

No enjoyment or desire for close relationships
Preference for solitary activities
Little, if any, interest at all in sexual activities
Enjoy a small number of activities, if any at all
Few close friends, if any at all
Indifferent to praise or criticism
Emotionally cold, detached, with limited emotional responses

On to Schizotypal personality disorder. Those with this personality disorder are described as behaving oddly, dressing in an eccentric fashion, and unusual thinking. These characteristics lead to difficulties in maintaining relationships. Approximately one-half of patients with Schizotypal personality disorder also have had one or more episodes of major depressive disorder and often also have substance use disorder. Five or more of the following must be present for diagnosis:

A belief that everyday events have a personal significance
Magical thinking such as clairvoyance, telepathy, superstitious beliefs, strange fantasies
Abnormal perceptual experiences, such as body illusions
Paranoia or suspiciousness
Inappropriate or restricted expression of emotion
Strange behavior or appearance
Lack of close friends
Odd speech or thinking
Excessive social anxiety

Cluster B Personality Disorders

When you use the word antisocial, you may use it to describe someone who has little desire to interact with others and tends to keep to themselves. Antisocial personality disorder, however, is something completely different. These patients constantly break rules and exploit others to meet their needs, with a lack of remorse or empathy. They appear charming to most despite their behavior. Co-existing conditions include mood disorders, substance use disorder, anxiety disorder, or a different personality disorder. Before age 15, these patients must be diagnosed with conduct disorder to meet the criteria for an Antisocial personality disorder diagnosis. The other diagnostic criteria include:

Disregard for social norms by committing unlawful acts
Constant lying, manipulation, and deceit for personal benefit
Impulsivity and a lack of planning for the future
Displays of aggression/irritability, leading to physical altercations or constant conflicts
Recklessness and a disregard for the safety of themselves or others
Lack of remorse
Inability to maintain employment and uphold financial obligations

Impulsivity, mood swings, repeated episodes of self-harm, or suicide attempts are key features of Borderline personality disorder. Patients with this disorder have a strong fear of abandonment and form intense attachments to others that fall apart due to minor conflicts. Unfortunately, they often have a history of childhood sexual, physical, or emotional abuse. Five or more of the following symptoms must be present for diagnosis:

Panicked efforts to avoid perceived or actual abandonment
Volatile relationships (extreme love-hate relationships)
Unstable self-image
Impulsive behavior in at least two potentially harmful ways, such as substance use, binge eating, sexual activity, etc.
Recurring suicidal threats or attempts, self-harm
Unstable mood
Pervasive feelings of emptiness
Challenges controlling anger
Paranoid ideas or dissociative symptoms related to stress

Histrionic personality disorder involves attention-seeking behavior, a dramatic, flirtatious nature, and excessive emotionality. These patients also tend to present more frequently with depression. Five or more of the following must be present for diagnosis:

Discomfort when they aren't the center of attention
Inappropriate seductive or provocative behavior
Use of physical appearance to garner attention
Shallow expression of emotion that rapidly shift
Theatrical level of emotional expression
Easily swayed by others
Overestimates the level of intimacy in relationships

The last Cluster B disorder to cover is Narcissistic personality disorder. Patients have a lack of empathy, a need for admiration, grandiosity, and fragile self-esteem. Narcissistic patients often develop depression when they do not receive their desired level of recognition from others. For diagnosis, five or more of these symptoms must be present:

An exaggerated sense of importance
Preoccupation with fantasies about power, beauty, success, money, etc.
A belief that they are special and only other high-status individuals can understand them
Need for excessive admiration
Sense of entitlement
Take advantage of others for self-benefit
Lack of empathy
Envious of others or belief that others are envious of them
Arrogant or haughty

Cluster C Personality Disorders

Let's begin with Avoidant personality disorder, which is classified by an overwhelming fear of rejection and intense sensitivity, causing patients to withdraw socially and avoid situations where someone may reject them. Unlike patients with Schizoid personality disorder, these patients desire companionship but are easily hurt and shy. There is also a higher incidence of anxiety and depressive disorders in these patients. At least four of the following must be present for diagnosis:

Will not interact with others unless they believe they are liked
Cautious of interpersonal relationships
Avoid jobs that require interpersonal interactions due to fear of critique/rejection
Worry about being criticized/rejected in social situations
Feel inadequate in new social environments, tend to be inhibited
Believe they are inferior
Reluctant to try new activities due to fear of embarrassment

Dependent personality disorder has a pattern of low self-confidence, fear of separation, clinginess, and an extreme need to be taken care of. These patients are more likely to stay in physically, emotionally, and/or sexually abusive relationships because they do not want to be alone. In terms of diagnostic criteria, five or more of the following must be present:

Difficulty with decision-making without external reassurance
Need for others to take responsibility for most areas of their lives
Avoidance of disagreements or conflicts due to fear of losing approval
Difficulty starting projects due to low self-confidence
Sense of helplessness when alone
Seeks new relationship rapidly after one ends
Fear of being left alone to care for themselves
Go to great lengths to receive support from others

We've officially reached the last personality disorder, Obsessive-compulsive personality disorder! Key characteristics include perfectionism, orderliness, and control. Inflexibility is also important to note in these patients. Though they often thrive professionally, their relationships with others suffer. Remember, this is not the same as obsessive-compulsive disorder. For diagnosis, four of the following traits must be present:

Preoccupation with schedules, lists, rules, and organization
Perfectionism interferes with completing tasks
Excessive devotion to work
Rigidity/stubbornness
Lack of flexibility regarding ethical/moral issues, values
Refuse to delegate work unless people agree to do it their way
Refusal to throw out worthless objects
Miserly spending habits for themselves and others

Causes and Risk Factors

What are the factors that contribute to the development of personality disorders? Currently, researchers have found a malfunctioning gene linked to the development of Obsessive-compulsive Personality Disorder. They're researching the genetic link between traits such as fear, aggression, anxiety, and the development of personality disorders.

Impactful childhood experiences, trauma, and verbal, physical, or sexual abuse are associated with a higher risk of developing certain disorders. For example, patients who experienced sexual abuse as children are more likely to develop Borderline or Antisocial personality disorders. In comparison, those who experienced verbal abuse are more likely to develop Borderline, Narcissistic, Paranoid, or Obsessive-compulsive disorders.

Environmental factors, such as a dysfunctional household, neglect, or a lack of constructive criticism, are linked to the development of personality disorders.

Diagnosis and Assessment

When diagnosing personality disorders, a comprehensive approach is essential. Evaluation should include a thorough clinical history, psychiatric history, physical exam, and mental status exam. It's also important to review each patient's work, educational, legal, and relationship history. These are generally areas where patients present with a long-term pattern of impairment. The diagnostic criteria we covered previously are also essential to making an accurate diagnosis.

Remember, these disorders are ego-syntonic, so patients have difficulty realizing they have a pattern of maladaptive behaviors, which can make diagnosis and treatment challenging.

Woman, like a therapist, speaking to female patient during a psychotherapy session.

Treatment Approaches

Psychotherapy is the primary treatment modality for personality disorders. Depending on the diagnosis, there are different types to employ, such as:

Teaching patients and their families about the diagnosis, treatment options for personality disorders, and coping strategies is also beneficial. If patients present with comorbid conditions, consider adding medications such as antidepressants, mood stabilizers, and anti-anxiety medications. Other ways to manage symptoms include exercise, avoiding alcohol and drugs, joining a support group, journaling, and mindfulness techniques.

Strategies for Treating Patients with Personality Disorders

It's important to remain empathetic and understanding when working with patients with personality disorders. These patients can evoke negative feelings from providers, such as anxiety, anger, hopelessness, and more. Awareness and acknowledgment of these feelings and addressing countertransference can lead to a better doctor-patient relationship. Lastly, collaboration with a multidisciplinary team is a great way to ensure comprehensive care.

Conclusion

We covered a wide variety of personality disorders, so here are a few key takeaways:

Personality disorders fall into three clusters. Each has distinct diagnostic criteria, and psychotherapy is helpful.
Patients with personality disorders have difficulty maintaining interpersonal relationships.
As a clinician, you should lead with empathy and compassion when building a clinician-patient relationship.
Making time to continue learning about personality disorders will help you accurately diagnose an often overlooked disorder.

These patients need our support. By reading this guide and checking out the latest research on personality disorders, we can all continue to promote awareness for these individuals and provide optimal care!

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Osmosis Team
Published on Aug 13, 2024. Updated on Aug 13, 2024.

Understanding Personality Disorders