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Personality Disorders

Overview :

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. In retrospect, however, 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.

Some psychiatrists maintain that the DSM-IV classification is inadequate and should be expanded to include three additional categories: passive-aggressive personality disorder, characterized by a need to control or punish others through frustrating them or sabotaging plans; cyclothymic personality disorder, characterized by intense mood swings alternating between high spirits and moroseness or gloom; and depressive personality disorder, characterized by a negative and pessimistic approach to life.

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-III-R, 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:


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 that 0.5-2.5% of the general population meet the criteria for paranoid personality disorder.


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.


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 or UFOs) 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.


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.


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.


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 the disorder has been more associated with womenin clinical settings, there may be bias toward diagnosing women with the histrionic personality disorder.


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.


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 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.


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.

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