PERSONALITY DISORDER

Personality disorders involve behavior that deviates from the norms or expectations of one’s culture. However, people who deviate from cultural norms are not necessarily dysfunctional, nor are people who conform to cultural norms necessarily healthy. Many personality disorders represent extreme variants of behavior patterns that people usually value and encourage. For example, most people value confidence but not arrogance, agreeableness but not submissiveness, and conscientiousness but not perfectionism.

Because no clear line exists between healthy and unhealthy functioning, critics question the reliability of personality disorder diagnoses. A behavior that seems deviant to one person may seem normal to another depending on one’s gender, ethnicity, and cultural background. The personal and cultural biases of mental health professionals may influence their diagnoses of personality disorders.

An estimated 20 percent of people in the general population have one or more personality disorders. Some people with personality disorders have other mental illnesses as well. About 50 percent of people who are treated for any psychiatric disorder have a personality disorder.

Mental health professionals rarely diagnose personality disorders in children because their manner of thinking, feeling, and relating to others does not usually stabilize until young adulthood. Thereafter, personality traits usually remain stable. Personality disorders often decrease in severity as a person ages.

KINDS OF PERSONALITY DISORDERS

The fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), published by the American Psychiatric Association, describes ten personality disorders. This article describes in detail two of the most common personality disorders, antisocial personality disorder and borderline personality disorder. It also provides brief descriptions of other types of personality disorders.

A.

Antisocial Personality Disorder

People with antisocial personality disorder act in a way that disregards the feelings and rights of other people. Antisocial personalities often break the law, and they may use or exploit other people for their own gain. They may lie repeatedly, act impulsively, and get into physical fights. They may mistreat their spouses, neglect or abuse their children, and exploit their employees. They may even kill other people. People with this disorder are also sometimes called sociopaths or psychopaths. Antisocial behavior in people less than 18 years old is called conduct disorder.

Antisocial personalities usually fail to understand that their behavior is dysfunctional because their ability to feel guilty, remorseful, and anxious is impaired. Guilt, remorse, shame, and anxiety are unpleasant feelings, but they are also necessary for social functioning and even physical survival. For example, people who lack the ability to feel anxious will often fail to anticipate actual dangers and risks. They may take chances that other people would not take.

Antisocial personality disorder affects about 3 percent of males and 1 percent of females. This is the most heavily researched personality disorder, in part because it costs society the most. People with this disorder are at high risk for premature and violent death, injury, imprisonment, loss of employment, bankruptcy, alcoholism, drug dependence, and failed personal relationships.

B.

Borderline Personality Disorder

People with borderline personality disorder experience intense emotional instability, particularly in relationships with others. They may make frantic efforts to avoid real or imagined abandonment by others. They may experience minor problems as major crises. They may also express their anger, frustration, and dismay through suicidal gestures, self-mutilation, and other self-destructive acts. They tend to have an unstable self-image or sense of self.

As children, most people with this disorder were emotionally unstable, impulsive, and often bitter or angry, although their chaotic impulsiveness and intense emotions may have made them popular at school. At first they may impress people as stimulating and exciting, but their relationships tend to be unstable and explosive.

About 2 percent of all people have borderline personality disorder. About 75 percent of people with this disorder are female. Borderline personalities are at high risk for developing depression, alcoholism, drug dependence, bulimia, dissociative disorders, and post-traumatic stress disorder. As many as 10 percent of people with this disorder commit suicide by the age of 30. People with borderline personality disorder are among the most difficult to treat with psychotherapy, in part because their relationship with their therapist may become as intense and unstable as their other personal relationships.

C.

Avoidant Personality Disorder

Avoidant personality disorder is social withdrawal due to intense, anxious shyness. People with avoidant personalities are reluctant to interact with others unless they feel certain of being liked. They fear being criticized and rejected. Often they view themselves as socially inept and inferior to others.

D.

Dependent Personality Disorder

Dependent personality disorder involves severe and disabling emotional dependency on others. People with this disorder have difficulty making decisions without a great deal of advice and reassurance from others. They urgently seek out another relationship when a close relationship ends. They feel uncomfortable by themselves.

E.

Histrionic Personality Disorder

People with histrionic personality disorder constantly strive to be the center of attention. They may act overly flirtatious or dress in ways that draw attention. They may also talk in a dramatic or theatrical style and display exaggerated emotional reactions.

F.

Narcissistic Personality Disorder

People with narcissistic personality disorder have a grandiose sense of self-importance. They seek excessive admiration from others and fantasize about unlimited success or power. They believe they are special, unique, or superior to others. However, they often have very fragile self-esteem.

G.

Obsessive-Compulsive Personality Disorder

Obsessive-compulsive personality disorder is characterized by a preoccupation with details, orderliness, perfection, and control. People with this disorder often devote excessive amounts of time to work and productivity and fail to take time for leisure activities and friendships. They tend to be rigid, formal, stubborn, and serious. This disorder differs from obsessive-compulsive disorder, which often includes more bizarre behavior and rituals.

H.

Paranoid Personality Disorder

People with paranoid personality disorder feel constant suspicion and distrust toward other people. They believe that others are against them and constantly look for evidence to support their suspicions. They are hostile toward others and react angrily to perceived insults.

I.

Schizoid Personality Disorder

Schizoid personality disorder involves social isolation and a lack of desire for close personal relationships. People with this disorder prefer to be alone and seem withdrawn and emotionally detached. They seem indifferent to praise or criticism from other people.

J.

Schizotypal Personality Disorder

People with schizotypal personality disorder engage in odd thinking, speech, and behavior. They may ramble or use words and phrases in unusual ways, and they may believe they have magical control over others. They feel very uncomfortable with close personal relationships and tend to be suspicious of others. Some research suggests this disorder is a less severe form of schizophrenia.

K.

Other Personality Disorders

Many psychiatrists and psychologists use two additional diagnoses. Depressive personality disorder is characterized by chronic pessimism, gloominess, and cheerlessness. In passive-aggressive personality disorder, a person passively resists completing tasks and chores, criticizes and scorns authority figures, and seems negative and sullen.

IV.

CAUSES

Personality disorders result from a complex interaction of inherited traits and life experience, not from a single cause. For example, some cases of antisocial personality disorder may result from a combination of a genetic predisposition to impulsiveness and violence, very inconsistent or erratic parenting, and a harsh environment that discourages feelings of empathy and warmth but rewards exploitation and aggressiveness. Borderline personality disorder may result from a genetic predisposition to impulsiveness and emotional instability combined with parental neglect, intense marital conflicts between parents, and repeated episodes of severe emotional or sexual abuse (see Child Abuse). Dependent personality disorder may result from genetically based anxiety, an inhibited temperament, and overly protective, clinging, or neglectful parenting.

V.

TREATMENT

The pervasive and chronic nature of personality disorders makes them difficult to treat. People with these disorders often fail to recognize that their personality has contributed to their social, occupational, and personal problems. They may not think they have any real problems despite a history of drug abuse, failed relationships, and irregular employment. Thus, therapists must first focus on helping the person understand and become aware of the significance of their personality traits.

People with personality disorders sometimes feel that they can never change their dysfunctional behavior because they have always acted the same way. Although personality change is exceedingly difficult, sometimes people can change the most dysfunctional aspects of their feelings and behavior.

Therapists use a variety of methods to treat personality disorders, depending on the specific disorder. For example, cognitive and behavioral techniques, such as role playing and logical argument, may help alter a person’s irrational perceptions and assumptions about himself or herself. Certain psychoactive drugs may help control feelings of anxiety, depression, or severe distortions of thought. Psychotherapy may help people to understand the impact of experiences and relationships during childhood.

Psychotherapy is usually ineffective for people with antisocial personality disorder because these individuals tend to be manipulative, unreliable, and dishonest with the therapist. Therefore, most mental health professionals favor removing people with this disorder from their current living situation and placing them in a residential treatment center. Such residential programs strictly supervise patients’ behavior and impose rigid, consistent rules and responsibilities. These programs appear to help some people, but it is unclear how long their beneficial effects last.

Therapists treating people with borderline personality disorder sometimes use a technique called dialectical behavior therapy. In this type of therapy, the therapist initially focuses on reducing suicidal tendencies and other behaviors that disrupt treatment. The therapist then helps the person develop skills to cope with anger and self-destructive impulses. In addition, the person learns to achieve personal strength through an acceptance of the many disappointments and interpersonal conflicts that are a natural part of life.