Personality Disorders Health Article

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.