Personality disorders

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CHAPTER 12 Personality disorders

Darryl Bassett, David J. Castle

Personality disorders represent ‘a class of syndromes defined by the early onset of inflexible and maladaptive traits that are exhibited in a wide range of social and personal contexts and that are relatively stable over a period of years’ (Pfol 1999).

There are many theories and classifications surrounding personality and personality disorders. We have attempted to simplify this very complex field; refer to the ‘References and further reading’ at the end of this chapter if a more comprehensive understanding is desired.

Personality

Personality is the persistent and integrated pattern with which a person perceives their internal experience and interacts with the world in general. This includes a person’s beliefs and understanding of their subjective life experience and identity, as well as their behaviour in relationships with other people. Personality features or traits are to some extent enduring throughout adult life, but are still open to psychological modification and adaptation to a limited degree.

According to Robert Cloninger, personality can be considered to result from the combination of temperament (‘emotional core’) and character (‘conceptual core’).

Temperament

Temperament consists of developing personality traits manifested as emotional expression, level of activity and social interactiveness. Temperament is evident from birth and has strong biological roots, modified by environmental factors. Temperament has four genetically determined dimensions:

1. ‘novelty seeking’ (tendency to explore)

2. ‘reward dependence’ (attachment seeking)

3. ‘harm avoidance’ (tendency to withdraw), and

4. ‘persistence’ (tendency to persist).

Character

Character is the way individuals regard relationships with others and are derived from combinations of temperament, interactions with significant others and individual life experiences. Character has three dimensions:

1. ‘cooperativeness’ (empathy with others)

2. ‘self-directedness’ (goal striving), and

3. ‘self-transcendence’ (sense of ‘spirituality’ or notions such as beliefs, values and meaning in life).

Personality disorders

The criteria for individual categories of personality disorders are lengthy and only a synopsis is presented in Table 12.1. We suggest that the respective manuals for DSM–IVTR and ICD–10 be consulted for further detail about the specific criteria.

TABLE 12.1 DSM–IVTR and ICD–10 classifications of personality disorders

DSM–IVTR (synopsis)

ICD–10 (synopsis)

General diagnostic criteria for a personality disorder

An enduring pattern of inner experience and behaviour that deviates markedly from the expectations of the individual’s culture. This pattern is manifested in two (or more) of the following areas:

• cognition (i.e. ways of perceiving and interpreting self, other people and events)

• affectivity (i.e. the range, intensity, lability and appropriateness of emotional response)

• interpersonal functioning, and

• impulse control.

The enduring pattern is inflexible and pervasive across a broad range of personal and social situations. The enduring pattern leads to clinically significant distress or impairment in social, occupational, or other important areas of functioning. The pattern is stable and of long duration, and its onset can be traced back at least to adolescence or early adulthood. The enduring pattern is not better accounted for as a manifestation or consequence of another mental disorder. The enduring pattern is not due to the direct physiological effects of a substance (e.g. a drug of abuse or a medication) or a general medical condition (e.g. head trauma)

Disorders of adult personality and behaviour (F60–F69)

This block includes a variety of conditions and behaviour patterns of clinical significance, which tend to be persistent and appear to be the expression of the individual’s characteristic lifestyle and mode of relating to himself or herself and others. Some of these conditions and patterns of behaviour emerge early in the course of individual development, as a result of both constitutional factors and social experience, while others are acquired later in life.

Specific personality disorders (F60.1 to F60.9), mixed and other personality disorders (F61.0 to F61.1), and enduring personality changes (F62.1 to F62.9), are deeply ingrained and enduring behaviour patterns, manifesting as inflexible responses to a broad range of personal and social situations. They represent extreme or significant deviations from the way in which the average individual in a given culture perceives, thinks, feels and, particularly, relates to others. Such behaviour patterns tend to be stable and to encompass multiple domains of behaviour and psychological functioning. They are frequently, but not always, associated with various degrees of subjective distress and problems of social performance

The concept of personality disorder requires judgments to be made about what is ‘maladaptive’ about persistent patterns of behaviour and self-perceptions. Determining what is maladaptive must take into account differences in cultural norms, social context and even moral values. However, loss of flexibility and adaptiveness in self-awareness and behaviour, which persistently and extensively impinge negatively upon relationships, can still be identified.

Recognising such difficulties clinically offers greater insights and opportunities for assistance for the people involved. A diagnosis of personality disorder can be used pejoratively and can become destructive. It may also provoke challenges that the problems are ‘normal variants’ and do not justify treatment or special consideration as the consequences of illness. This ignores the destructiveness of personality dysfunction to both the patient and others, as well as the lack of choice experienced by such patients with their problems.

The current classifications first assign people with personality dysfunctions into clusters and then into specific disorders. Such categories have the value of identifying broad common features, which illustrate the problems of rigidity and maladaptiveness mentioned above. They also illustrate the limitations of categories which do not reflect the many variations in human beings, both at any one time and over a period of time. However, the clusters can also be considered to reflect dimensions of personality dysfunction which have been grouped into broad categories for conceptual convenience (see Box 12.1).

BOX 12.1 Personality disorders by cluster

Cluster A

These individuals tend to be persistently cold, awkward and isolative in their interactions with other people in their culture or social group. Robert Cloninger suggests they exhibit ‘low reward dependence’ among other prominent variable traits. This cluster includes:

• paranoid personality disorder, which is characterised by pervasive distrust and suspiciousness of others such that their motives are interpreted as malevolent

• schizoid personality disorder, which is characterised by a pervasive pattern of detachment from social relationships and a restricted range of expression of emotions in interpersonal settings, and

• schizotypal personality disorder, which is characterised by a pervasive pattern of social and interpersonal deficits marked by acute discomfort with, and reduced capacity for, close relationships, as well as by cognitive or perceptual distortions and eccentricities of beliefs and behaviour.

Cluster B

These individuals tend to be emotionally highly dramatic, labile and distressed (particularly in relationships with other people) in comparison with other people in their culture or social group. Robert Cloninger suggests they exhibit high ‘novelty seeking’, among other prominent variable traits. This cluster includes:

• antisocial personality disorder, which is characterised by a pervasive pattern of disregard for and violation of the rights of others

• borderline personality disorder, which is characterised by a pervasive pattern of instability of interpersonal relationships, self-image and affects, and marked impulsivity

• histrionic personality disorder, which is characterised by a pervasive pattern of excessive emotionality and attention seeking, beginning by early adulthood, and

• narcissistic personality disorder, which is characterised by a pervasive pattern of grandiosity (in fantasy, self-evaluation and behaviour), need for admiration and lack of empathy for others.

Cluster C

These individuals tend to be persistently anxious and inhibited in relationships and behaviour, compared with other people in their culture or social group. Robert Cloninger suggests they exhibit high ‘harm avoidance’, among other prominent variable traits. This cluster includes:

• avoidant personality disorder, which is characterised by a pervasive pattern of social inhibition, feelings of inadequacy and hypersensitivity to negative evaluation

• dependent personality disorder, which is characterised by a pervasive and excessive need to be taken care of that leads to clinging and submissive behaviour, and fears of separation, and

• obsessive-compulsive personality disorder, which is characterised by a pervasive pattern of preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness and efficiency.

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