Personality Disorders

Definition

Personality disorders are a group of mental disturbances defined by the fourth edition, text revision (2000) of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) as "enduring pattern[s] of inner experience and behavior" that are sufficiently rigid and deep-seated to bring a person into repeated conflicts with his or her social and occupational environment. DSM-IV specifies that these dysfunctional patterns must be regarded as nonconforming or deviant by the person's culture, and cause significant emotional pain and/or difficulties in relationships and occupational performance. In addition, the patient usually sees the disorder as being consistent with his or her self-image (ego-syntonic) and may blame others for his or her social, educational, or work-related problems.

Description

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:

Paranoid

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

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.

Schizotypal

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.

Antisocial

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.

Borderline

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.

Histrionic

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

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.

Avoidant

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

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.

Obsessive-compulsive

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.

Causes and symptoms

Personality disorders are thought to result from a bad interface, so to speak, between a child's temperament and character on one hand and his or her family environment on the other. Temperament can be defined as a person's innate or biologically shaped basic disposition. Human infants vary in their sensitivity to light or noise, their level of physical activity, their adaptability to schedules, and similar traits. Even such traits as shyness or novelty-seeking may be at least in part determined by the biology of the brain and the genes one inherits.

Character is defined as the set of attitudes and behavior patterns that the individual acquires or learns over time. It includes such personal qualities as work and study habits, moral convictions, neatness or cleanliness, and consideration of others. Since children must learn to adapt to their specific families, they may develop personality disorders in the course of struggling to survive psychologically in disturbed or stressful families. For example, nervous or high-strung parents might be unhappy with a baby who is very active and try to restrain him or her at every opportunity. The child might then develop an avoidant personality disorder as the outcome of coping with constant frustration and parental disapproval. As another example, child abuse is believed to play a role in shaping borderline personality disorder. One reason that some therapists use the term developmental damage instead of personality disorder is that it takes the presumed source of the person's problems into account.

Some patients with personality disorders come from families that appear to be stable and healthy. It has been suggested that these patients are biologically hypersensitive to normal family stress levels. Levels of the brain chemical (neurotransmitter) dopamine may influence a person's level of novelty-seeking, and serotonin levels may influence aggression.

Other factors that have been cited as affecting children's personality development are the mass media and social or group hysteria, particularly after the events of September 11, 2001. Cases of so-called mass sociogenic illness have been identified, in which a group of children began to vomit or have other physical symptoms brought on in response to an imaginary threat. In two such cases, the children were reacting to the suggestion that toxic fumes were spreading through their school. Some authors believe that overly frequent or age-inappropriate discussions of terrorist attacks or bioterrorism may make children more susceptible to sociogenic illness as well as other distortions of personality.

Diagnosis

Diagnosis of personality disorders is complicated by the fact that affected persons rarely seek help until they are in serious trouble or until their families (or the law) pressure them to get treatment. The reason for this slowness is that the problematic traits are so deeply entrenched that they seem normal (ego-syntonic) to the patient. Diagnosis of a personality disorder depends in part on the patient's age. Although personality disorders originate during the childhood years, they are considered adult disorders. Some patients, in fact, are not diagnosed until late in life because their symptoms had been modified by the demands of their job or by marriage. After retirement or the spouse's death, however, these patients' personality disorders become fully apparent. In general, however, if the onset of the patient's problem is in mid- or late-life, the doctor will rule out substance abuse or personality change caused by medical or neurological problems before considering the diagnosis of a personality disorder. It is unusual for people to develop personality disorders "out of the blue" in mid-life.

There are no tests that can provide a definitive diagnosis of personality disorder. Most doctors will evaluate a patient on the basis of several sources of information collected over a period of time in order to determine how long the patient has been having difficulties, how many areas of life are affected, and how severe the dysfunction is. These sources of information may include:

Interviews

The doctor may schedule two or three interviews with the patient, spaced over several weeks or months, in order to rule out an adjustment disorder caused by job loss, bereavement, or a similar problem. An office interview allows the doctor to form an impression of the patient's overall personality as well as obtain information about his or her occupation and family. During the interview, the doctor will note the patient's appearance, tone of voice, body language, eye contact, and other important non-verbal signals, as well as the content of the conversation. In some cases, the doctor may contact other people (family members, employers, close friends) who know the patient well in order to assess the accuracy of the patient's perception of his or her difficulties. It is quite common for people with personality disorders to have distorted views of their situations or to be unaware of the impact of their behavior on others.

Psychologic testing

Doctors use psychologic testing to help in the diagnosis of a personality disorder. Most of these tests require interpretation by a professional with specialized training. Doctors usually refer patients to a clinical psychologist for this type of test.

PERSONALITY INVENTORIES. Personality inventories are tests with true/false or yes/no answers that can be used to compare the patient's scores with those of people with known personality distortions. The single most commonly used test of this type is the Minnesota Multiphasic Personality Inventory, or MMPI. Another test that is often used is the Millon Clinical Multiaxial Inventory, or MCMI.

PROJECTIVE TESTS. Projective tests are unstructured. Unstructured means that instead of giving one-word answers to questions, the patient is asked to talk at some length about a picture that the psychologist has shown him or her, or to supply an ending for the beginning of a story. Projective tests allow the clinician to assess the patient's patterns of thinking, fantasies, worries or anxieties, moral concerns, values, and habits. Common projective tests include the Rorschach, in which the patient responds to a set of ten inkblots; and the Thematic Apperception Test (TAT), in which the patient is shown drawings of people in different situations and then tells a story about the picture.

Treatment

At one time psychiatrists thought that personality disorders did not respond very well to treatment. This opinion was derived from the notion that human personality is fixed for life once it has been molded in childhood, and from the belief among people with personality disorders that their own views and behaviors are correct, and that others are the ones at fault. More recently, however, doctors have recognized that humans can continue to grow and change throughout life. Most patients with personality disorders are now considered to be treatable, although the degree of improvement may vary. The type of treatment recommended depends on the personality characteristics associated with the specific disorder.

Hospitalization

Inpatient treatment is rarely required for patients with personality disorders, with two major exceptions: borderline patients who are threatening suicide or suffering from drug or alcohol withdrawal; and patients with paranoid personality disorder who are having psychotic symptoms.

Psychotherapy

Psychoanalytic psychotherapy is suggested for patients who can benefit from insight-oriented treatment. These patients typically include those with dependent, obsessive-compulsive, and avoidant personality disorders. Doctors usually recommend individual psychotherapy for narcissistic and borderline patients, but often refer these patients to therapists with specialized training in these disorders. Psychotherapeutic treatment for personality disorders may take as long as three to five years.

Insight-oriented approaches are not recommended for patients with paranoid or antisocial personality disorders. These patients are likely to resent the therapist and see him or her as trying to control or dominate them.

Supportive therapy is regarded as the most helpful form of psychotherapy for patients with schizoid personality disorder.

Cognitive-behavioral therapy

Cognitive-behavioral approaches are often recommended for patients with avoidant or dependent personality disorders. Patients in these groups typically have mistaken beliefs about their competence or likableness. These assumptions can be successfully challenged by cognitive-behavioral methods. More recently, Aaron Beck and his coworkers have successfully extended their approach to cognitive therapy to all ten personality disorders as defined by DSM-IV.

Group therapy

Group therapy is frequently useful for patients with schizoid or avoidant personality disorders because it helps them to break out of their social isolation. It has also been recommended for patients with histrionic and antisocial personality disorders. These patients tend to act out, and pressure from peers in group treatment can motivate them to change. Because patients with antisocial personality disorder can destabilize groups that include people with other disorders, it is usually best if these people meet exclusively with others who have APD (in homogeneous groups).

Family therapy

Family therapy may be suggested for patients whose personality disorders cause serious problems for members of their families. It is also sometimes recommended for borderline patients from overinvolved or possessive families.

Medications

Medications may be prescribed for patients with specific personality disorders. The type of medication depends on the disorder. In general, however, patients with personality disorders are helped only moderately by medications.

ANTIPSYCHOTIC DRUGS. Antipsychotic drugs, such as haloperidol (Haldol), may be given to patients with paranoid personality disorder if they are having brief psychotic episodes. Patients with borderline or schizotypal personality disorder are sometimes given antipsychotic drugs in low doses; however, the efficacy of these drugs in treating personality disorder is less clear than in schizophrenia.

MOOD STABILIZERS. Carbamazepine (Tegretol) is a drug that is commonly used to treat seizures, but is also helpful for borderline patients with rage outbursts and similar behavioral problems. Lithium and valproate may also be used as mood stabilizers, especially among people with borderline personality disorder.

ANTIDEPRESSANTS AND ANTI-ANXIETY MEDICATIONS. Medications in these categories are sometimes prescribed for patients with schizoid personality disorder to help them manage anxiety symptoms while they are in psychotherapy. Antidepressants are also commonly used to treat people with borderline personality disorder.

Treatment with medications is not recommended for patients with avoidant, histrionic, dependent, or narcissistic personality disorders. The use of potentially addictive medications should be avoided in people with borderline or antisocial personality disorders. However, some avoidant patients who also have social phobia may benefit from monoamine oxidase inhibitors (MAO inhibitors), a particular class of antidepressant.

Prognosis

The prognosis for recovery depends in part on the specific disorder. Although some patients improve as they grow older and have positive experiences in life, personality disorders are generally life-long disturbances with periods of worsening (exacerbations) and periods of improvement (remissions). Others, particularly schizoid patients, have better prognoses if they are given appropriate treatment. Beck and his coworkers estimate that effective cognitive therapy with patients with personality disorders takes two to three years on average. Patients with paranoid personality disorder are at some risk for developing delusional disorders or schizophrenia.

The personality disorders with the poorest prognoses are the antisocial and the borderline. Borderline patients are at high risk for developing substance abuse disorders or bulimia. About 80% of hospitalized borderline patients attempt suicide at some point during treatment, and about 5% succeed in committing suicide. Borderline patients are also the most likely to sue their mental health professional for malpractice.

Prevention

The most effective preventive strategy for personality disorders is early identification and treatment of children at risk. High-risk groups include abused children, children from troubled families, children with close relatives diagnosed with personality disorders, children of substance abusers, and children who grow up in cults or extremist political groups.

KEY TERMS

Character— An individual's set of emotional, cognitive, and behavioral patterns learned and accumulated over time.

Character disorder— Another name for personality disorder.

Cognitive therapy— A form of psychotherapy that focuses on changing people's patterns of emotional reaction by correcting distorted patterns of thinking and perception.

Developmental damage— A term that some therapists prefer to personality disorder, on the grounds that it is more respectful of the patient's capacity for growth and change.

Ego-syntonic— Consistent with one's sense of self, as opposed to ego-alien or dystonic (foreign to one's sense of self). Ego-syntonic traits typify patients with personality disorders.

Neuroleptic— Another name for older antipsychotic medications, such as haloperidol. The term does not apply to such newer atypical agents as clozapine (Clozaril).

Personality— The organized pattern of behaviors and attitudes that makes a human being distinctive. Personality is formed by the ongoing interaction of temperament, character, and environment.

Projective tests— Psychological tests that probe into personality by obtaining open-ended responses to such materials as pictures or stories. Projective tests are often used to evaluate patients with personality disorders.

Rorschach test— A well-known projective test that requires the patient to describe what he or she sees in each of 10 inkblots. It is named for the Swiss psychiatrist who invented it.

Temperament— A person's natural or genetically determined disposition.

Resources

BOOKS

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed., revised. Washington, D.C.: American Psychiatric Association, 2000.

Beck, Aaron T., Arthur Freeman, Denise D. Davis, et al. Cognitive Therapy of Personality Disorders. 2nd ed. New York: The Guilford Press, 2004.

Beers, Mark H., MD, and Robert Berkow, MD., editors. "Personality Disorders." In The Merck Manual of Diagnosis and Therapy. Whitehouse Station, NJ: Merck Research Laboratories, 2004.

PERIODICALS

Battle, C. L., M. T. Shea, D. M. Johnson, et al. "Childhood Maltreatment Associated with Adult Personality Disorders: Findings from the Collaborative Longitudinal Personality Disorders Study." Journal of Personality Disorders 18 (April 2004): 193-211.

Bienenfeld, David, MD. "Personality Disorders." eMedicine August 18, 2004. 〈http://www.emedicine.com/med/topic3472.htm〉.

Doyle, C. R., J. Akhtar, R. Mrvos, and E. P. Krenzelok. "Mass Sociogenic Illness—Real and Imaginary." Veterinary and Human Toxicology 46 (April 2004): 93-95.

Gutheil, T. G. "Suicide, Suicide Litigation, and Borderline Personality Disorder." Journal of Personality Disorders 18 (June 2004): 248-256.

Jordan, A. "The Role of Media in Children's Development: An Ecological Perspective." Journal of Developmental and Behavioral Pediatrics 25 (June 2004): 196-206.

ORGANIZATIONS

American Academy of Child and Adolescent Psychiatry (AACAP). 3615 Wisconsin Avenue, NW, Washington, DC 20016-3007. (202) 966-7300. Fax: (202) 966-2891. 〈http://www.aacap.org〉.

American Psychiatric Association (APA). 1400 K Street, NW, Washington, DC 20005. 〈http://www.psych.org〉.

National Institute of Mental Health (NIMH). 6001 Executive Boulevard, Room 8184, MSC 9663, Bethesda, MD 20892-9663. (301) 443-4513. 〈http://www.nimh.nih.gov〉.

Personality disorders

Definition

Personality disorders are a group of personality flaws defined by the fourth (1994) edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) as "enduring pattern[s] of inner experience and behavior" that are sufficiently rigid and deep-seated to bring a person into repeated conflicts with his or her social and occupational environment. DSM-IV specifies that these dysfunctional patterns must be regarded as non-conforming or deviant by the person's culture, and cause significant emotional pain and/or difficulties in relationships and occupational performance. In addition, the patient usually sees the disorder as being consistent with his or her self-image (ego-syntonic) and may blame others.

Description

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. But, in retrospect, many individuals with personality disorders could be judged to have shown evidence of the problems in childhood.

It is difficult to accurately estimate the percentage of the population that suffer from 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 suffers from personality disorders, 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 socalled dual diagnosis; for example, they may have more than one personality disorder, or a personality disorder together with a substance-abuse problem.

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.

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-IIIR, 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 other cultures 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 described below. Certain personality disorders, such as paranoid, schizoid, and schizotypal, should not be confused with psychotic disorders with the same or similar names. Psychotic disorders are characterized by more seriously disordered thinking, frequently involving hallucinations (seeing things that aren't present or hearing voices) and delusions (having unrealistic beliefs, such as thinking one has god-like powers), with an inability to distinguish reality from fantasy.

Paranoid

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 that0.5–2.5% of the general population meet the criteria for paranoid personality disorder.

Schizoid

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.

Schizotypal

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) 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. There is some evidence that schizotypal personality disorder and the psychotic disorder, schizophrenia , are genetically related.

Antisocial

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.

Borderline

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 conflicting 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.

Histrionic

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

Narcissistic

Narcissistic patients are characterized by a sense of 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.

Avoidant

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

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.

Obsessive-compulsive

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.

Causes and symptoms

Personality disorders are thought to be a disparity between a child's temperament or character and his or her family or social relationships. Temperament can be defined as a person's innate or biologically shaped basic disposition. Human infants vary in their sensitivity to light or noise, their level of physical activity, their adaptability to schedules, and other aspects. Even traits such as "shyness" and "novelty-seeking" may be, at least in part, determined by the biology of the brain and the genes one inherits.

Character is defined as the set of attitudes and behavior patterns that the individual acquires or learns over time. It includes such personal qualities as work and study habits, moral convictions, neatness or cleanliness, and consideration of others. Since children must learn to adapt to their specific families, they may develop personality disorders in the course of struggling to survive psychologically in disturbed or stressful families. For example, nervous or high-strung parents might be unhappy with a baby who is very active and try to restrain him or her at every opportunity. The child might then develop an avoidant personality disorder as the outcome of coping with constant frustration and parental disapproval. As another example, child abuse is believed to play a role in shaping borderline personality disorder. One reason that some therapists use the term developmental damage instead of personality disorder is that it takes the presumed source of the person's problems into account.

Some patients with personality disorders come from families that appear to be stable and healthy. It has been suggested that these patients are biologically hypersensitive to normal family stress levels. Levels of the brain chemical (neurotransmitter) dopamine may influence a person's level of novelty-seeking, and serotonin levels may influence aggression.

Diagnosis

Diagnosis of personality disorders is complicated by the fact that persons suffering from them rarely seek help until they are in serious trouble or until their families (or the law) pressure them to get treatment. The reason for this slowness is that the problematic traits are so deeply entrenched that they seem normal (ego-syntonic) to the patient. Diagnosis of a personality disorder depends in part on the patient's age. Although personality disorders originate during the childhood years, they are considered to be adult disorders. Some patients, in fact, are not diagnosed until late in life because their symptoms had been modified by the demands of their job or by marriage. After retirement or the spouse's death, however, these patients' personality disorders become fully apparent. In general, however, if the onset of the patient's problem is in mid- or late-life, the doctor will rule out substance abuse or personality change caused by medical or neurological problems before considering the diagnosis of a personality disorder. It is unusual for people to develop personality disorders "out of the blue" in mid-life.

There are no tests that can provide a definitive diagnosis of personality disorder. Most doctors will evaluate a patient on the basis of several sources of information collected over a period of time in order to determine how long the patient has been having difficulties, how many areas of life are affected, and how severe the dysfunction is. These sources of information may include:

Interviews

The doctor may schedule two or three interviews with the patient, spaced over several weeks or months, in order to rule out an adjustment disorder caused by job loss, bereavement, or a similar problem. An office interview allows the doctor to form an impression of the patient's overall personality as well as obtain information about his or her occupation and family. During the interview, the doctor will note the patient's appearance, tone of voice, body language, eye contact, and other important non-verbal signals, as well as the content of the conversation. In some cases, the doctor may contact other people (family members, employers, close friends) who know the patient well in order to assess the accuracy of the patient's perception of his or her difficulties. It is quite common for people with personality disorders to have distorted views of their situations, or to be unaware of the impact of their behavior on others.

Psychological testing

Doctors use psychological testing to help in the diagnosis of a personality disorder. Most of these tests require interpretation by a professional with specialized training. Doctors usually refer patients to a clinical psychologist for this type of test.

PERSONALITY INVENTORIES. Personality inventories are tests with true/false or yes/no answers that can be used to compare the patient's scores with those of people with known personality distortions. The single most commonly used test of this type is the Minnesota Multiphasic Personality Inventory, or MMPI. Another test that is often used is the Millon Clinical Multiaxial Inventory, or MCMI.

PROJECTIVE TESTS. Projective tests are unstructured, meaning that instead of giving one-word answers to questions, the patient is asked to talk at some length about a picture that the psychologist presents, or to supply an ending for the beginning of a story. Projective tests allow the clinician to assess the patient's patterns of thinking, fantasies, worries or anxieties, moral concerns, values, and habits. Common projective tests include the Rorschach, in which the patient responds to a set of 10 inkblots; and the Thematic Apperception Test (TAT), in which the patient is shown drawings of people in different situations and then tells a story about the picture.

Prognosis

At one time psychiatrists thought that personality disorders did not respond very well to treatment. This opinion was derived from the notion that human personality is fixed for life once it has been molded in childhood, and from the belief among people with personality disorders that their own views and behaviors are correct, and that others are the ones at fault. More recently, however,

KEY TERMS

Character —An individual's set of emotional, cognitive, and behavioral patterns learned and accumulated over time.

Character disorder —Another name for personality disorder.

Developmental damage —A term that some therapists prefer to personality disorder, on the grounds that it is more respectful of the patient's capacity for growth and change.

Ego-syntonic —Consistent with one's sense of self, as opposed to ego-alien or dystonic (foreign to one's sense of self). Ego-syntonic traits typify patients with personality disorders.

Neuroleptic —Another name for older antipsychotic medications, such as haloperidol. The term does not apply to newer "atypical" agents, such as clozapine (Clozaril).

Personality —The organized pattern of behaviors and attitudes that makes a human being distinctive. Personality is formed by the ongoing interaction of temperament, character, and environment.

Projective tests —Psychological tests that probe into personality by obtaining open-ended responses to such materials as pictures or stories. Projective tests are often used to evaluate patients with personality disorders.

Rorschach —A well-known projective test that requires the patient to describe what he or she sees in each of 10 inkblots. It is named for the Swiss psychiatrist who invented it.

SSRI medications —A group of antidepressants known as selective serotonin reuptake inhibitors.

Temperament —A person's natural or genetically determined disposition.

doctors have recognized that humans can continue to grow and change throughout life. Most patients with personality disorders are now considered to be treatable, although the degree of improvement may vary. The type of treatment recommended depends on the personality characteristics associated with the specific disorder.

Treatment

A number of treatments are available for patients with personality disorders. One of the newer treatments is the use of certain antidepressant medications such as the SSRI (selective serotonin reuptake inhibitors) antidepressants.

Hospitalization

Inpatient treatment is rarely required for patients with personality disorders, with two major exceptions: borderline patients who are threatening suicide or suffering from drug or alcohol withdrawal; and patients with paranoid personality disorder who are having psychotic symptoms.

Psychotherapy

Psychoanalytic psychotherapy is suggested for patients who can benefit from insight-oriented treatment. These patients typically include those with dependent, obsessive-compulsive, and avoidant personality disorders. Doctors usually recommend individual psychotherapy for narcissistic and borderline patients, but often refer these patients to therapists with specialized training in these disorders. Psychotherapeutic treatment for personality disorders may take as long as three to five years.

Insight-oriented approaches are not recommended for patients with paranoid or antisocial personality disorders. These patients are likely to resent the therapist and see him or her as trying to control or dominate them.

Supportive therapy is regarded as the most helpful form of psychotherapy for patients with schizoid personality disorder.

Cognitive-behavioral therapy

Cognitive-behavioral approaches are often recommended for patients with avoidant or dependent personality disorders. Patients in these groups typically have mistaken beliefs about their competence or likableness. These assumptions can be successfully challenged by cognitive-behavioral methods.

Group therapy

Group therapy is frequently useful for patients with schizoid or avoidant personality disorders because it helps them to break out of their social isolation. It has also been recommended for patients with histrionic and antisocial personality disorders. These patients tend to act out, and pressure from peers in group treatment can motivate them to change. Because patients with antisocial personality disorder can destabilize groups that include people with other disorders, it is usually best if these people meet exclusively with others with the same disorder (in "homogeneous" groups).

Family therapy

Family therapy may be suggested for patients whose personality disorders cause serious problems for members of their families. It is also sometimes recommended for borderline patients from overinvolved or possessive families.

Medications

Medications may be prescribed for patients with specific personality disorders. The type of medication depends on the disorder.

ANTIPSYCHOTIC DRUGS. Antipsychotic drugs , such as haloperidol (Haldol), may be given to patients with paranoid personality disorder if they are having brief psychotic episodes. Patients with borderline or schizotypal personality disorder are sometimes given antipsychotic drugs in low doses; however, the efficacy of these drugs in treating personality disorder is less clear than in schizophrenia.

MOOD STABILIZERS. Carbamazepine (Tegretol) is a drug that is commonly used to treat seizures, but is also helpful for borderline patients with rage outbursts and similar behavioral problems. Lithium and valproate may also be used as mood stabilizers, especially among people with borderline personality disorder.

ANTIDEPRESSANTS AND ANTI-ANXIETY MEDICATIONS. Medications in these categories are sometimes prescribed for patients with schizoid personality disorder to help them manage anxiety symptoms while they are in psychotherapy. Antidepressants are also commonly used to treat people with borderline personality disorder.

Treatment with medications is not recommended for patients with avoidant, histrionic, dependent, or narcissistic personality disorders. The use of potentially addictive medications should be avoided in people with borderline or antisocial personality disorders. However, some avoidant patients who also have social phobia may benefit from monoamine oxidase inhibitors (MAO inhibitors), a particular class of antidepressant.

Prognosis

The prognosis for recovery depends in part on the specific disorder and the existence of a mood disorder or coexisting psychiatric diagnosis. Although some patients improve as they grow older and have positive experiences in life, personality disorders are generally life-long disturbances with periods of worsening (exacerbations) and periods of improvement (remissions). Others, particularly schizoid patients, have better prognoses if they are given appropriate treatment. Patients with paranoid personality disorder are at some risk for developing delusional disorders or schizophrenia. The personality disorders with the poorest prognoses are the antisocial and the borderline. Borderline patients are at high risk for developing substance abuse disorders or bulimia. About 80% of hospitalized borderline patients attempt suicide at some point during treatment, and about 5% succeed in committing suicide.

Health care team roles

Nursing staff and allied health professionals can assist in the treatment of personality disorders by being aware of the symptoms of each cluster. Since personality disorders often present as relationship difficulties, nursing staff and allied health professionals may recognize personality disorders in particularly problematic patients.

During the treatment phase, nursing staff and allied health professionals can help patients by providing them with appropriate educational materials and referrals for ongoing psychotherapy or group therapy, if applicable.

Prevention

The most effective preventive strategy for personality disorders is early identification and treatment of children and adults who are at risk. High-risk groups include abused children, children from troubled families, children with close relatives diagnosed with personality disorders, children of substance abusers, and children who grow up in cults or political extremist groups.

Resources

BOOKS

Eisendrath, Stuart J. "Psychiatric Disorders." In Current Medical Diagnosis & Treatment 1998, edited by Lawrence M. Tierney Jr., et al. Stamford, CT: Appleton & Lange, 1997.

Mental Health Net. Personality Disorders. <http://personalitydisorders.mentalhelp.net> (2000).

"Personality Disorders." In Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: The American Psychiatric Association, 1994.

Bethanne Black

Personality Disorders

Definition

Personality disorders are a group of personality flaws defined by the fourth (1994) edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) as "enduring pattern[s] of inner experience and behavior" that are sufficiently rigid and deep-seated to bring a person into repeated conflicts with his or her social and occupational environment. DSM-IV specifies that these dysfunctional patterns must be regarded as non-conforming or deviant by the person's culture, and cause significant emotional pain and/or difficulties in relationships and occupational performance. In addition, the patient usually sees the disorder as being consistent with his or her self-image (ego-syntonic) and may blame others.

Description

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. But, in retrospect, many individuals with personality disorders could be judged to have shown evidence of the problems in childhood.

It is difficult to accurately estimate the percentage of the population that suffer from personality disorders. Patients with certain personality disorders, including antisocial and borderline disorders, are more likely to get into trouble with the law or other-wise 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 suffers from personality disorders, 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.

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.

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 other cultures 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 described below. Certain personality disorders, such as paranoid, schizoid, and schizotypal, should not be confused with psychotic disorders with the same or similar names. Psychotic disorders are characterized by more seriously disordered thinking, frequently involving hallucinations (seeing things that aren't present or hearing voices) and delusions (having unrealistic beliefs, such as thinking one has god-like powers), with an inability to distinguish reality from fantasy.

Paranoid

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

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.

Schizotypal

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) 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. There is some evidence that schizotypal personality disorder and the psychotic disorder, schizophrenia, are genetically related.

Antisocial

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.

Borderline

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 conflicting 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.

Histrionic

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

Narcissistic

Narcissistic patients are characterized by a sense of 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.

Avoidant

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

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.

Obsessive-compulsive

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.

Causes and symptoms

Personality disorders are thought to be a disparity between a child's temperament or character and his or her family or social relationships. Temperament can be defined as a person's innate or biologically shaped basic disposition. Human infants vary in their sensitivity to light or noise, their level of physical activity, their adaptability to schedules, and other aspects. Even traits such as "shyness" and "novelty-seeking" may be, at least in part, determined by the biology of the brain and the genes one inherits.

Character is defined as the set of attitudes and behavior patterns that the individual acquires or learns over time. It includes such personal qualities as work and study habits, moral convictions, neatness or cleanliness, and consideration of others. Since children must learn to adapt to their specific families, they may develop personality disorders in the course of struggling to survive psychologically in disturbed or stressful families. For example, nervous or high-strung parents might be unhappy with a baby who is very active and try to restrain him or her at every opportunity. The child might then develop an avoidant personality disorder as the outcome of coping with constant frustration and parental disapproval. As another example, child abuse is believed to play a role in shaping borderline personality disorder. One reason that some therapists use the term developmental damage instead of personality disorder is that it takes the presumed source of the person's problems into account.

Some patients with personality disorders come from families that appear to be stable and healthy. It has been suggested that these patients are biologically hypersensitive to normal family stress levels. Levels of the brain chemical (neurotransmitter) dopamine may influence a person's level of novelty-seeking, and serotonin levels may influence aggression.

Diagnosis

Diagnosis of personality disorders is complicated by the fact that persons suffering from them rarely seek help until they are in serious trouble or until their families (or the law) pressure them to get treatment. The reason for this slowness is that the problematic traits are so deeply entrenched that they seem normal (ego-syntonic) to the patient. Diagnosis of a personality disorder depends in part on the patient's age. Although personality disorders originate during the childhood years, they are considered to be adult disorders. Some patients, in fact, are not diagnosed until late in life because their symptoms had been modified by the demands of their job or by marriage. After retirement or the spouse's death, however, these patients' personality disorders become fully apparent. In general, however, if the onset of the patient's problem is in mid- or late-life, the doctor will rule out substance abuse or personality change caused by medical or neurological problems before considering the diagnosis of a personality disorder. It is unusual for people to develop personality disorders "out of the blue" in mid-life.

There are no tests that can provide a definitive diagnosis of personality disorder. Most doctors will evaluate a patient on the basis of several sources of information collected over a period of time in order to determine how long the patient has been having difficulties, how many areas of life are affected, and how severe the dysfunction is. These sources of information may include:

Interviews

The doctor may schedule two or three interviews with the patient, spaced over several weeks or months, in order to rule out an adjustment disorder caused by job loss, bereavement, or a similar problem. An office interview allows the doctor to form an impression of the patient's overall personality as well as obtain information about his or her occupation and family. During the interview, the doctor will note the patient's appearance, tone of voice, body language, eye contact, and other important non-verbal signals, as well as the content of the conversation. In some cases, the doctor may contact other people (family members, employers, close friends) who know the patient well in order to assess the accuracy of the patient's perception of his or her difficulties. It is quite common for people with personality disorders to have distorted views of their situations, or to be unaware of the impact of their behavior on others.

Psychological testing

Doctors use psychological testing to help in the diagnosis of a personality disorder. Most of these tests require interpretation by a professional with specialized training. Doctors usually refer patients to a clinical psychologist for this type of test.

PERSONALITY INVENTORIES. Personality inventories are tests with true/false or yes/no answers that can be used to compare the patient's scores with those of people with known personality distortions. The single most commonly used test of this type is the Minnesota Multiphasic Personality Inventory, or MMPI. Another test that is often used is the Millon Clinical Multiaxial Inventory, or MCMI.

PROJECTIVE TESTS. Projective tests are unstructured, meaning that instead of giving one-word answers to questions, the patient is asked to talk at some length about a picture that the psychologist presents, or to supply an ending for the beginning of a story. Projective tests allow the clinician to assess the patient's patterns of thinking, fantasies, worries or anxieties, moral concerns, values, and habits. Common projective tests include the Rorschach, in which the patient responds to a set of 10 inkblots; and the Thematic Apperception Test (TAT), in which the patient is shown drawings of people in different situations and then tells a story about the picture.

Prognosis

At one time psychiatrists thought that personality disorders did not respond very well to treatment. This opinion was derived from the notion that human personality is fixed for life once it has been molded in childhood, and from the belief among people with personality disorders that their own views and behaviors are correct, and that others are the ones at fault. More recently, however, doctors have recognized that humans can continue to grow and change throughout life. Most patients with personality disorders are now considered to be treatable, although the degree of improvement may vary. The type of treatment recommended depends on the personality characteristics associated with the specific disorder.

Treatment

A number of treatments are available for patients with personality disorders. One of the newer treatments is the use of certain antidepressant medications such as the SSRI (selective serotonin reuptake inhibitors) antidepressants.

Hospitalization

Inpatient treatment is rarely required for patients with personality disorders, with two major exceptions: borderline patients who are threatening suicide or suffering from drug or alcohol withdrawal; and patients with paranoid personality disorder who are having psychotic symptoms.

Psychotherapy

Psychoanalytic psychotherapy is suggested for patients who can benefit from insight-oriented treatment. These patients typically include those with dependent, obsessive-compulsive, and avoidant personality disorders. Doctors usually recommend individual psychotherapy for narcissistic and borderline patients, but often refer these patients to therapists with specialized training in these disorders. Psychotherapeutic treatment for personality disorders may take as long as three to five years.

Insight-oriented approaches are not recommended for patients with paranoid or antisocial personality disorders. These patients are likely to resent the therapist and see him or her as trying to control or dominate them.

Supportive therapy is regarded as the most helpful form of psychotherapy for patients with schizoid personality disorder.

Cognitive-behavioral therapy

Cognitive-behavioral approaches are often recommended for patients with avoidant or dependent personality disorders. Patients in these groups typically have mistaken beliefs about their competence or likableness. These assumptions can be successfully challenged by cognitive-behavioral methods.

Group therapy

Group therapy is frequently useful for patients with schizoid or avoidant personality disorders because it helps them to break out of their social isolation. It has also been recommended for patients with histrionic and antisocial personality disorders. These patients tend to act out, and pressure from peers in group treatment can motivate them to change. Because patients with antisocial personality disorder can destabilize groups that include people with other disorders, it is usually best if these people meet exclusively with others with the same disorder (in "homogeneous" groups).

Family therapy

Family therapy may be suggested for patients whose personality disorders cause serious problems for members of their families. It is also sometimes recommended for borderline patients from overinvolved or possessive families.

Medications

Medications may be prescribed for patients with specific personality disorders. The type of medication depends on the disorder.

ANTIPSYCHOTIC DRUGS. Antipsychotic drugs, such as haloperidol (Haldol), may be given to patients with paranoid personality disorder if they are having brief psychotic episodes. Patients with borderline or schizotypal personality disorder are sometimes given antipsychotic drugs in low doses; however, the efficacy of these drugs in treating personality disorder is less clear than in schizophrenia.

MOOD STABILIZERS. Carbamazepine (Tegretol) is a drug that is commonly used to treat seizures, but is also helpful for borderline patients with rage outbursts and similar behavioral problems. Lithium and valproate may also be used as mood stabilizers, especially among people with borderline personality disorder.

ANTIDEPRESSANTS AND ANTI-ANXIETY MEDICATIONS. Medications in these categories are sometimes prescribed for patients with schizoid personality disorder to help them manage anxiety symptoms while they are in psychotherapy. Antidepressants are also commonly used to treat people with border-line personality disorder.

Treatment with medications is not recommended for patients with avoidant, histrionic, dependent, or narcissistic personality disorders. The use of potentially addictive medications should be avoided in people with borderline or antisocial personality disorders. However, some avoidant patients who also have social phobia may benefit from monoamine oxidase inhibitors (MAO inhibitors), a particular class of antidepressant.

Prognosis

The prognosis for recovery depends in part on the specific disorder and the existence of a mood disorder or coexisting psychiatric diagnosis. Although some patients improve as they grow older and have positive experiences in life, personality disorders are generally life-long disturbances with periods of worsening (exacerbations) and periods of improvement (remissions). Others, particularly schizoid patients, have better prognoses if they are given appropriate treatment. Patients with paranoid personality disorder are at some risk for developing delusional disorders or schizophrenia. The personality disorders with the poorest prognoses are the antisocial and the borderline. Borderline patients are at high risk for developing substance abuse disorders or bulimia. About 80% of hospitalized borderline patients attempt suicide at some point during treatment, and about 5% succeed in committing suicide.

Health care team roles

Nursing staff and allied health professionals can assist in the treatment of personality disorders by being aware of the symptoms of each cluster. Since personality disorders often present as relationship difficulties, nursing staff and allied health professionals may recognize personality disorders in particularly problematic patients.

During the treatment phase, nursing staff and allied health professionals can help patients by providing them with appropriate educational materials and referrals for ongoing psychotherapy or group therapy, if applicable.

Prevention

The most effective preventive strategy for personality disorders is early identification and treatment of children and adults who are at risk. High-risk groups include abused children, children from troubled families, children with close relatives diagnosed with personality disorders, children of substance abusers, and children who grow up in cults or political extremist groups.

KEY TERMS

Character— An individual's set of emotional, cognitive, and behavioral patterns learned and accumulated over time.

Character disorder— Another name for personality disorder.

Developmental damage— A term that some therapists prefer to personality disorder, on the grounds that it is more respectful of the patient's capacity for growth and change.

Ego-syntonic— Consistent with one's sense of self, as opposed to ego-alien or dystonic (foreign to one's sense of self). Ego-syntonic traits typify patients with personality disorders.

Neuroleptic— Another name for older antipsychotic medications, such as haloperidol. The term does not apply to newer "atypical" agents, such as clozapine (Clozaril).

Personality— The organized pattern of behaviors and attitudes that makes a human being distinctive. Personality is formed by the ongoing interaction of temperament, character, and environment.

Projective tests— Psychological tests that probe into personality by obtaining open-ended responses to such materials as pictures or stories. Projective tests are often used to evaluate patients with personality disorders.

Rorschach— A well-known projective test that requires the patient to describe what he or she sees in each of 10 inkblots. It is named for the Swiss psychiatrist who invented it.

SSRI medications— A group of antidepressants known as selective serotonin reuptake inhibitors.

Temperament— A person's natural or genetically determined disposition.

Resources

BOOKS

Eisendrath, Stuart J. "Psychiatric Disorders." In Current Medical Diagnosis & Treatment 1998, edited by Lawrence M. Tierney Jr., et al. Stamford, CT: Appleton & Lange, 1997.

"Personality Disorders." In Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Washington, DC: The American Psychiatric Association, 1994.

OTHER

Mental Health Net. Personality Disorders. 〈http://personalitydisorders.mentalhelp.net〉 (2000).

Personality disorders

Definition

Personality disorders (PD) are a group of psychiatric conditions characterized by experience and behavior patterns that cause serious problems with respect to any two of the following: thinking, mood, personal relations, and the control of impulses.

Description

Most personality disorders are associated with problems in personal development and character which peak during adolescence and are then defined as personality disorders. Children and adolescents with a personality disorder have great difficulty dealing with others. They tend to be inflexible, rigid, with inadequate response to the changes and demands of life. They have a narrow view of the world and find it hard to participate in social activities. There are many formally identified personality disorders, each with its own types of associated behaviors. Most PDs, however, fall into three distinct categories or clusters, namely: cluster A, which includes disorders characterized by odd or eccentric behavior; cluster B, which includes disorders marked by dramatic, emotional or erratic behavior; and cluster C, which includes disorders accompanied by anxious and fearful behavior. The most common disorders in each cluster are given below.

Cluster A disorders

These disorders include the following:

• Schizoid personality disorder. Schizoid personalities are introverted, withdrawn, solitary, emotionally cold, and distant. Often absorbed with their own thoughts and feelings, they fear closeness and intimacy with others. People suffering from schizoid personality tend to be more daydreamers than practical action takers, often living "in a world of their own."
• Paranoid personality disorder. Paranoid personalities interpret the actions of others as deliberately threatening or demeaning. People with paranoid personality disorder are untrusting, unforgiving, and often resort to angry or aggressive outbursts without justification because they see others as unfaithful, disloyal, or dishonest. Paranoid personalities are often jealous, guarded, secretive, and scheming, and may appear to be emotionally "cold" or excessively serious.
• Schizotypal personality disorder. Schizotypal personalities tend to have odd or eccentric manners of speaking or dressing. They often have strange, outlandish, or paranoid beliefs and thoughts. People with schizotypal personality disorder have difficulties bonding with others and experience extreme anxiety in social situations. They tend to react inappropriately or not react at all during a conversation, or they may talk to themselves. They also have delusions characterized by "magical thinking," for example, by saying that they can foretell the future or read other people's minds.

Cluster B disorders

Cluster B disorders include the following:

• Antisocial personality disorder . Antisocial personalities typically ignore the normal rules of social behavior. These individuals are impulsive, irresponsible, and callous. They often have a history of violent and irresponsible behavior, aggressive and even violent relationships. They have no respect for other people and feel no remorse about the effects of their behavior on others. Antisocial personalities are at high risk for substance abuse, since it helps them to relieve tension, irritability, and boredom.
• Borderline personality disorder. Borderline personalities are unstable in interpersonal relationships, behavior, mood, and self-image. They are prone to sudden and extreme mood changes, stormy relationships, unpredictable and often self-destructive behavior. These personalities have great difficulty with their own sense of identity and often experience the world in extremes, viewing experiences and others as either "black" or "white." They often form intense personal attachments only to quickly dissolve them over a perceived offense. Fears of abandonment and rejection often lead to an excessive dependency on others. Self-mutilation or suicidal threats may be used to get attention or manipulate others. Impulsive actions, persistent feelings of boredom or emptiness, and intense anger outbursts are other traits of this disorder.
• Narcissistic personality disorder. Narcissistic personalities tend to have an exaggerated sense of self-importance, and are absorbed by fantasies of unlimited success. They also seek constant attention, and are oversensitive to failure, often complaining about multiple physical disorders. They also tend to be prone to extreme mood swings between self-admiration and insecurity, and tend to exploit interpersonal relationships.

Cluster C disorders

Cluster C disorders include the following:

• Avoidant personality disorder. Avoidant personalities are often fearful of rejection and unwilling to become involved with others. They are characterized by excessive social discomfort, shyness , fear of criticism, and avoidance of social activities that involve interpersonal contact. They are afraid of saying something considered foolish by others and are deeply hurt by any disapproval from others. They tend to have no close relationships outside the family circle and are upset at their inability to form meaningful relationships.
• Dependent personality disorder . As the name implies, dependent personalities exhibit a pattern of dependent and submissive behavior, relying on others to make decisions for them. They fear rejection, need constant reassurance and advice, and are oversensitive to criticism or disapproval. They feel uncomfortable and helpless if they are alone and can be devastated when a close relationship ends. Typically lacking in self-confidence, the dependent personality rarely initiates projects or does things independently.
• Compulsive personality disorder. Compulsive personalities are conscientious, reliable, dependable, orderly, and methodical, but with an inflexibility that often makes them incapable of adapting to changing circumstances. They have such high standards of achievement that they constantly strive for perfection. Never satisfied with their performance or with that of others, they take on more and more responsibilities. They also pay excessive attention to detail, which makes it very hard for them to make decisions and complete tasks. When their feelings are not under strict control, when events are unpredictable, or when they must rely on others, compulsive personalities often feel a sense of isolation and helplessness.

Demographics

In 2001 to 2002, fully 16.4 million Americans (7.9% of all adults) had obsessive-compulsive personality disorder; 9.2 million (4.4%) had paranoid personality disorder; 7.6 million (3.6%) had antisocial personality disorder; 6.5 million (3.1%) had schizoid personality disorder; 4.9 million (2.4%) had avoidant personality disorder; and 1.0 million (0.5%) had dependent personality disorder. According to the National Institutes of Health, nearly 31 million Americans meet criteria for at least one personality disorder. A 2004 survey showed that nearly 14.8 percent of adult Americans met diagnostic criteria for personality disorders as defined by the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders. The risk of having avoidant, dependent, and paranoid personality disorders is greater for females than males, whereas risk of having antisocial personality disorder is greater for males than females. There are no gender differences in the risk of having compulsive or schizoid personality disorders. In general, other risk factors contributing to the emergence of personality disorders include being Native American or African American; being a young adult; having a low socioeconomic status; and having any other status than married.

Causes and symptoms

The exact cause of personality disorders is unknown. However, evidence points to genetic and environmental factors such as a history of personality disorders in the family. Some experts believe that traumatic events occurring in early childhood exert a crucial influence upon behavior later in life. Others propose that people are genetically predisposed to personality disorders or that they have an underlying biological disturbance (anatomical, electrical, or neurochemical).

Symptoms vary widely depending on the specific type of PD, but according to the American Psychiatric Association, individuals with personality disorders have most of the following symptoms in common:

• self-centeredness that manifests itself through a "me-first," self-preoccupied attitude
• lack of individual accountability that results in a "victim mentality" and blaming others for their problems
• lack of empathy and caring
• manipulative and exploitative behavior
• unhappiness, suffering from depression, and other mood and anxiety disorders
• vulnerability to other mental disorders
• distorted or superficial understanding of self and others' perceptions that results in being unable to see how objectionable, unacceptable, and disagreeable their behavior is
• self-destructive behavior
• socially maladaptive, changing the "rules of the game," or otherwise influencing the external world to conform to their own needs

When to call the doctor

An appointment should be made with a healthcare provider or a mental health professional if a child has persistent symptoms of a personality disorder. Parents are often concerned about their child's emotional health or behavior, but they do not know where to start to get help. The mental health system can also be complicated and difficult for parents to understand. When worried about their child's behavior, parents can start by talking to the child's pediatrician or family physician about their concerns. Personality disorders require treatment and parents should try to find a mental health professional with advanced training and experience with children, adolescents, and families. Parents should always ask about the professional's training and experience. It is also very important to find a good match between child, family, and the mental health professional.

Diagnosis

The character of a person is shown through his or her personality, by the way the person thinks, feels, and behaves. When the behavior is inflexible, maladaptive, and antisocial, then that individual is diagnosed with a personality disorder. Personality disorders are diagnosed following a psychological evaluation that records the history and severity of the symptoms. A personality disorder must fulfill several criteria. A deeply ingrained, inflexible pattern of relating, perceiving, and thinking that is serious enough to cause distress or impaired functioning defines a personality disorder. Personality disorders are usually recognizable by adolescence or earlier, continue throughout adulthood, and become less obvious in middle age.

Treatment

There are many types of help available for the different personality disorders. Treatment may include individual, group, or family psychotherapy. Medications, prescribed by a patient's physician, may also be helpful in relieving some of the symptoms of personality disorders, such as problems with anxiety and delusions. Psychotherapy is a form of treatment designed to help children and families understand and resolve the problems due to PD and modify the inappropriate behavior. In some cases a combination of medication with psychotherapy may be more effective. PD psychotherapy focuses on helping patients see the unconscious conflicts that are causing their disorder. It also helps them become more flexible and is aimed at reducing the behavior patterns that interfere with everyday living. In psychotherapy, patients have the opportunity to learn to recognize the effects of their behavior on others. The different types of psychotherapies available to children and adolescents include the following:

• Cognitive behavior therapy (CBT). CBT is focused on improving a child's moods and behavior by examining confused or distorted patterns of thinking. With CBT, the child learns that thoughts cause feelings and moods that can influence behavior. For example, if a child has problematic behavior patterns, the therapist seeks to identify the underlying thinking that is causing them. The therapist then helps the child replace this thinking with thoughts that result in more appropriate feelings and behaviors.
• Dialectical behavior therapy (DBT). DBT is used to treat older adolescents with suicidal thoughts or who intentionally engage in self-destructive behavior or who have borderline personality disorder. DBT teaches how to take responsibility for one's problems and how to deal with conflict and negative feelings. DBT often involves a combination of group and individual sessions.
• Family therapy . This therapy approach is designed to help the family unit function in more positive and constructive ways by exploring patterns of communication and providing support and education. Family therapy sessions can include the child or adolescent along with parents and siblings.
• Group therapy (GT). GT uses group dynamics and peer interactions to increase understanding, communication, and improve social skills.
• Play therapy. This type of therapy is directed at helping younger children. It involves the use of toys , blocks, dolls, puppets, drawings , and games to help the child recognize, identify, and verbalize feelings. The psychotherapist observes how the child uses play materials and identifies themes or patterns to understand the child's problems. Through a combination of talk and play the child has an opportunity to better understand conflicts, feelings, and behavior.

Alternative treatment

Alternative treatments are available for personality disorders and most are complementary to conventional psychotherapy. They include the following:

• Coloring therapy. CT uses the activity of coloring as a self-help medium. While a person colors (with felt tipped markers, colored pens, pencils, etc.) a state of consciousness similar to meditation occurs. The approach is based on how people speak to themselves on the "inside." During a coloring session, people are asked to listen to the thoughts going on in their minds so as to become aware of where their thoughts, feelings, and opinions come from.
• Creative arts therapies. These therapies include art therapy, dance/movement therapy, drama therapy, music therapy, poetry therapy, and psychodrama. They use arts and creative processes to promote health, communication, and expression; they encourage the integration of physical, emotional, cognitive, and social functioning while enhancing self-awareness and facilitating change.
• Neurolinguistic programming. NLP is a method of examining the way a person thinks and acts through language and using this knowledge to effect change.

Nutritional concerns

The notion that foods and nutrients influence brain function and behavior generated in the early 2000s widespread interest in the general public and in the scientific community. However, the evaluation data are still ambiguous when it comes to establishing a direct link between personality disorders and diet, aside from recommending the avoidance of alcoholic and stimulant beverages.

Prognosis

The PD outlook varies. Some personality disorders diminish during middle age without any treatment, while others persist throughout life despite treatment.

Prevention

The prevention of personality disorders is an area surrounded with pessimism and controversy. Many mental health specialists believe that these disorders are untreatable, that individuals with personality disorder have little capacity for change; therefore not surprisingly, they remain skeptical about prevention prospects. However, even though the innate temperament of a person cannot be modified, understanding the factors that influence the development of personality disorders (such as genetic risks and environmental factors) may help prevention. Accordingly, some mental health professionals advocate primary prevention steps, which should include education of parents and primary healthcare workers, as well as early psychotherapy and protection of traumatized children, which can be carried out by child developing services. Some evidence suggests that traditional doctor-patient relationships are of much less value than programs which enable parents to see their own role as crucial and their own actions as able to bring changes for the better in their child's behavior. High quality parenting plays a critical role in child development and, thus, in the prevention of personality disorders.

Parental concerns

Understanding personality disorders can be challenging for parents as well as for children. During the last third of the twentieth century, great advances were made in the areas of diagnosis and treatment of personality disorders. Parents can help children understand that these are real illnesses that can be treated. In order for parents to talk with a child about a personality disorder, they must be knowledgeable of the subject. Parents may have to do some homework to become better informed. They should have a basic understanding and answers to questions such as what are personality disorders, who gets them, what causes them, how are diagnoses made, and what treatments are available. When explaining to a child about how personality disorders affect a person, it may be helpful to explain that feelings of anxiety, worry, and irritability are common for most people. However, when these feelings get very intense, last for a long period of time, and begin to interfere with school and relationships, it may be a sign of a personality disorder that can, however, be treated.

A child's personality disorder often causes disruption to both the parents' and the child's world. Parents may have difficulty being objective. They may blame themselves or worry that others such as teachers or family members will blame them. Recognizing these feelings and seeking the help of professional care providers and support groups is the best way to cope with this issue.

Medication can also be an effective part of the treatment for several personality disorders in childhood and adolescence. A doctor's recommendation to use medication often raises many concerns and questions in both the parents and the child. The physician who recommends medication should be experienced in treating psychiatric illnesses in children and adolescents. He or she should fully explain the reasons for medication use, what benefits the medication should provide, as well as the possible negative side-effects or dangers and other treatment alternatives.

KEY TERMS

Anxiety —Worry or tension in response to real or imagined stress, danger, or dreaded situations. Physical reactions, such as fast pulse, sweating, trembling, fatigue, and weakness, may accompany anxiety.

Caring —The demonstration of an awareness of and a concern for the good of others.

Character —An individual's set of emotional, cognitive, and behavioral patterns learned and accumulated over time.

Delusion —A belief that is resistant to reason or contrary to actual fact. Common delusions include delusions of persecution, delusions about one's importance (sometimes called delusions of grandeur), or delusions of being controlled by others.

Eccentric —Deviating from the center; conduct and behavior departing from accepted norms and conventions.

Empathy —A quality of the client-centered therapist, characterized by the therapist s conveying appreciation and understanding of the client's point of view.

Erratic —Having no fixed course; behavior that deviates from common and accepted opinions.

Introversion —A personal preference for solitary, non-social activities and settings.

Maladaptive —Unsuitable or counterproductive; for example, maladaptive behavior is behavior that is inappropriate to a given situation.

Personality —The organized pattern of behaviors and attitudes that makes a human being distinctive. Personality is formed by the ongoing interaction of temperament, character, and environment.

Substance abuse —Maladaptive pattern of drug or alcohol use that may lead to social, occupational, psychological, or physical problems.

Temperament —A person's natural disposition or inborn combination of mental and emotional traits.

See also Antisocial behavior; Antisocial personality disorder; Anxiety.

Resources

BOOKS

Moskovitz, Richard, A. Lost in the Mirror: An Inside Look at Borderline Personality Disorder. Lanham, MD: Taylor Trade Publishing, 2001.

Kantor, Martin. Distancing: Avoidant Personality Disorder. Westport, CT: Praeger Publishers, 2003.

PERIODICALS

Chiesa, M. et al. "Residential versus community treatment of personality disorders: a comparative study of three treatment programs." American Journal of Psychiatry 161, no. 8 (August, 2004): 1463–70.

Gothelf, D., et al. "Life events and personality factors in children and adolescents with obsessive-compulsive disorder and other anxiety disorders." Comprehensive Psychiatry 45, no. 3 (May-June, 2004): 192–98.

Haugaard, J. J. "Recognizing and treating uncommon behavioral and emotional disorders in children and adolescents who have been severely maltreated: borderline personality disorder." Child Maltreatment 9, no. 2 (May, 2004): 139–45.

Krueger, R. F., and S. R. Carlson. "Personality disorders in children and adolescents." Current Psychiatry Reports 3, no. 1 (February, 2001): 46–51.

ORGANIZATIONS

American Academy of Child & Adolescent Psychiatry (AACAP). 3615 Wisconsin Ave., NW, Washington, DC 20016–3007. Web site: <www.aacap.org>.

American Psychiatric Association. 1000 Wilson Boulevard, Suite 1825, Arlington, Va. 22209–3901. Web site: <www.psych.org>.

Federation of Families for Children's Mental Health. 1101 King Street, Suite 420, Alexandria, VA 22314. Web site: <www.ffcmh.org>.

National Mental Health Association (NMHA). 2001 N. Beauregard Street, 12th Floor, Alexandria, VA 22311. Web site: <www.nmha.org>.

WEB SITES

Lebelle, Linda. "Personality Disorders." Focus Adolescent Services. Available online at <www.focusas.com/PersonalityDisorders.html> (accessed October 13, 2004).

Monique Laberge, Ph.D.

Personality Disorders

Definition

The Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV), defines a personality disorder as “an enduring pattern of inner experience and behavior that differs markedly from the expectations of the individual's culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment.” Personality disorders represent long-standing and maladaptive patterns of perceiving and responding to other people and to stressful circumstances.

Description

DSM-IV defines 10 personality disorders, grouped into three clusters, plus an eleventh, Personality disorder not otherwise specified (PDNOS).

Cluster A disorders

People diagnosed with personality disorders in Cluster A are characterized by odd or eccentric behavior.

The three personality disorders in this cluster are:

• Paranoid personality disorder (PPD). People with this disorder are frankly suspicious and distrustful of others. They may think that others are “out to get them,” plotting behind their backs, or deceiving or manipulating them in some way. They have a recurrent pattern of interpreting the behavior of others as hostile or malicious.
• Schizoid personality disorder. People with this type of personality disorder are seen by others as cold and aloof, uninterested in close relationships, and socially isolated.
• Schizotypal personality disorder. People with schizotypal personality disorder have strange beliefs and hallucinations or other disturbances of perception. They may dress in a peculiar or highly individualistic fashion. They often display magical thinking (the notion that their words or thoughts can affect the outside world) or ideas of reference (the notion that people in their vicinity are talking about them, or that events in the outside world have been arranged or contrived to send them a personal message).

Cluster B disorders

People diagnosed with Cluster B personality disorders behave in exaggerated, dramatic, and highly emotional ways.

There are four personality disorders in Cluster B:

• Antisocial personality disorder. People with antisocial personality disorder act out their emotions and ignore the usual rules of social behavior. They are typically aggressive, angry, and irresponsible, and often have a long history of arrests, imprisonment, or other legal problems. They are at high risk of alcoholism and substance abuse because they use alcohol and drugs to relieve boredom or angry feelings.
• Borderline personality disorder (BPD). BPD is considered a major mental health problem as of the early 2000s because of its impact on family members, teachers, employers, and others involved with people with this disorder. People with BPD are extremely unstable, alternating between clinging to other people and pushing them away. They have problems with a sense of personal identity, and typically view the world in stark all-or-nothing terms; people are either all good or totally evil. Common symptoms of BPD include recurrent suicide threats or attempts, self-mutilation (cutting), temper tantrums, sexual promiscuity, and other impulsive actions.
• Histrionic personality disorder. People with histrionic personality disorder are “drama queens,” seeking attention from others through displays of emotionality or dramatic gestures. They are often sexually seductive or provocative. The term histrionic comes from the Latin word for actor.
• Narcissistic personality disorder (NPD). People with NPD are characteristically grandiose, arrogant, have a strong sense of entitlement, demand constant admiration from others, and take what they want from others without any sense of reciprocity or empathy. Unlike those with other personality disorders, however, people with NPD may be quite successful in business, politics, or professional life.

Cluster C disorders

People with these personality disorders are typically anxious and fearful.

There are three personality disorders in Cluster C:

• Avoidant personality disorder. People with avoidant personality disorder are extremely fearful of rejection or criticism and will typically avoid social events or relationships unless they are sure they will be liked and accepted. Unlike people with schizoid personality disorder, people with avoidant personality disorder would like to have relationships but are paralyzed by their anxiety and low self-esteem.
• Dependent personality disorder. People with dependent personality disorder have an excessive need to be taken care of and often exhibit clinging or submissive behavior. They typically have difficulty making decisions for themselves or disagreeing with others, want others to take responsibility for most areas in their lives, and are extremely afraid of being alone or having to fend for themselves.
• Obsessive-compulsive personality disorder. People with this type of personality disorder are often workaholics and may do quite well in occupations that call for attention to detail or following standard methods and procedures. They are conscientious, dependable, and thorough, but are often perfectionistic, may take on more responsibilities than they can handle, and often find it hard to complete tasks because they are overly concerned with details. They are also often stingy, moralistic, and stubborn.

Demographics

The demographics of personality disorders in seniors are difficult to assess for several reasons. First, the category itself is relatively new; in the 1950s and early 1960s, these disorders were referred to as character disorders, and defined as “patterns of behavior and emotional response that are socially disapproved or unacceptable, with little evidence of anxiety or other symptoms seen in neuroses.” They were called “character” disorders to distinguish them from issues of temperament, which refers to the genetically or biologically based dimension of personality. Beginning in the 1950s, such researchers as Alexander Thomas and Stella Chess studied children in order to discover how temperament affected their social and psychological adjustment in later life. They identified nine factors, ranging from activity level and regularity of eating and sleeping patterns to attention span and intensity of emotion, which they analyzed as influential in shaping children's relationships with other family members, adjustment to school, and other milestones throughout the lifespan. In contrast to temperament, which is innate, character is defined as the set of qualities, behavior patterns, or traits that a person develops in the course of interacting with family members and the outside world. The term “character disorder” was then coined to describe problematic patterns of interaction that seemed normal or natural to the individuals who had them.

Second, the list of disturbances now called personality disorders has changed from one edition of the DSM to the next. The present list of ten is neither long-standing nor universally accepted. In addition, many of the DSM criteria overlap, so that a person can be diagnosed with more than one personality disorder. Moreover, most people who meet the criteria for a personality disorder also meet criteria for one or more anxiety disorders, mood disorders, eating disorders, substance abuse disorders, or post-traumatic syndromes, which adds to the complications of obtaining reliable demographic statistics.

Third, DSM-IV criteria for personality disorders were derived from studies of disturbed young and middle-aged adults in the 1980s and 1990s, not from studies of seniors. The reason why this factor is significant is that the demographics of mental disorders have changed over the years because of broad-based cultural changes. Many of the disorders that Freud wrote about in the 1880s and 1890s are now unusual, while some others are much more commonplace. People who are 75 or older as of the early 2000s grew up in a much different society from that which shaped baby boomers or later generations; it is therefore highly unlikely that demographic statistics for personality disorders in the general American population in the early 2000s would hold true for older seniors.

Fourth, it is difficult to sort out which changes in a senior's personality are the result of a personality disorder and which are simply side effects, so to speak, of aging. An example would be the increased cautiousness that many seniors display as they grow older. Although some seniors may indeed meet the criteria for paranoid personality disorder, it would be a mistake to assume that any older adult who becomes less trusting or more careful of strangers as they get older is necessarily developing PPD. What is known as of the early 2000s is that personality disorders emerge in late adolescence or the early adult years; they rarely develop for the first time in adults over 40, and they often moderate by middle age. A senior who seems to be undergoing rapid changes in personality should be evaluated for an organic brain disorder or depression or anxiety before being evaluated for a personality disorder.

Fifth, some personality disorders as defined by DSM-IV are underrepresented among seniors because those who suffer from them are more likely to die at relatively early ages from suicide , substance abuse, reckless driving, or other self-destructive behaviors.

According to DSM-IV, between 10 and 15 percent of the general adult population in the United States is affected by personality disorders. The distribution of specific personality disorders in the general population is estimated to be:

• Paranoid: Between 0.5 and 2.5 percent of adults.
• Schizoid: Less than 1 percent; slightly more common in men than in women.
• Schizotypal: About 3 percent.
• Antisocial: 1 percent of women, 3 percent of men.
• Borderline: 2 percent; 75 percent of these are women.
• Histrionic: 2–3 percent. l Narcissistic: 1 percent; 50–75 percent of these are men.
• Avoidant: Between 0.5 and 1 percent.
• Dependent: About 2 percent, possibly less.
• Obsessive-compulsive: About 1 percent; 67 percent of these are men.

Causes and symptoms

At one time personality disorders were thought to be almost entirely the result of childhood trauma. Researchers in the early 2000s think, however, that these disorders are better understood as resulting from a combination of genetic or temperamental vulnerability and dysfunctional parenting or other early traumatic experiences.

Personality disorders affect several different dimensions of a person's functioning, and specific symptoms appear in one or more of these areas:

• Cognition (thinking). People with personality disorders understand or interpret themselves, other people, and events in distorted or narrow ways.
• Affect (feelings). People with personality disorders run to emotional extremes, have wide emotional swings within brief periods of time, experience emotions that are inappropriate to the immediate circumstances (such as laughing at a funeral), or express emotions inappropriately.
• Interpersonal functioning. People with personality disorders have a longstanding history of serious difficulties in school, the workplace, or family life because they do not get along well with others. They may have a history of school failure, being fired from one job after another, changing occupations frequently, having a number of short-term unsuccessful relationships, or being estranged from their family.
• Problems with impulse control. These may appear in regard to drugs, alcohol, food, money (gambling and compulsive spending), sex, or anger.

Diagnosis The diagnosis of a personality disorder is made on the basis of a psychiatric interview. It is unusual, however, for adults with personality disorders to seek help on their own initiative because they regard their thought patterns and behaviors as normal and natural; they typically fail to see the effects of their behavior on others or the part they play in causing problems with others. In some cases an older adult with a personality disorder may be brought for an evaluation by friends or family members who have been distressed for some time by the senior's attitudes or actions. People with BPD or NPD are particularly likely to be brought for treatment by family members because their behaviors (suicide threats or attempts, substance abuse, exploitativeness, reckless driving, arrogance and lack of empathy, etc.) can cause severe emotional, financial, or legal problems for others around them.

In other cases the senior's primary care physician may detect indications of a personality disorder in his or her interactions with the senior, as many “difficult patients” in family practice have personality disorders. Common signs of personality disorders in the doctor's office include behavior that is inappropriate to the situation (hostile, seductive, overly friendly, etc.); unrealistic expectations of the doctor or excessive demands on his or her time; and refusal to comply with medical treatment.

There may be physical evidence that the senior is abusing alcohol or other substances, or has scars from a failed suicide attempt, but otherwise there are no physical symptoms associated with any of the personality disorders as such.

In most cases the primary care physician will give the senior a mental status examination to check for dementia and refer the senior to a psychiatrist for more detailed evaluation. If the psychiatrist thinks that a personality disorder would explain the senior's symptoms more adequately than a mood or anxiety disorder, he or she may administer one or more questionnaires designed to identify personality disorders. The tests most widely used are the International Personality Disorder Examination (IPDE), first published in 1994, and the Millon Clinical Multiaxial Inventory-III (MCMI-III), first used in 1995. The IPDE takes about an hour and a half to administer and the MCMI-III takes about half an hour. Other tests that may be given are the Minnesota Multiphasic Personality Inventory (MMPI) and the Eysenck Personality Inventory.

Treatment

Treatment of personality disorders is usually a combination of psychotherapy and medications. Psychotherapy is the core of treatment for personality disorders. The approaches most often used are psychodynamic psychotherapy and cognitive behavioral therapy (CBT). Psychodynamic psychotherapy is insight-oriented; the patient explores his or her history in order to identify the sources of his or her perceptual and cognitive distortions and to correct them through feedback from the therapist. The patient also learns more adaptive behaviors and responses to other people. Treatment usually lasts several years at a frequency from several times a week to once a month.

A cognitive behavioral approach to personality disorders is based on the notion that cognitive errors rooted in longstanding beliefs influence and distort the patient's perceptions of and reactions to others. It is aimed at identifying the distortions and helping the patient develop more appropriate behaviors. Patients are often given homework assignments to complete between sessions, such as keeping a diary of their dysfunctional thoughts and how they handled them. CBT is typically shorter than psychodynamic therapy; the usual pattern is weekly appointments over a period of 6 to 20 weeks. Patients with personality disorders may require several courses of CBT therapy spaced over several years, or occasional booster sessions when under stress .

QUESTIONS TO ASK YOUR DOCTOR

• Does the older person in my life have a personality disorder?
• What should I know about his or her condition?
• How is it treated?
• How can I help with his or her treatment?
• Will I need professional help or advice in coping with this disorder?

Group psychotherapy is sometimes recommended for patients with personality disorders in that they can receive feedback from other group members as well as the therapist. Family therapy is often recommended for families coping with a member with BPD or NPD, as these particular personality disorders frequently cause serious problems for care givers and other family members.

Medications are given sparingly, and usually only to treat depression or anxiety that the senior may be experiencing as a result of the personality disorder. There are no drugs as of the early 2000s that can cure personality disorders. The drugs most commonly given are the selective serotonin reuptake inhibitors (SSRIs) rather than the tricyclic antidepressants (TCAs), because the poor impulse control of many patients with personality disorders increases the risk of an intentional overdose; such drugs as fluoxetine (Prozac) and sertraline (Zoloft) are safer than the TCAs. Because of the additional risk of interactions with drugs that the senior may be taking for other conditions, antidepressants are given for as short a period of time as possible.

Nutrition/Dietetic concerns

Nutritional concerns are not usually prominent in personality disorders unless the patient is abusing alcohol or other drugs or has a concurrent eating disorder. In that case the senior may be referred to a dietitian for advice about nutrition or a diet plan.

KEY TERMS

Character disorder —An older term for what are now called personality disorders.

Ideas of reference —The notion that irrelevant or unrelated events are related to the self in a special way. An example would be the thought that a radio announcer is talking directly to or about oneself, or that a small group of people at a large party who are laughing about a joke are laughing specifically at oneself.

Magical thinking —Thinking that one's words or thoughts can affect the external world. An example would be the notion that being angry with someone will cause them to die.

Temperament —The dimension of an individual's personality that is rooted in genetic or biological factors.

Therapy

Therapy for personality disorders is primarily psychotherapy, with medications as needed.

Prognosis

The prognosis for recovery from a personality disorder depends on the specific disorder, the coexistence of other mental disorders or chronic physical illnesses, the availability of family and social support, and the senior's cognitive status. Since psychotherapy for personality disorders relies heavily on cognitive and insight-oriented approaches, a senior in the early stages of cognitive decline is unlikely to benefit from these techniques.

Prevention

The only known preventive for personality disorders is adequate parenting in childhood combined with lack of exposure to overwhelming traumatic experiences at an early age.

Caregiver concerns

Caregiver concerns for a senior with a personality disorder include making sure the senior is compliant with his or her treatment, including attending therapy sessions and taking medications as directed by the doctor. Care givers of seniors with borderline or narcissistic personality disorder should seek professional advice on coping with the stresses and disruptions these disorders are likely to cause in their own lives. In addition, they should be on the lookout for indications of suicidal thinking in seniors with these disorders. Older people with NPD are at increased risk of suicide as they age, even if they have been highly successful in their earlier years, because they see the aging process as a blow to their sense of superiority and perfection.

Resources

BOOKS

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th edition, text revision. Washington, DC: American Psychiatric Association, 2000.

Beck, Aaron T., Arthur Freeman, and Denise D. Davis. Cognitive Therapy of Personality Disorders, 2nd ed. New York: Guilford Press, 2004.

Beers, Mark H., M. D., and Thomas V. Jones, MD. Merck Manual of Geriatrics, 3rd ed., Chapter 32, “Aging and Mental Health.” Whitehouse Station, NJ: Merck, 2005.

Donaldson-Pressman, Stephanie, and Robert M. Pressman. The Narcissistic Family: Diagnosis and Treatment. San Francisco, CA: Jossey-Bass Publishers, 1997.

Mason, P. T., and R. Kreger. Stop Walking on Eggshells: Taking Your Life Back When Someone You Care about Has Borderline Personality Disorder. Oakland, CA: New Harbinger Publications, 1998.

PERIODICALS

Balsis, S., et al. “Overdiagnosis and Underdiagnosis of Personality Disorders in Older Adults.” American Journal of Geriatric Psychiatry 15 (September 2007):742–753.

Haas, Leonard J., et al. “Management of the Difficult Patient.” American Family Physician 72 (November 15, 2005): 2063–2068.

Heisel, M. J., P. S. Links, D. Conn, et al. “Narcissistic Personality and Vulnerability to Late-Life Suicidality.” American Journal of Geriatric Psychiatry 15 (September 2007): 734–741.

Lenzenweger, M. F., et al. “DSM-IV Personality Disorders in the National Comorbidity Survey Replication.” Biological Psychiatry 62 (September 15, 2007): 553–564. Pietrzak, R. H., J. A. Wagner, and N. M. Petry. “DSM-IV Personality Disorders and Coronary Heart Disease in Older Adults: Results from The National Epidemiologic Survey on Alcohol And Related Conditions.” Journals of Gerontology, Series B, Psychological Sciences and Social Sciences 62 (September 2007): P295–P299.

Ward, Randy K. “Assessment and Management of Personality Disorders.” American Family Physician 70 (October 15, 2004): 1505–1512.

Zanni, G. R. “The Graying of Personality Disorders: Persistent, But Different.” Consultant Pharmacist 22 (December 2007): 995–1003.

OTHER

Bienenfeld, David. “Personality Disorders.” eMedicine, November 13, 2006. http://www.emedicine.com/med/topic3472.htm [cited March 19, 2008] Gunderson, John, MD. A BPD Brief, revised edition.

Belmont, MA: McLean Hospital, 2006. Available online at http://www.borderlinepersonalitydisorder.com/documents/A%20BPD%20BRIEF%20revised% 202006%20WORD%20version%20–%20Jun%2006.pdf [cited March 19, 2008].

National Mental Health Association (NMHA) Fact Sheet. Personality Disorders. Available online at http://www1.nmha.org/infoctr/factsheets/91.cfm [cited March 19, 2008].

ORGANIZATIONS

American Psychiatric Association, 1000 Wilson Boulevard, Suite 1825, Arlington, VA, 22209, (703) 907-7300, [email protected], http://www.psych.org/.

National Alliance on Mental Illness (NAMI), Colonial Place Three, 2107 Wilson Blvd., Suite 300, Arlington, VA, 22201, (703) 524-7600, (800) 950-NAMI (6264), (703) 524-9094, http://www.nami.org/Hometemplate.cfm.

National Institute of Mental Health (NIMH), 6001 Executive Boulevard, Room 8184, MSC 9663, Bethesda, MD, 20892, (301) 443-4513, (866) 615-6464, (301) 443 4279, [email protected], http://www.nimh.nih.gov/index.shtml.

National Mental Health Association (NMHA), 2000 N.

Beauregard Street, 6th Floor, Alexandria, VA, 22311, (703) 684-7722, (800) 969-NMHA, (703) 684-5968, http://www1.nmha.org/.

Rebecca J. Frey Ph.D.