Personality Disorders: An Overview

Personality Disorders

An Introduction

Maxym Choptiany, MD FRCPC

What is a personality disorder?



Chronic, inflexible, and maladaptive pattern of relating to the

world.



Evident in the way a person thinks, feels, and behaves.



The most noticeable and significant feature is their negative

effect on interpersonal relationships.



Relationships they do form are often fraught with problems

and difficulties.

What is a personality disorder?



Often those with personality disorders who experience

difficulties in their relationships or in their functioning don’t

believe that there is anything wrong with them (egosyntonic).



If anything, believe society (not them) should change 

–

alloplastic thinking.



As a result maladaptive behaviour is repeated.

What is a personality disorder?



Differ from personality traits (ie. features of personality that

do not meet threshold for a PD).



Diagnosis is warranted only if personality traits are:



Inflexible, maladaptive, and enduring.



Start in childhood/adolescence.



Cause functional impairment/subjective distress.

History



First formal attempt to classify personality disorders

occurred in 1952 with the publication of DSM-I.



7 personality disorders identified.



Classification in various form throughout history.



Hippocrates described 4 temperaments:



earth, air, fire, and water



the optimistic sanguine, the irritable choleric, the sad

melancholic, and the apathetic phlegmatic.



Variation on the temperaments up to 20

th 

Century.

Epidemiology



Up to 10-20% of the general population.



Greater in psychiatric samples 

–

 up to 30-50%.



Antisocial Personality Disorder is the only PD with an age

specification (18 years) and that certain childhood

behaviours be present (conduct disorder).



Some more frequent in men (ASPD).



Some more frequent in women (BPD).

Epidemiology



Associated with impaired social, personal, and occupational

adjustment.



Family life, marriage, academic and work difficulties.



Increased rates of unemployment, homelessness, divorce and

separation, domestic violence and substance misuse.



Increased rates of healthcare utilization.

Epidemiology



Individuals suffering from personality disorders are at high

risk of early death from suicide or accident.



Suicide rate is as high as that seen for major depression.



Although personality disorders tend to be stable, some

studies have shown that they tend to improve as a patient

ages.

Epidemiology



Presence of personality disorder is associated with poorer

response to treatment, particularly antidepressant

medication and electroconvulsive therapy.

Etiology



Historical psychoanalytical view theorized that personality

disorders occurred when an individual failed to progress

through appropriate psychosexual stage of development.



Adverse childhood experience (abuse, maltreatment, or

neglect) is associated with risk for development of

personality disorder.



Genetic association (eg. schizotypal and schizophrenia).

Etiology



Neurobiological correlates 

–

 eg. low levels of 5-

hydroxyindoleacetic acid (5-HIAA) a metabolite of serotonin

–

 linked to impulsivity and aggression (ASPD and BPD)



Chronic nervous system under-arousal is thought to

contribute to thrill seeking, impulsivity and dangerousness in

ASPD.

Etiology



Interaction between an individual’s genetic predisposition

towards certain traits and an individual’s early experiences.



Over time people develop habits of interpreting and

responding to the environment that influence the way they

experience and interpret their world ("personality traits”).



Once these patterns have formed, they are maintained and

become fairly stable.

Etiology



Overdeveloped and underdeveloped behavioural strategies

specific to each personality disorder that are used across

situations and across time; even when the strategies are

dysfunctional.



Strategies are developed to cope with highly negative core

beliefs.



Strategies may have been adaptive when first developed.

DSM-5 Diagnostic Criteria



An enduring pattern of inner experience and behaviour that

deviates markedly from the expectations of the individual's

culture.



Enduring pattern is inflexible and pervasive across range of

personal and social situations.



Has an onset in adolescence or early adulthood and is stable

over time.

DSM-5 Diagnostic Criteria



Symptoms must cause impairment in social, occupational, or

other important areas of functioning (ie. difficult for them to

function well in society) and /or subjective distress.



Not better explained as a manifestation of another mental

disorder.



Not attributable to substance or other medical condition (eg.

head trauma).

DSM-5 Diagnostic Criteria



NOT diagnosed in children due to the requirement that

personality disorders represent enduring problems across

time.

DSM-5 Diagnostic Criteria

This enduring pattern manifests in 2 or more of the following

areas:



Thinking

 - distorted thinking patterns



Feeling

 - problematic emotional responses



Impulse control 

– over/under regulated impulse control



Interpersonal functioning 

- problematic relationships)

Distorted Thinking Patterns



Distortions in the way they interpret and think about the

world, and in the way they think about themselves.



Thinking patterns may be extreme and distorted.

Distorted Thinking Patterns



Black-or-white thinking patterns



Idealizing then devaluing other people or themselves.



Distrustful, suspicious thoughts.



Unusual or odd beliefs (contrary to cultural standards).



Perceptual distortions and bodily illusions.

Diagnosis



Thorough personal and social history



Mental Status Exam



Collateral information 

–

 especially where the individual

denies or is unaware of their maladaptive traits.



Caution in diagnosing when individual is suffering from

another mental disorder 

–

 eg depression (anxious,

dependent).

Diagnosis



Objective psychological testing may be of assistance in

diagnosing personality disorder.



Eg. Minnesota Multiphasic Personality Inventory II

DSM-5



10 specific personality disorders



3 clusters of personality disorders



Each disorder has a set criteria of observable characteristics.



Diagnosis requires that a minimum number of criteria are

met.



Can be co-occurrence/overlap in personality disorders.

Clusters



Cluster A - odd, eccentric



Cluster B - dramatic, emotional, erratic



Cluster C - anxious, fearful

Cluster A (Odd, Eccentric)



Paranoid



Schizoid



Schizotypal

Cluster B (Dramatic, Emotional, Erratic)



Antisocial



Borderline



Histrionic



Narcissistic

Cluster C (Anxious, Fearful)



Avoidant



Dependent



Obsessive-Compulsive

Other Personality Disorders



Personality Change Due to Another Medical Condition



Other Specified Personality Disorder



Symptoms characteristic of PD predominate but do not meet full

diagnostic criteria.



Unspecified Personality Disorder



Mixed or atypical traits that do not fit into better-defined

categories.

Cluster A (Odd, Eccentric)



Paranoid



Schizoid



Schizotypal

Cluster A



Characterized by a pervasive pattern of abnormal cognition

(eg. suspiciousness), self-expression (eg. odd speech), or

relating to others (eg. seclusiveness).

Cluster A 

–

 Paranoid PD



SUSPECT (4 criteria).



S: Spouse fidelity suspected

U: Unforgiving (bears grudges)

S: Suspicious of others

P: Perceives attacks (and reacts quickly)

E: "Enemy or friend" (suspects associates, friends)

C: Confiding in others feared

T: Threats perceived in benign events

Cluster A 

–

 Paranoid PD

Cluster A 

–

 Paranoid PD



Expect exploitation.



Misinterpret statements or acts as hostile



Isolate to protect themselves.



Rarely seek treatment because of their suspiciousness of

others (including therapists and psychiatrists).



Tend to be identified when presenting for a mood or anxiety

disorder.

Cluster A 

–

 Paranoid PD



Prevalence ~4%. More common in males.



Treatment involves supportive approach, treating the main

complaint, and once rapport is established alternative

explanations for misperceptions can be offered.

Cluster A 

–

 Schizoid PD



DISTANT (4 criteria).



D: Detached (or flattened) affect

I: Indifferent to criticism and praise

S: Sexual experiences of little interest

T: Tasks (activities) done solitarily

A: Absence of close friends

N: Neither desires nor enjoys close relations

T: Takes pleasure in few activities

Cluster A 

–

 Schizoid PD

Cluster A 

–

 Schizoid PD



Profound defect in the ability to form personal relationships

and to respond to others in a meaningful way.



No close relationships.



Choose solitary activities



Rarely experience strong emotions.



Express little desire for sexual experience with another

person.

Cluster A 

–

 Schizoid PD



Indifferent to praise or criticism.



Display constricted affect.



Prevalence ~3%.



Uncommon in psychiatric setting because they rarely seek

out psychiatric help except for co-occurring depression,

anxiety, substance abuse, etc.

Cluster A 

–

 Schizoid PD



Treat the identified disorder (eg. mood)



May benefit from day or drop in programs.

Cluster A 

–

 Schizotypal PD



ME PECULIAR (5 criteria).



M: Magical thinking or odd beliefs

E: Experiences unusual perceptions



P: Paranoid ideation

E: Eccentric behaviour or appearance

C: Constricted (or inappropriate) affect

U: Unusual (odd) thinking and speech

L: Lacks close friends

I: Ideas of reference

A: Anxiety in social situations

R: Rule out psychotic disorders and pervasive developmental

disorder

Cluster A 

–

 Schizotypal PD

Cluster A 

–

 Schizotypal PD



Considered to be part of the schizophrenia spectrum.



Characterized by a pattern of peculiar behaviour, odd

speech and thinking, and unusual perceptual experiences.



Socially isolated



Magical beliefs 

–

 eg. 6

th

 sense, supernatural experience



Mild paranoia

Cluster A 

–

 Schizotypal PD



Inappropriate or constricted affect



Social anxiety



Prevalence of 3-5% (common)



Mood, anxiety, and substance use disorders common.

Cluster A 

–

 Schizotypal PD



Treat the identified disorder.



May benefit from social skills training.



Goal is to help individual develop insight into their

behaviours and to develop repertoire of social skills.

Cluster B (Dramatic, Emotional, Erratic)



Antisocial



Borderline



Histrionic



Narcissistic

Cluster B (Dramatic, Emotional, Erratic)



Characterized by a pervasive pattern of violating social

norms (eg. criminal behaviour), impulsivity, excessive

emotionality, grandiosity, “acting out” (eg. tantrums, self-

abusive behaviour, angry outbursts), or violating the rights of

others (eg. criminal behaviour).

Cluster B - ASPD



CORRUPT (3 criteria).



C: Conformity to law lacking

O: Obligations ignored

R: Reckless disregard for safety of self or others

R: Remorse lacking

U: Underhanded (deceitful, lies, cons others)

P: Planning insufficient (impulsive)

T: Temper (irritable and aggressive)

Cluster B - ASPD



Pervasive pattern of disregard for and violation of the rights

of others occurring since age 15 years.



The individual is at least age 18 years.



There is evidence of conduct disorder with onset before age

15 years.

Cluster B - ASPD



Conduct Disorder - TRAP



T: Theft – B&E, deceiving, non-confrontational stealing



R: Rule Breaking – running away, skipping school, out late



A: Aggression – people, animals, weapons, forced sex



P: Property Destruction

Cluster B - ASPD

Cluster B - ASPD



First recognized in the early 19

th

 century.



“Mania without delirium”



“Moral insanity”



Described immoral or guiltless behaviour in the absence of

impaired reasoning.



20

th

 Century 

–

 termed psychopathic personality



DSM-I 

–

 sociopathic personality

Cluster B - ASPD



DSM-III 

–

 antisocial personality disorder.



Described in Hervey Cleckley’s 

–

 The Mask of Sanity (1941) 

–

identified 16 traits descriptive of the disorder.

Cluster B - ASPD



Typical childhood behaviour of fighting, lying, cheating,

stealing, fire setting, and cruelty to animals and other

children.



As antisocial youth achieves adulthood, problems reflect age-

appropriate responsibilities 

–

 uneven job performance,

domestic abuse.

Cluster B - ASPD



Unreliability, reckless behaviour, inappropriate aggression,

criminal behaviour, pathological lying, and use of aliases are

characteristic.



Often act impulsively without thinking of long-term

consequences. Legal issues common.

Cluster B - ASPD



2-4% of men.



0.5 -1% of women.



Higher amongst psychiatric, prison, and homeless

population.



Chronic disorder but worse early on.

Cluster B - ASPD



Comorbid substance use disorders, mood and anxiety

disorders, ADHD, pathological gambling and other PDs

(BPD).



Alcohol and SUD - 12 month prevalence



AUD 28.6%, SUD 47.7%



Any alcohol or SUD 84% lifetime



Depression and Anxiety (1 study)



35% MDE



27% phobic disorder

Cluster B - ASPD



High death rate 

–

 suicide, accidents, homicides.



No standard treatment.



Target aggression 

–

 eg. mood stabilizer and antipsychotics.



CBT to target distorted beliefs and attitudes.



Emotion regulation / anger management.



Difficult to treat due to treatment interfering traits 

–

 lie, blame

others, impulsive, low frustration tolerance.

Psychopathy



Psychopathy is a personality construct involving a

combination of both personality traits and behaviours.



Most offenders who are psychopaths meet criteria for ASPD.

Psychopathy



3 key symptom groupings:



Arrogant, interpersonally exploitative and deceitful interpersonal

style of relating.



Shallow/deficient way of experiencing and expressing affect.



Irresponsible, impulsive, antisocial behavioural lifestyle

Psychopathy



PCL-R is an operationalized checklist of Cleckley’s clinical

observations consisting of 20 items, composed of 2 factors (4

facets)

Psychopathy



Factor 1 (Affective/Interpersonal)



Interpersonal:



Glib/superficial



Grandiose self-worth



Pathological lying



Conning/manipulative



Affective:



Lack of remorse/guilt



Shallow affect



Callous/lack of empathy



Fail to accept responsibility for own actions

Psychopathy



Factor 2 (Behavioural/Antisocial)



Behavioural (lifestyle)



Stimulation seeking



Parasitic lifestyle



Lack of realistic goals



Impulsivity



Irresponsibility



Antisocial



Poor behavioural controls



Early behaviour problems



Juvenile delinquency



Revocation of conditional release



Criminal versatility

Psychopathy



2 additional items: 



Promiscuous sexual behaviour



Many short term relationships

Cluster B - BPD



“Stably unstable” Pervasive pattern of:



Mood instability



Unstable and intense interpersonal relationships



Impulsivity



Inappropriate or intense anger



Lack of control of anger



Recurrent suicidal threats and gestures



Self-mutilating behaviour

Cluster B - BPD



Marked and persistent identity disturbance



Chronic feelings of emptiness or boredom



Frantic efforts to avoid real or imagined abandonment



Transient paranoid or dissociative symptoms

Cluster B - BPD



AM SUICIDE (5 criteria).



A: Abandonment

M: Mood instability (marked reactivity of mood)



S: Suicidal (or self-mutilating) behaviour

U: Unstable and intense relationships

I: Impulsivity (in two potentially self-damaging areas)

C: Control of anger

I: Identity disturbance

D: Dissociative (or paranoid) symptoms that are transient and

stress-related

E: Emptiness (chronic feelings of)

Cluster B - BPD

Cluster B - BPD



DSM-I 

–

 emotionally unstable personality



Borderline schizophrenia 

–

 transient episodes of psychosis



1-2% in general population



10% of psychiatric outpatients



15-25% of psychiatric inpatients



Account for up to 50% of all persons with PDs.

Cluster B - BPD



Etiology unknown.



Likely interaction between genetic vulnerability, life

experiences, reinforced interpersonal behaviours.



Emotionally vulnerable temperament transacting with an

invalidating environment - Linehan 1993.

Cluster B - BPD



3:1 female to male



Up to ¾ engage in in deliberate self-harm (cutting, burning,

over-dose)



Reasons for SIB: to cause physical pain, control feelings,

express anger, overcome numbness



SIB: cutting>bruising, biting, burning, head banging



Up to 10% will commit suicide.

Cluster B - BPD



Frequent comorbid MDD, anxiety, and substance misuse.



PTSD?



Burnout with age 

–

 maturity, skills.



Positive prognostic indicators: higher intelligence, self-

discipline, social support, lack of substance abuse, and lack

of history of abuse.



Negative prognostic indicators: anger, antisocial behaviour,

suspiciousness, and vanity traits.

Cluster B - BPD



Treatment involves targeting mood, anxiety etc.



DBT 

–

 reduces self-harm, hospitalization rates, and emotional

dyscontrol.



DBT 

–

 targets dysfunctional attitudes and beliefs and

improves coping skills, stress tolerance, and emotion

regulation.



Frequent acting out in therapy.

Cluster B - BPD



Treatment on an out-patient basis where patients can deal

with their issues.



Hospitalization for acute/emergent issues. Risk of

regression/acting out/destabilization in hospital.



Psychoeducation.

Cluster B 

–

 Histrionic PD



PRAISE ME (5 criteria)



P: Provocative (or sexually seductive) behaviour

R: Relationships (considered more intimate than they are)

A: Attention (uncomfortable when not the center of attention)

I: Influenced easily

S: Style of speech (impressionistic, lacks detail)

E: Emotions (rapidly shifting and shallow)



M: Made up (physical appearance used to draw attention to

self)

E: Emotions exaggerated (theatrical)

Cluster B 

–

 Histrionic PD

Cluster B 

–

 Histrionic PD



Show a pattern of excessive emotionality and attention-

seeking behaviour.



Excessive concern with appearance.



Wanting to be the centre of attention.



Superficially charming.



Manipulative, vain, demanding.

Cluster B 

–

 Histrionic PD



Prevalence 

–

 2% general population



More common in women.



Seek out medical attention and make use of health services.

Cluster B 

–

 Histrionic PD



Treatment



Supportive, problem solving, CBT to counter distorted

thinking.



IPT to assist in targeting meaningful relationships.



Group therapy to target provocative, attention seeking

behaviour.

Cluster B 

–

 NPD



SPECIAL (5 criteria).



S: Special (believes he or she is special and unique)

P: Preoccupied with fantasies (of unlimited success, power,

brilliance, beauty, or ideal love)

E: Entitlement

C: Conceited (grandiose sense of self-importance)

I: Interpersonal exploitation

A: Arrogant (haughty)

L: Lacks empathy

Cluster B 

–

 NPD



Introduced in DSM-III



Named after Narcissus from Greek mythology, who fell in

love with his own reflection.



Characterized by grandiosity, lack of empathy, and

hypersensitivity to evaluation by others.



Tend to be egotistical, inflate their accomplishments, and

manipulate/exploit those around them for their own aims.

Cluster B 

–

 NPD

Cluster B 

–

 NPD



Have an exaggerated sense of entitlement.



Expect love and admiration but have little empathy for

others.



Tend to have little insight into their own narcissism.



1% prevalence. More common in males.

Cluster B 

–

 NPD



No consensus on treatment.



Difficult to work with.



Present after narcissistic injury sustained 

–

 anger or

depression post humiliation in a situation that they did not

get what they felt they were entitled to.



CBT, dynamic psychotherapy.



Treat comorbidities.

Cluster C (Anxious, Fearful)



Avoidant



Dependent



Obsessive-Compulsive

Cluster C (Anxious, Fearful)



Characterized by a pervasive pattern of abnormal fears

involving social relationships, separation, and need for

control.

Cluster C 

–

 Avoidant PD



CRINGES (4 criteria).



C: Certainty (of being liked required before willing to get

involved with others)

R: Rejection (or criticism) preoccupies one's thoughts in

social situations

I: Intimate relationships (restraint in intimate relationships

due to fear of being shamed)

N: New interpersonal relationships (is inhibited in)

G: Gets around occupational activity (involving significant

interpersonal contact)

E: Embarrassment (potential) prevents new activity or taking

personal risks

S: Self viewed as unappealing, inept, or inferior

Cluster C 

–

 Avoidant PD

Cluster C 

–

 Avoidant PD



Predecessor 

–

 inadequate personality



Tend to be inhibited, introverted, and anxious.



Tend to have low self-esteem



Rejection hypersensitivity



Apprehensive and mistrustful



Socially awkward and timid



Fear being embarrassed or acting foolish in public.



Overlap with social anxiety disorder.

Cluster C 

–

 Avoidant PD



Treatment:



Assertiveness and social skills training.



CBT 

–

 focus on sensitization to treat anxiety, shyness and

introversion.



CBT 

–

 to target dysfunctional attitudes / thought distortion.



Antidepressants (SSRIs) to target anxiety.

Cluster C 

–

 Dependent PD



RELIANCE (5 criteria).



R: Reassurance required for decisions

E: Expressing disagreement difficult (due to fear of loss of

support or approval)

L: Life responsibilites (needs to have these assumed by

others)

I: Initiating projects difficult (due to lack of self-confidence)

A: Alone (feels helpless and discomfort when alone)

N: Nurturance (goes to excessive lengths to obtain

nurturance and support)

C: Companionship (another relationship) sought urgently

when close relationship ends

E: Exaggerated fears of being left to care for self

Cluster C 

–

 Dependent PD

Cluster C 

–

 Dependent PD



Predecessor 

–

 subtype of DSM-1 passive-aggressive

personality



Characterized by a pattern of relying excessively on others

for emotional support.



Comorbid psychiatric disorders are common 

–

 mood,

anxiety, etc.



Tend to have poor social supports because their dependency

promotes conflict.

Cluster C 

–

 Dependent PD



Treatment



Little consensus.



Target associated mental disorder (mood, anxiety, etc.)



CBT 

–

 assertiveness, effective decision making, and

independence.



Assertiveness training and social skills training.

Cluster C - OCPD



LAW FIRMS (4 criteria).



L: Loses point of activity (due to preoccupation with detail)

A: Ability to complete tasks (compromised by perfectionism)

W: Worthless objects (unable to discard)



F: Friendships (and leisure activities) excluded (due to a

preoccupation with work)

I: Inflexible, scrupulous, overconscientious (on ethics, values,

or morality, not accounted for by religion or culture)

R: Reluctant to delegate (unless others submit to exact

guidelines)

M: Miserly (toward self and others)

S: Stubbornness (and rigidity)

Cluster C - OCPD

Cluster C - OCPD



Characterized by obstinacy, parsimony, and orderliness.



Lifelong pattern of perfectionism and inflexibility, associated

with over-conscientiousness and constricted emotions.



No 1:1 relationship with OCD.



Very common. In one study prevalence was estimated at up

to 8% of the general population.

Cluster C - OCPD



Patients suffering from OCPD are prone to major depression.



Difficult to treat.



CBT to target black and white thinking.



Antidepressants to target mood, anxiety, and possibly

ritualized behaviour.

Summary



Personality Disorders encompass maladaptive, pervasive,

and deeply ingrained behaviour.



Given the enduring, long-term nature of the maladaptive

patterns of behaviour, they cannot be easily reversed.