Personality disorders

Personality disorders are pervasive and persistent patterns of behavior that cause significant distress and impairment in functioning. There are 10 distinct personality disorders, grouped into three clusters. Diagnosis is based on clinical findings. Treatment involves psychotherapy and sometimes medication.

Personality traits are patterns of thinking, perceiving, responding, and relating that are relatively stable over time and across situations. Personality traits typically become evident from late adolescence to early adulthood, and although many traits remain constant throughout life, some may fade or change with age. A personality disorder is present when these traits become so rigid and maladaptive that they interfere with functioning. The psychological coping mechanisms that everyone uses unconsciously from time to time are often immature and maladaptive in people with personality disorders.

People with personality disorders are often frustrated and may even take their anger out on others (including doctors). Most are worried about their lives, have problems with work and relationships. Personality disorders are often associated with mood disorders, anxiety, substance abuse, and eating disorders. Patients with severe personality disorders have a high risk of hypochondria, violence, and self-destructive behavior. In the family, they may lead inconsistent, disjointed, overly emotional, cruel, or irresponsible upbringing, leading to the development of physical and somatic problems in their children.

About 13% of the general population have a personality disorder. Antisocial personality disorder occurs in about 2% of the population, with a higher prevalence among men than women (6:1). Borderline personality disorder occurs in about 2% of the population, with a higher prevalence among women than men (3:1).

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Diagnosis and classification of personality disorders

The patient's emotional reactions, his view of the causes of his problems, the attitude of others towards him - all this can provide information about the disorder. The diagnosis is based on the observation of recurring features of behavior or perception that cause distress and disturbances in social functioning. The patient is usually not critical enough about these features of behavior, so the assessment is best started with information from people who come into contact with the patient. Often, the suspicion of the presence of a personality disorder comes from a feeling of discomfort in the doctor, usually if the doctor begins to feel anger or tension.

According to the general criteria (DSM-IV) of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, the emphasis is on considering the possible influence of other mental or physical disorders (e.g., depression, substance abuse, hyperthyroidism) on the patient's behavior. DSM-IV identifies 10 different personality disorders, which are divided into three clusters: A - unusual/eccentric; B - impressionable/changeable; and C - anxious/fearful.

Coping mechanisms

Mechanism	Definition	Result	Personality disorders
Projection	Attributing one's own unconscious feelings to others	Leads to prejudice, withdrawal from close relationships due to paranoid suspicions, excessive alertness to external danger and collecting injustices	Typical of paranoid and schizotypal personality; seen in people with borderline, antisocial or narcissistic personality in situations of acute stress
Split	Black and white, all or nothing perception or thinking, where all people are divided into good saviors and terrible villains	Allows you to avoid the discomfort of ambivalence (for example, feeling love and dislike for the same person), uncertainty and helplessness	Typical for a borderline personality
Action outside	Direct behavioral manifestations of unconscious desires or urges that allow a person to avoid awareness of the accompanying painful or pleasant affect	Leads to a variety of delinquent, thoughtless, disordered and substance-related behaviors that may become so habitual that the actor remains unaware and free from the sense that he or she initiated the action	Very common in people with antisocial, cyclothymic or borderline personality
Directing aggression against oneself	Directing anger not at others but at oneself; if directly, it is called self-harm, if indirectly, it is called passive aggression	Internalization of feelings about others' failures; engaging in silly, provocative clowning	Underlies passive-aggressive and depressive personality; dramatic in patients with borderline personality who express anger at others in the form of self-harm
Fantasies	The tendency to use imaginary relationships and one's own belief system to resolve conflicts and relieve loneliness	Leads to eccentricity and avoidance of intimacy	Used by people with avoidant or schizoid personalities who, unlike psychotic patients, are unsure of reality and do not act on their fantasies
Hypochondria	Use somatic complaints to attract attention	May seek sympathetic attention from others; may show anger at others who are not aware of it	Used by people with dependent, hysterical or borderline personality

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Cluster A

Patients belonging to cluster A tend to be detached and suspicious.

The paranoid personality has characteristics such as coldness and distancing in relationships, with a need to control the situation and a tendency to jealousy if an attachment is formed.

People with this disorder are often secretive and distrustful. They tend to be suspicious of change and often see hostile and evil motives in other people's actions. These hostile motives are usually a projection of their own hostility toward others. Their reactions sometimes surprise or frighten others. They may use the resulting anger and rejection of others (i.e., projective identification) to confirm their own perceptions. Paranoid people tend to feel righteous indignation and often take legal action against others. These people can be highly skilled and conscientious, although they usually need relative isolation to work. This disorder must be differentiated from paranoid schizophrenia.

The schizoid personality is characterized by introversion, social withdrawal, isolation, emotional coldness, and distancing. Such people are usually absorbed in their own thoughts and feelings and avoid close, intimate relationships with others. They are silent, prone to daydreaming, and prefer theoretical reasoning to practical action.

Schizotypal personality, like schizoid personality, includes social withdrawal and emotional coldness, but also unusual thinking, perception, and communication, such as magical thinking, clairvoyance, ideas of reference, or paranoid thinking. These quirks suggest schizophrenia, but are not severe enough to meet its criteria. People with schizotypal personality are thought to have latent expression of genes that cause schizophrenia.

Cluster B

These patients tend to be emotionally unstable, impulsive, and impressionable.

The borderline personality is characterized by unstable self-perception, mood, behavior, and relationships with others. These individuals tend to believe that they were not adequately cared for as children and, as a result, feel empty, angry, and complain about their upbringing. As a result, they constantly seek care and are sensitive to the feeling of its absence. Their relationships with people tend to be dramatic and intense. When they feel cared for, they appear as lonely drifters seeking help for depression, substance abuse, eating disorders, or past abuse. When they fear losing their caregiver, they often display inappropriate, intense anger. These mood swings are usually accompanied by extreme changes in their views of the world, themselves, and others, for example, from bad to good, from hate to love. When they feel lonely, they may dissociate or become very impulsive. Their concept of reality is so weak that they may develop brief episodes of psychotic disorders such as paranoid delusions or hallucinations. They often become self-destructive and may self-harm and attempt suicide. They initially tend to demand special attention, but after repeated crises, vague, unfounded complaints and failure to follow therapeutic recommendations, they are perceived as complainers who avoid help. Borderline personality disorder tends to become less severe and stabilize with age.

Antisocial personality is characterized by gross disregard for the rights and feelings of others. People with antisocial personality disorder exploit others for material gain or personal pleasure. They are easily frustrated and have poor stress tolerance. They are characterized by impulsive and irresponsible outward manifestations of their conflicts, sometimes accompanied by aggression and violence. They cannot foresee the consequences of their behavior and usually do not experience guilt or remorse afterwards. Many of them have a well-developed ability to actively rationalize their behavior and blame it in others. Fraud and deceit permeate their relationships with others. Punishment rarely leads to changes in their behavior and improved law-abidingness. Antisocial personality disorder often leads to alcoholism, drug use, promiscuity, failure to fulfill commitments, frequent travel, and difficulties in observing the law. Life expectancy is reduced, but the disorder becomes less intense and may stabilize with age.

The narcissistic personality is characterized by grandiosity. Such people have an exaggerated sense of their own superiority and expect to be treated with respect. Their relationships are characterized by the need for admiration from others, they are extremely sensitive to criticism, failures and losses. If such people are faced with the inability to live up to their high opinion of themselves, they may become enraged or deeply depressed and suicidal. They often believe that others are jealous of them. They may exploit others because they believe that their superiority justifies it.

The histrionic (hysteroid) personality is characterized by a conspicuous search for attention. Such people also attach excessive importance to their appearance and behave theatrically. Their displays of emotion often seem exaggerated, immature, and superficial. In addition, they often demand benevolent and erotic attention from others. Relationships with others are usually easy to establish, sexuality is overemphasized, but there is a tendency for contacts to be superficial and short-lived. Their seductive behavior and tendency to exaggerate somatic problems [i.e., hypochondria] often conceal basic desires for dependency and protection.

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Cluster C

Such patients tend to be nervous and passive or rigid and preoccupied.

The dependent personality is characterized by shifting responsibility to others. Such people may defer to others in order to gain their support. For example, they allow the needs of the people they depend on to dominate their own. They lack self-confidence and have a strong sense that they cannot take adequate care of themselves. They believe that others are more capable and are reluctant to voice their fear that their initiative will offend the people they depend on. Dependency in other personality disorders may be hidden behind overt behavioral disturbances; for example, histrionic or borderline behavior masks the underlying dependency.

The avoidant personality is characterized by hypersensitivity to rejection and a fear of starting new relationships or doing something new because of the risk of failure or disappointment. Because of a strong conscious desire for affection and approval, such people often experience distress due to isolation and the inability to maintain comfortable relationships with others. They respond with withdrawal to even small hints of rejection.

The obsessive-compulsive personality is characterized by conscientiousness, accuracy, and reliability, but their lack of flexibility often makes them unable to adapt to change. They take responsibility seriously, but because they hate mistakes and incompleteness, they get bogged down in details and forget the goal. As a result, they have trouble making decisions and completing tasks. Such problems make responsibility a source of anxiety, and such patients rarely derive much satisfaction from their achievements. Most obsessive-compulsive traits are adaptive if expressed in moderation. People with these personality traits can achieve a lot, especially in the sciences and other academic fields where order, perfectionism, and persistence are desirable. However, they may feel uncomfortable when feelings, interpersonal relationships, and situations are out of control, or when they must rely on other people, or when events are unpredictable.

Other personality types: Some personality types are described but not classified as disorders in the DSM-IV.

The passive-aggressive (negativistic) personality usually gives the impression of stupidity or passivity, but behind such behavior is a desire to avoid responsibility, control, or punishment by others. Passive-aggressive behavior is confirmed by procrastination, incompetence, unrealistic statements about one's helplessness. Often such people, having agreed to do a task, do not want to do it and then subtly sabotage the completion of the task. Such behavior usually indicates denial, or hidden hostility, or disagreement.

The cyclothymic personality fluctuates between ardent cheerfulness and despondency and pessimism; each mood variant lasts a week or more. Characteristically, rhythmic mood changes are regular and occur without a reliable external cause. If these features do not disrupt social adaptation, cyclothymia is considered a temperament and is present in many gifted and creative people.

The depressive personality is characterized by constant gloom, anxiety, and shyness. Such people have a pessimistic outlook that destroys their initiative and depresses others. Self-satisfaction seems undeserved and sinful. They unconsciously consider their suffering as an emblem of virtue, necessary to deserve the love or favor of others.

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Treatment of personality disorders

Although treatment varies depending on the type of personality disorder, there are some general principles. Family and friends may act in ways that either increase or decrease the patient's problematic behavior or thoughts, so their involvement is helpful and often key. Early attempts should be made to help the patient see that the problem is within him or herself. Another principle is that treatment of personality disorders takes a long time. Repeated confrontation in long-term psychotherapy or in encounters with others is usually necessary for the person to become aware of his or her psychological defenses, beliefs, and maladaptive behavior patterns.

Because personality disorders are extremely difficult to treat, it is important that the therapist be experienced, enthusiastic, and have an understanding of the patient's expected areas of emotional sensitivity and habitual coping mechanisms. Positive attitudes and advice alone do not affect personality disorders. Treatment of personality disorders may involve a combination of psychotherapy and medication. However, symptoms usually do not respond well to medication.

Relieving anxiety and depression is a primary goal, and medication may help. Reducing external stress can also quickly reduce these symptoms. Maladaptive behavior, characterized by recklessness, social withdrawal, lack of confidence, and emotional outbursts, may change over months. Group therapy and behavior modification, conducted in the home or in a day hospital setting, are sometimes effective. Participation in self-help groups or family therapy may also help change socially inappropriate behavior. Behavior changes are most important for patients with borderline, antisocial, or avoidant personality disorders. Dialectical behavior therapy (DBT) has been shown to be effective for borderline personality disorder. DBT, which includes weekly individual and group therapy, as well as telephone contact with a therapist between scheduled sessions, helps the patient gain insight into his or her behavior and teaches him or her problem-solving skills and adaptive behavior. Psychodynamic therapy is also highly effective for patients with borderline and avoidant personality disorders. An important component of such therapy is to help the patient with a personality disorder transform his or her emotional state and think about the impact of his or her behavior on others.

Resolving interpersonal relationship problems such as dependency, mistrust, arrogance, and manipulativeness usually takes more than 1 year. The basis for effective changes in interpersonal relationships is individual psychotherapy, which helps the patient understand the sources of his or her problems in relationships with people. The therapist should repeatedly point out the undesirable consequences of the patient's thoughts and behavioral characteristics, and periodically set boundaries in the patient's behavior. Such therapy is necessary for patients with histrionic, dependent, or passive-aggressive personality disorders. Some patients with personality disorders that include different preferences, expectations, and beliefs (i.e., narcissistic or obsessive-compulsive types) are recommended psychoanalysis, usually for 3 years or more.