What are Personality Disorders?
Personality disorders are different from clinical disorders because they are not temporary and are characteristic of long-term symptoms, despite counseling efforts. My clients with personality disorders have long-term maladaptive behaviors and responses to others. For people under the age of 18, they cannot be diagnosed without having symptoms for less than a year. Personality disorders start in adolescents and become more chronic over time without any counseling. The maladaptive cognitive-behavioral-emotional patterns from these disorders cause problems in general functioning and close relationships. The patterns of people with personality disorders are related to how they think of themselves and others, how they respond emotionally, how they relate to others, and how they control their own behavior as well as the behavior of others. They are based on thoughts different from one’s culture and intense emotional experience associated with them. People with one personality disorder will sometimes have symptoms or a diagnosis of another personality disorder. An estimated nine percent of U.S. adults have at least one personality disorder (What are Personality Disorders, 2016)
Types and Definitions of Personality Disorders Related to Cognitive-Behavioral Functioning
There are ten different personality disorders, grouped into three categories or clusters in the DSM 5 diagnostic book (DSM-5, 2013; Lenzenweger, et al., 2007).
Cluster A: Odd or Eccentric Behavior: Including Paranoid Personality Disorder, Schizoid Personality Disorder, and Schizotypal Personality Disorder. Clients with these personality disorders have thoughts, behaviors, or emotions about others that limit their social interactions. (DSM-5, 2013; Lenzenweger, et al., 2007).
- Paranoid Personality Disorder: My clients with this paranoid personality have a long- term pattern of distrust or suspicion of the behaviors and intention of others in which they think others deceive or cause harm to them. Other characteristics include holding grudges and the hesitation to confide in others because of irrational fears that others will use the information against them. They perceive certain situations as threatening when they are not, and respond angrily to comments they interpret as personal insults or attacks.
- Schizoid Personality Disorder: My clients with schizoid personality disorder have a long-term pattern of detachment from relationships and limited emotional expression. They prefer limited interaction with others and are unaffected by how others perceive them. Other characteristics are the appearance of being cold or different, the inability to recognize social cues, and the inability to enjoy most activities.
- Schizotypal Personality Disorder: My clients with this personality disorder have a long-term pattern of irrational or distorted beliefs, or of magical thinking (belief that they can influence people and events with their thoughts and unusual behavior) or incorrect interpretations of social situations such as thinking certain events have hidden messages meant only for them.
Cluster B: Dramatic, Emotional and Erratic Behavior: Including Borderline Personality Disorder, Narcissistic Personality Disorder, Anti-social Personality Disorder, and Histrionic Personality Disorder. People with these personality disorders have erratic behavior based on dramatic, extreme, and unrealistic thoughts and feelings about themselves and others. (DSM-5, 2013; Lenzenweger, et al., 2007).
- Borderline Personality Disorder: My clients with this personality disorder have a long-term patterned behavior of unstable emotional responses, quick mood swings, and unstable close relationships resulting from feelings of severe emptiness and identity issues. Behaviors include fear and avoidance of abandonment, inability to maintain relationships, and exhibition of intense anger, self-harm, and repetitive suicidal thoughts and behaviors. Other characteristics are stress related such as up and down moods and paranoia that comes and goes as a reaction to interpersonal stress.
- Narcissistic Personality Disorder: My clients with this personality disorder have long- term patterned thoughts of grandiosity, great self-importance, and entitlement. Other thoughts include the belief of being special and more important than others, fantasies about power and success, exaggeration of achievements or talents, expectations of constant praise and admiration, and unreasonable expectations of favors. Behaviors include taking advantage of others and a demonstrated lack of remorse, and low empathy.
- Antisocial Personality Disorder: My clients with this personality disorder have long patterned behaviors of acting impulsively, irresponsibility, and exhibiting nonconformity to cultural “norms” or community rules. These includes behaviors of repeated deception, aggressive behavior, and of violating the rights of others, and recurring legal arrests. Other characteristics are a disregard for safety, and the needs (and feelings) of others.
- Histrionic Personality Disorder: My clients with this personality disorder have long patterned behaviors described as being excessively emotional, dramatic, or sexually provocative to gain attention. Some will also speak dramatically with strong opinions despite lack facts or details to back them up. Other characteristics include rapid changing shallow emotions, excessive concern with physical appearance, thinking relationships are closer than they really are, and being easily influenced by others.
Cluster C: Anxious and Fearful Behavior: Includes Avoidant Personality Disorder, Dependent Personality Disorder, and Obsessive-Compulsive Personality Disorder. (DSM-5, 2013; Lenzenweger, et al., 2007).
- Avoidant Personality Disorder: My clients with this personality disorder have a long-term pattern of social inhibition and isolation, being shy and timid, fear of disapproval or embarrassment, sensitivity to criticism, and feeling inadequate and inferior. Behaviors include avoidance of work activities that require interpersonal contact and social events if they are not sure of being liked and of gaining approval.
- Dependent Personality Disorder: My clients with this personality disorder have a long-term pattern of the feeling of loneliness, needing to be taken care of, and not being able to make decisions without the reassurance of others. Other characteristics include difficulty starting or doing projects on their own due to lack of self-confidence, problems disagreeing with others, fear of disapproval, high tolerance to unfair treatment despite available options, and an urgent need to start a new relationship when another has terminated.
- Obsessive-Compulsive Personality Disorder: My clients with this personality disorder have a long-term pattern of inflexibility of rigid values and preoccupation with order, perfectionism, and details. Behaviors include working excessively hindering social relationships and leisure activities. Other characteristics are feeling unable to finish a project because they don't meet your own strict standards, desire to be in control of situations, the inability to delegate tasks, and miserly control over budgeting and spending money.
Causes of Personality Disorders
Personality disorders are characterized by the inter-relationship of thoughts, feelings, and behaviors. They may be a result of biological internal factors, as well as environmental, external situations. There is some genetic evidence that the traits of temperament, aggression, fear, and anxiety associated with personality disorders are inherited from one generation to the next. A malfunctioning gene has been found in obsessive-compulsive disorder. Variations of brain chemistry and structure are also biological factors in the development of personality disorders. High reactivity to visual and auditory stimuli has been associated with personality traits of being shy, timid, and anxious (American Psychological Association, n.d.).
Along with genetics, situations can trigger the beginnings of personality disorders in early adolescence. Trauma from verbal abuse, emotional neglect, and emotional manipulation and control by parents, along with an unstable and chaotic family life are related to low self-esteem characteristic of personality disorders. People with borderline personality disorder (BPD), for example, are more likely to have had childhood sexual trauma than people who do not have borderline personality disorder. People with borderline, narcissistic, obsessive-compulsive, or paranoid personality disorders in adulthood are three times more likely to have experienced verbal abuse in childhood than other adults (American Psychological Association, n.d.).
Childhood emotional neglect and verbal abuse is associated with people with borderline personality disorder and narcissistic personality disorder. They are more likely to have had childhood emotional neglect and verbal abuse. They have a lack of “whole object relations” and “object constancy.” Whole object relation is the ability to see oneself and others in an integrated way so they can identify both good and bad qualities in one person. Object constancy is the ability to maintain a positive connection to someone that you like despite the anger, hurt, and frustration felt when disappointed by isolated incidents or behaviors of that person. (Greenberg, 2017). People with borderline personality disorder will see a person as either all bad or all good, and the perceptions could change from bad to good and good to bad. A person with narcissistic personality disorder likes people when they make them feel good, but will change their mind if they feel that they are even slightly criticized.
Treatment for Personality Disorders
The treatment of personality disorders includes medication, counseling, and family/group support. The type of treatment and counselling modalities depends on the specific personality disorder, the severity of symptoms, and the effects on functioning. Although there are no medications specific to treating personality disorders, anti-anxiety medication and antidepressants, as well as mood stabilizers can be prescribed for symptoms. Individual counseling would include;
- The education of their disorder to learn about their symptoms and how to cope with them.
- Psychotherapy to understands the effect of their behavior on relationships and their functioning.
- Dialectic Brief Treatment to use mindfulness and relaxation exercises to reduce emotional symptoms.
- Cognitive Behavior Therapy to learn how their symptoms are related to their thoughts, feelings, and behaviors.
- Family sessions and group counseling are recommended to reduce isolation and build stronger connections in relationships.
American Psychological Association. (n.d.). What Causes Personality Disorders? Retrieved from http://www.apa.org/topics/personality/disorders-causes.aspx
American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition.
Greenberg, Elinor. Ph.D. (2017). The Truth about Narcissistic Personality Disorder. Retrieved from https://www.psychologytoday.com/us/blog/understanding-narcissism/201708/the-truth-about-narcissistic-personality-disorder
Lenzenweger MF, Lane MC, Loranger AW, Kessler RC. 2007. DSM-IV Personality Disorders in the National Comorbidity Survey Replication. Biological Psychiatry, 62(6), 553-564.
Reviewed by Ranna Parekh, M.D., M.P.H. Mayo Foundation for Medical Education and Research (MFMER). (n.d.). Mayo Clinic, Personality Disorder: Symptoms and Causes. Retrieved from https://www.mayoclinic.org/diseases-conditions/personality-disorders/symptoms-causes/syc-20354463
.American Psychiatric Association. (2016.). What are Personality Disorders? Retrieved from https://www.psychiatry.org/patients-families/personality-disorders/what-are-personality-disorders