I recently had the opportunity to attend an excellent training program on Personality Disorders, and I thought it might be useful to share some of the most interesting and beneficial information from the training.
Lets clarify how mental health clinicians classify symptoms and mental illness. In the UK we use two different books; the ICD11 and the DSM-5. In print or online the ICD-11 and the DSM-5 are essentially two different diagnostic systems used for classification of mental disorders.
- ICD-11 (International Classification of Diseases 11th Revision) is developed by the World Health Organization (WHO) and is used globally for health statistics and medical billing purposes.
- DSM-5 (Diagnostic and Statistical Manual of Mental Disorders 5th Edition) on the other hand, is developed by the American Psychiatric Association and primarily used in the United States and other countries for clinical diagnosis and treatment planning.
Both systems share many similar diagnoses, but there are some differences in criteria, terminology and cultural emphasis. It’s important to note that while DSM-5 is widely used, ICD-11 is considered to have a more comprehensive and culturally sensitive approach to classification of mental disorders.
DSM-5 sees personality disorders are a type of mental disorder that affects the way individuals think, feel and behave. It can be defined as an enduring pattern of inner experiences and behaviors that differ significantly from the expectations of an individual’s culture.
There are ten types of Personality Disorders recognized by the DSM-5 and they are:
- Paranoid Personality Disorder: Individuals with this disorder display a persistent distrust of others and are constantly on the lookout for any signs of deception, manipulation or exploitation. They also have difficulty in establishing close relationships with others and can be extremely suspicious of others’ motives.
- Schizoid Personality Disorder: People with this disorder display a marked disinterest in social relationships and prefer to lead a solitary life. They are often described as emotionally cold and aloof and are known to have difficulties expressing their emotions.
- Schizotypal Personality Disorder: This disorder is characterized by odd or eccentric behavior, distorted thinking, and a tendency to have unconventional beliefs. People with this disorder often struggle to form close relationships and experience intense discomfort in social situations.
- Antisocial Personality Disorder: This disorder is characterized by a disregard for the rights of others, a tendency to engage in criminal behavior and a lack of guilt or remorse. Individuals with this disorder often have a history of lying, cheating and manipulating others.
- Borderline Personality Disorder: This disorder is characterized by intense and unstable emotions, impulsivity, and a tendency to engage in self-destructive behavior. People with this disorder often have a distorted self-image and struggle with intense feelings of abandonment.
- Narcissistic Personality Disorder: This disorder is characterized by a grandiose sense of self-importance, a preoccupation with fantasies of unlimited power and success, and a lack of empathy for others. People with this disorder often have a sense of entitlement and a need for admiration and adoration.
- Avoidant Personality Disorder: This disorder is characterized by a pervasive pattern of social inhibition and feelings of inadequacy. People with this disorder avoid social situations and are extremely self-conscious, fearing rejection and criticism from others.
- Dependent Personality Disorder: This disorder is characterized by a pervasive pattern of submissive and clinging behavior that is related to an excessive need to be taken care of. People with this disorder struggle to make decisions on their own and often cling to others for support.
- Obsessive-Compulsive Personality Disorder: This disorder is characterized by a preoccupation with orderliness, perfectionism, and control. People with this disorder are often described as rigid, inflexible and struggle with the idea of delegating tasks.
- Histrionic Personality Disorder: This disorder is characterized by a pervasive pattern of excessive emotionality and attention-seeking behavior. People with this disorder are often described as overly dramatic, seductive and tend to be overly concerned with their appearance.
It’s important to note that not everyone with a Personality Disorder will display all the symptoms associated with it. However, the presence of a significant number of symptoms can indicate a Personality Disorder.
The ICD-11 has recently changed the diagnostic criteria and now considers level of severity of personality disorder and the pattern of personality disorder from the 6 patterns listed below:
Patterns of Personality Disorder
These are core features to look for. Not all features will be present in every person all the time, and there is no specific recommended number of these symptoms to qualify for a diagnosis.
Borderline Pattern (PDBP)
- Pervasive pattern of instability of interpersonal relationships, self-image, and affects
- Marked impulsivity
- Frantic efforts to avoid real or imagined abandonment
- Unstable and intense interpersonal relationships
- Identity disturbance (markedly and persistently unstable self-image or sense of self)
- Rash behavior in states of high negative affect, leading to potentially self-damaging behaviors
- Recurrent episodes of self-harm
- Emotional instability due to marked reactivity of mood
- Chronic feelings of emptiness
- Inappropriate intense anger or difficulty controlling anger
- Transient dissociative symptoms or psychotic-like features in situations of high affective arousal
Negative Affectivity Pattern
- Broad range of negative emotions with a frequency and intensity out of proportion to the situation
- Emotional lability and poor emotion regulation
- Negativistic attitudes, low self-esteem, and self-confidence
- Social detachment (avoidance of social interactions, lack of friendships, and avoidance of intimacy)
- Emotional detachment (reserve, aloofness, and limited emotional expression and experience)
- Self-centeredness (e.g., sense of entitlement, expectation of admiration, attention-seeking behaviors, concern for one’s own needs, desires, and comfort, not others)
- Lack of empathy (e.g., indifference to consequences of actions on others, deceptive, manipulative, exploitative, callousness, ruthless in achieving goals)
- Lack of planning
- Perfectionism (e.g., concern with social rules, obligations, norms of right and wrong, meticulous attention to detail, rigid routines, hyper-scheduling, planfulness, emphasis on organization, orderliness, and neatness)
- Emotional and behavioral constraint (e.g., rigid control over emotional expression, stubbornness, inflexibility, risk-avoidance, perseveration, deliberativeness)
Comparing and analysing the two different diagnostic criteria is not something I will attempt in a blog post, it is enough to be aware of the differences. However, this article by Roger T. Mulder (2021) provides further reading on the subject.
Mulder, R. T. (2021). ICD-11 Personality Disorders: Utility and Implications of the New Model. Frontiers in Psychiatry, 12, 655548. https://doi.org/10.3389/fpsyt.2021.655548
Diagnosis and Treatment
Diagnosis and treatment of personality disorders can have a significant impact on the well-being of affected individuals. A proper diagnosis can provide a clear understanding of the difficulties being faced, leading to appropriate treatment and a clearer path for recovery. Treatment can help individuals manage their symptoms, improve their relationships, and increase their overall quality of life. The process of diagnosis and treatment can also bring a sense of relief, as individuals feel less alone and have more realistic expectations for their future. By receiving a proper diagnosis and engaging in effective treatment, individuals with personality disorders can work towards leading fulfilling and satisfying lives.
It’s worth mentioning that studies have shown that there is a strong link between childhood trauma and the development of personality disorders. Childhood experiences such as abuse, neglect, and abandonment can lead to the development of maladaptive coping mechanisms and patterns of behavior that persist into adulthood. I will side-step discussion around the role of trauma in personality disorders but it is something for clinicians to consider. However, please avoid assumptions; trauma is not an automatic precursor for developing a personality disorder and personality disorder is not always indicative of past trauma.
The diagnosis of a personality disorder can have both advantages and disadvantages for an individual. On one hand, it offers a structure for comprehending one’s difficulties and can lead to appropriate treatment. It can also provide a sense of belonging and help individuals understand what to expect in terms of progress. However, the diagnosis can also be viewed as a label rather than a true understanding of the individual. It may also restrict access to the right treatment and put an emphasis on the person’s shortcomings rather than past experiences and current relationships. Additionally, the broad definition of personality disorders can result in misunderstandings.
Treatment for Personality Disorders can involve a combination of psychotherapy, medication, and lifestyle changes. Psychotherapy is the primary form of treatment for Personality Disorders and can involve a variety of approaches such as Cognitive-Behavioral Therapy, Dialectical Behavior Therapy, and Psychodynamic Therapy.
Cognitive-Behavioral Therapy (CBT) is a short-term, goal-oriented psychotherapy that helps individuals identify and challenge negative thoughts and behaviors. CBT can be effective in treating personality disorders by helping individuals identify and change negative thought patterns and behaviors that maintain their disorder.
Dialectical Behavior Therapy (DBT) is a form of CBT that emphasizes the balance between change and acceptance. DBT can be useful in treating personality disorders by teaching individuals coping skills to regulate their emotions, manage interpersonal relationships, and reduce self-harm behaviors.
Psychodynamic Therapy is a form of psychotherapy that focuses on unconscious thoughts and past experiences that may be impacting current behaviors and relationships. Psychodynamic therapy can be helpful in treating personality disorders by exploring the unconscious motivations and conflicts that contribute to the development and maintenance of the disorder. The goal of psychodynamic therapy is to increase the patient’s self-awareness and improve their ability to manage their thoughts, behaviors, and relationships.
Working with people living with a personality disorder
Working with people with personality disorders can present unique challenges in terms of interpersonal difficulties. Some common behaviors that may be observed include:
Fear of abandonment: Clients may express a strong fear of being abandoned or left alone, which can lead to excessive demands for attention and reassurance.
Clients who are ambivalent or disengaged: Some clients may withdraw from support or disengage from therapy just as they are starting to make progress. This can be a defense mechanism to avoid being “rejected.”
Intense relationships: People with personality disorders may form intense relationships with their therapists, idealizing them or becoming overly familiar. They may also make demands that are outside of the therapist’s role, such as requesting more time or asking for things that go beyond their professional capacity.
Clingy or dependent behavior: Clients may become overly dependent on their therapist, requesting more frequent sessions or longer appointments. They may also express feelings of emptiness or dissatisfaction with the support they receive.
Rejecting behavior: On the other hand, clients may reject their therapist’s help and support, expressing dissatisfaction with their efforts and calling into question their competence.
In order to effectively work with clients with personality disorders, it is essential to maintain clear and consistent boundaries. As a practitioner, you have a role to play in modeling healthy and predictable boundaries for your clients, who may have experienced inconsistent or traumatic boundary violations in the past. However, maintaining these boundaries can be challenging, given the powerful emotions that can be generated in both the client and the practitioner.