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Personality Disorders
Personality disorders are complex and difficult to characterize. The American Psychiatric Association defines personality disorders as “an enduring pattern of inner experience and behavior that deviates 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” (American Psychiatric Association, 2000). Persons with these disorders often alienate others with their lack of flexibility, make poor choices for themselves, and create a self-fulfilling prophecy of strife and disorder. Personality disorders are diagnosed by qualified mental health professionals who consider an individual's broad patterns of functioning over time.
Personality disorders may be related to early childhood stress and trauma. Research suggests that this relationship may be significantly more complex than previously thought, however, potentially involving gene-environment interactions, comorbid psychiatric conditions, and other as yet unidentified factors. This entry summarizes our current understanding of the history, types, causes, and epidemiologic characteristics, as well as treatment options for personality disorders.
History
Once referred to as “character disorders,” personality disorders were first recognized by the American Psychiatric Association as distinct from other psychopathologies in 1980 with the publication of the Diagnostic and Statistical Manual of Mental Disorders, Third Edition (DSM-III). Along with mental retardation, these disorders were designated as Axis II in the DSM-III's five-axial system of diagnosis. With the publication of the DSM-III, specific personality disorders were named and diagnoses were clarified, although these diagnoses were thought to be somewhat unreliable. This was largely because of the high degree of overlap in symptoms between personality disorders and other psychopa-thology. With the publication of DSM-IV, specific criteria for the general characteristics of a personality disorder were specified—that is, clinicians were given a set of criteria to identify personality disorders in an individual in general (in addition to specified criteria for diagnosis of specific personality disorders). It is anticipated that the DSM-V, planned for publication in 2013, will include significant changes to the assessment and diagnosis of these disorders.
Specific Personality Disorders
The American Psychiatric Association currently recognizes 10 personality disorders. Characterization of each of these disorders is beyond the scope of this entry; however, the disorders are grouped into three clusters, based on overall characteristics of the pathology, as follows:
Cluster A. Individuals seem odd or eccentric. This cluster consists of paranoid personality disorder, schizoid personality disorder, and schizotypal personality disorder.
Cluster B. Individuals are overly dramatic, emotional, or irrational. Antisocial personality disorder, borderline personality disorder, histrionic personality disorder, and narcissistic personality disorder are included in this cluster.
Cluster C. Individuals are overly anxious or fearful. Included in this cluster are avoidant personality disorder, dependent personality disorder, and obsessive-compulsive personality disorder. (Note that obsessive-compulsive personality disorder is distinct from obsessive-compulsive disorder, which is an anxiety disorder.) In addition, a category labeled as personality disorder not otherwise specified (NOS) is provided. This category is characterized by behavioral patterns that do not fit within the diagnostic criteria of the 10 specific personality disorders listed earlier, but nevertheless suggest presence of a personality disorder.
Causes and Epidemiology
The causes of personality disorders are unknown. Genetics, early childhood experiences including trauma, and variations in brain anatomy have been implicated, along with other potential factors. Until relatively recently, specific personality disorders, such as borderline personality disorder (BPD), were thought to be caused (at least partly) by childhood sexual trauma. Newer research, however, suggests that the apparent high percentages of patients with BPD who reported a history of childhood sexual abuse may actually result from patients' tendencies to misremember, lie, and manipulate, and to have willingly participated in sexual encounters at a young age. Similar explanations for the role of trauma in development of personality disorders are possible for other specific diagnoses because of the pervasiveness of cognitive, emotional, and interpersonal difficulties in those patients.
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