Personality disorders

Personality denotes characteristic ways of thinking, feeling, behaving, and reacting to the environment. When this “psychological signature” strikes a useful balance between consistency and adaptive flexibility, we speak of personality traits. A personality disorder is said to exist when a person chronically uses certain mechanisms of coping in an inappropriate, stereotyped, and maladaptive fashion.

DIAGNOSIS OF PERSONALITY DISORDERS

The Diagnositc and Statistical Manual of the American Psychiatric Association (DSM-III) recognizes 11 distinctive personality disorders. These are grouped into three thematic clusters. Paranoid, schizoid, and schizotypal personality disorders are characterized by oddness or eccentricity. Histrionic, narcissistic, antisocial, and borderline personality disorders share a dramatic presentation along with self-centeredness, emotionality, and erratic behavior. Anxiety and fear underlie avoidant, dependent, compulsive, and passive-aggressive personalities.

The DSM-III diagnostic classification scheme stipulates specific inclusion and exclusion criteria for diagnosis of each disorder. Since the number of criteria for individual disorders ranges from 3 to 24, the descriptions in this chapter are highlights rather than complete expositions. The reader is referred to the DSM-III for the detailed listing of the necessary signs and symptoms required to make the diagnosis of the various personality disorders.

Paranoid personality disorder

People with this disorder are suspicious and hypersensitive to perceived slights and injuries. They are hypervigilant to the possibility that someone might trick or harm.

Psychiatry them and tend to be guarded and secretive and to blame others. They may be jealous and concerned with hidden meanings. They tend to exaggerate difficulties and to take offense and become hostile easily. Their affective range is limited, and they are often perceived as cold, unemotional, and humorless.

Schizoid personality disorder Schizoid individuals are loners who seem to have little need for others. They appear emotionally cold and aloof and indifferent to praise and criticism; they lack close friendships, and may be social recluses.

In earlier nomenclatures eccentric thinking was sometimes added to the schizoid picture. DSM-III, however, has split off a second category, schizotypal, to describe persons whose principal difficulties are cognitive rather than interpersonal.

Schizotypal personality disorder

Schizotypal persons share with schizophrenics certain eccentricities of thinking, perception, speech, and interpersonal interaction; however, the degree and pervasiveness of such “schizophrenic-like” symptomatology is not sufficient to meet diagnostic criteria for schizophrenia. Odd speech (e.g., vague, circumstantial, metaphorical), ideas of reference (inappropriately inferring that neutral events have some special relevance to the person), magical thinking, and suspiciousness can be prominent. Many schizotypal persons are also socially isolated, and this can lead to confusion with schizoid personality.

Borderline personality disorder

Borderline persons have been described as having “stable instability,” characterized by chronic difficulty in regulating mood and interpersonal attachments and in maintaining a consistent self-image. Borderline persons can manifest impulsive behavior, some of it self-damaging (e.g., self-mutilation, suicidal behavior). Their mood is unpredictable. Some have brief outbursts of anger, irritability, sadness, and fear. Others suffer from a chronic emptiness. Despite having chaotic interpersonal relationships punctuated by intense love and hate, borderline persons generally are intolerant of being alone. The defense mechanism of “splitting” (regarding persons and events either as “all good” or “all bad”) can be prominent.

Histrionic personality disorder

People with a histrionic personality have seemingly intense but actually superficial relationships. They present in a dramatic, engaging, but self-centered fashion. There is an exaggerated expression of emotions, attention seeking, craving for excitement, and a tendency to overreact. While superficially warm and charming, histrionic persons are generally perceived as shallow, inconsiderate, self-indulgent, vain, demanding, dependent, and manipulative. Some make frequent suicidal threats or attempts.

Narcissistic personality disorder

The narcissistic person has an inflated sense of self-importance, and may be preoccupied with being unique, powerful, and gifted. The patient exaggerates his or her talents and contributions, seeks admiration, and uses others to achieve a better position, while being indifferent to their feelings and needs. A rejection can produce excessive rage, inferiority, shame, or humiliation. The narcissistic person has difficulty seeing others in a realistic light, tending either to overidealize or devalue them.

Antisocial personality disorder

Antisocial behavior is characterized by unconcern with the rules and expectations of society and repeated violation of the rights of others. The diagnosis is limited to adults (persons under 18 with antisocial features are classified as having conduct disorder) and requires a history of antisocial behaviors which have their onset before age 15. Such behaviors include truancy, delinquency, running away from home, lying, precocious sexuality, troubles with the law, and alcohol or drug abuse. Beyond such historical considerations, the antisocial diagnosis requires current evidence of certain deviant behaviors which include irresponsibility in work, as a parent, in financial matters, and in personal behavior (e.g., recklessness, driving while intoxicated). Additionally, antisocial persons will usually commit multiple illegal acts, lie and deceive, manifest an inability to maintain a long-term attachment to a sexual partner, and exhibit irritability and agressiveness. Alcohol or other substance abuse is common.

Avoidant personality disorder

People who are inappropriately concerned with rejection or humiliation, and for this reason avoid close ties with others, are classified as having an avoidant personality disorder. Despite being withdrawn, they give evidence for wishing that they did have intimate relations with others. In contrast with the narcissistic individual, the avoidant person tends to manifest low self-esteem and a tendency to exaggerate his or her shortcomings.

Dependent personality disorder Dependent people allow others to assume responsibility for major aspects of their life and decision making. Because they see themselves as helpless or inept, they are willing to subordinate their needs and wishes to those of others in order to avoid taking personal responsibility.

Passive-aggressive personality disorder

Passive-aggressive people resent responsibility, either social or work-related. Rather than expressing their opposition directly, they tend to procrastinate, dawdle, behave stubbornly, work inefficiently, and “forget.” As a consequence, they fail to achieve their potential.

Compulsive personality disorder

This disorder, which is equivalent to the term obsessive-compulsive personality, describes people who tend to be preoccupied with rules, procedures, and detail. They are often stubbornly insistent on certain things being done a particular way, yet at other times may become indecisive to the point of ineffectiveness. Compulsives tend to value their work and possessions more than their interpersonal relationships. They have difficulties expressing warm and tender feelings toward others and are sometimes seen as stiff, cold, and awkward.

A typical, mixed, or other personality disorder

This residual DSM-III category accommodates personality disturbances that do not fit neatly into any of the categories listed above. The most commonly used is mixed personality disorder, which indicates that an individual’s behavior fulfills the criteria for more than one personality disorder, e.g., passive-aggressive and dependent. Atypical personality disorder is used when a personality disorder is suspected but there is not sufficient information to make a clear classification. Other personality disorder indicates presence of a personality disturbance not specifically included in DSM-lll, e.g., masochistic, impulsive, or immature personality (which are concepts from other diagnostic schemes). One increasingly recognized disorder is adult attention deficit disorder (ADD), a residual form of childhood ADD (hyperkinesis). As adults, such individuals continue to have problems in attending and manifest labile mood, explosive temper, impulsivity, stress intolerance, and inability to complete tasks. They may also manifest a paradoxical (calming) reaction to central nervous system (CNS) stimulants.