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Introduction   

We all have unique personalities. Our personalities consist of patterns of thoughts, feelings, and behaviors. While many definitions of personality exist, the focus is usually on behavior patterns (1). Genetics and environment influence personalities. The word ‘personality’ originates from the Latin word persona, which referred to a theatrical mask worn to disguise the identities of performers as they played their parts and roles (1).

Our personalities remain with us throughout our lives and allow us to cope with life, manage our emotions, and connect with others. When someone develops a personality disorder, the ability to cope, manage life, and connect with others is significantly impacted.

Personality disorders are mental health disorders that are characterized by disruptive patterns of thinking, behaviors, mood, and ability to relate to other people. These disorders result in significant distress for those suffering from them and significantly impact their ability to function (2). Personality disorders are very complex and can be a lifelong condition.

Definitions

It is evident that personality defines us as individuals and determines how we interact with the world around us. The individual with a personality disorder may have a different perception of the world. They may experience disordered perceptions of reality and abnormal behaviors. This can affect their work, socialization, relationships, and other aspects of life. What contributes to the complexity of this disorder is the possibility that those experiencing this may not recognize their behaviors or the effect they are having on others (2).

Personality disorders can be complicated and challenging to treat; therefore, it is important to understand exactly what a personality disorder is.

There are ten types of personality disorders, including (3):

• Paranoid personality disorder
• Schizoid personality disorder
• Schizotypal personality disorder
• Antisocial personality disorder
• Borderline personality disorder
• Histrionic personality disorder
• Narcissistic personality disorder
• Avoidant personality disorder
• Dependent personality disorder
• Obsessive-compulsive personality disorder

Some characteristics are present within all personality disorders, relating to how people think, perceive, feel, and relate to others. These features include (3):

• Overwhelming negative feelings
• Feelings of distress, anxiety, worthlessness, and anger
• Avoiding other people
• Feeling emotionally disconnected
• Odd behavior
• Relationship difficulties
• Out of touch with reality

While there are common characteristics within the personality disorders, each of the ten types has its different characteristics and unique symptoms. Recognizing these is important in diagnosing personality disorders and ensuring correct treatment is provided.

Paranoid Personality Disorder

People with paranoid personality disorder experience paranoia. They feel suspicious of others and are mistrustful. These feelings usually have no basis. They often feel others are trying to harm, demean, or threaten them (2).

Specific characteristics of paranoid personality disorder include (5):

• Suspicious of others
• Lacks trust
• Questions the loyalty of others
• Does not confide in others, fears others will use information against them
• Perceives remarks or situations that are not threatening as personal attacks and insults
• Becomes hostile if they believe they are insulted
• Holds a grudge
• Suspects that spouse or partners are unfaithful without a valid reason

Schizoid Personality Disorder

Those suffering from schizoid personality disorder will display disinterest in interpersonal relationships. They display detachment from others. When interacting with others they will display a limited range of emotions (2).

Specific characteristics of schizoid personality disorder include (5):

• The behavior appears to be aloof or not interested in others
• Prefers to be alone
• Limited emotional responses and expressions
• Does not take pleasure in most activities
• Does not pick up on social cues
• Has little or no interest in personal or romantic relationships

Schizotypal Personality Disorder

A person with schizotypal personality disorder may have a distorted view of reality and exhibit superstitious and unusual behaviors. They do not feel a need for close relationships and feel discomfort when approached with a close relationship (2).

Specific characteristics of schizotypal personality disorder include (5):

• Displays unusual behavior or speech
• Has unusual thinking and beliefs
• Has flat emotions and emotional responses that are socially different
• Thinks or feels strange things
• Experiences social anxiety
• Uncomfortable with close relationships
• Has ‘magical thinking’ and believes that their thoughts can affect events or other people
• Believes that some things have hidden messages

Antisocial Personality Disorder (ASPD)

The person with ASPD will display a lack of respect towards others. They will not follow socially accepted behavior. They will often break the rules. These individuals will frequently break the law and disregard the negative consequences of their behaviors. They often cause physical and emotional harm to others. They will seldom take responsibility for their actions or behavior (2).

Specific characteristics of ASPD include (5):

• Little concern about the feelings or needs of others
• Dishonesty, theft, and manipulation of others
• Has repeated issues with law enforcement
• Frequently violates the rights of others
• Displays aggression and violence
• Lacks concern for personal safety or the safety of others
• Very impulsive
• Displays reckless behavior
• Has little remorse or regret regarding how their behavior affects others

Borderline Personality Disorder (BPD)

People experiencing BPD have difficulty with emotional regulation. They often suffer from low self-esteem, mood swings, impulsive behaviors, and have difficulty with relationships (2).

Specific characteristics of BPD include (5):

• Has extreme fear of being alone or abandoned
• Has feelings of emptiness
• Perceives self as weak
• Has extreme mood swings
• Threatens to self-harm
• Displays feelings of anger
• Very impulsive
• Displays risky behaviors, such as unsafe sex, substance use, binge eating, gambling
• Has stress-related paranoia

Histrionic Personality Disorder

Characteristics of histrionic personality disorder include a distorted self-image and intense unstable emotions. They often seek the approval of others and have a strong need to be noticed by others. They will display inappropriate or dramatic behaviors to gain attention (2).

Specific characteristics of histrionic personality disorder include (5):

• Frequently seeks attention
• Is overly emotional and dramatic
• Speaks very dramatically,
• Is easily led by others
• Has shallow emotions
• Very concerned about physical appearance
• Perceives relationships with others are closer than they are

Narcissistic Personality Disorder

The individual with narcissistic personality disorder has a strong desire to be admired by others and will seek praise. This originates from low self-esteem and lack of confidence. They will exhibit superiority and grandiosity and have very little empathy for other people (2).

Specific characteristics of narcissistic personality disorder include (5):

• Believes they are special and more important than others
• Has fantasies about being successful, powerful, and being attractive to others
• Lacks understanding of the needs and feelings of others
• Lies about their achievements and talents
• Seeks constant praise and admiration
• Feels superior to others and brags about themselves
• Expects special treatment
• Frequently takes advantage of others
• Experiences feelings of jealousy of others and frequently believes others are jealous of them

Avoidant Personality Disorder

A person with avoidant personality disorder suffers from chronic feelings of inadequacy. They are very sensitive to being negatively judged by others. They tend to withdraw from social activities due to fear of being rejected (2).

Specific characteristics of avoidant personality disorder include (5):

• Is sensitive to rejection and criticism
• Does not feel important or attractive enough, does not feel they are good enough
• Avoids activities
• Isolates self
• Avoids new activities and meeting new people
• Is extremely shy in social settings
• Fears of being embarrassed or being made fun of
• Fears disapproval

Dependent Personality Disorder

The individual with dependent personality disorder has a need to be cared for. They will exhibit submissive behaviors with a need for reassurance. They have difficulty making decisions. They have a fear of separation and will display clinging behaviors (2).

Specific characteristics of dependent personality disorder include (5):

• Feels they need to be taken care of
• Relies on others
• Is submissive and clings to others
• Fears having to take care of themselves if left alone
• Lacks confidence
• Need advice frequently, and needs help making decisions
• Lacks self-confidence
• Fears others will disapprove of them
• Will need to start a new relationship urgently when an old one ends

Obsessive Compulsive Personality Disorder (OCPD)

The person with OCPD will be consumed by an ongoing need for perfectionism, control, and orderliness. They are not flexible. They usually are not aware of their behaviors (2).

Specific characteristics of obsessive-compulsive personality disorder include (5):

• Focuses on details, rules, and order
• Is a perfectionist, everything needs to be perfect. Becomes upset when it is not
• Unable to finish tasks or projects due to inability to achieve perfection
• Feels the need to be in control of people and situations
• Unable to delegate tasks to others
• Extreme focus on work or projects
• Unable to discard broken or worthless objects
• Very rigid and stubborn
• Is not flexible regarding morality, values, and ethics
• Very rigid on spending money and budgeting

Clusters

The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) recognizes personality disorders as a psychiatric condition. The DSM-5 has organized the ten personality disorders into three groups or clusters. This is based on the key features that certain personality disorders share (4).

The three groups or clusters are organized by these key components (4).

Cluster A

This cluster is characterized by odd or eccentric behavior. These individuals have difficulty maintaining relationships as they are perceived as peculiar, detached, or suspicious (4). Cluster A personality disorders include:

• Paranoid personality disorder
• Schizoid personality disorder
• Schizotypal personality disorder

Cluster B

This cluster is characterized by dramatic and erratic behavior. These individuals have very intense emotions. The characteristic behaviors include impulsivity, promiscuous behavior, and law-breaking behaviors (4). Cluster B personality disorders include.

• Antisocial personality disorder
• Borderline personality disorder
• Histrionic personality disorder
• Narcissistic personality disorder

Cluster C

This cluster is characterized by anxiety and fearfulness (4). Cluster C personality disorders include.

• Avoidant personality disorder
• Dependent personality disorder
• Obsessive-compulsive personality disorder

Assessment

Personality disorders can occur in anyone, and different types of personality disorders affect individuals differently. Personality disorders are very complex and one of the most difficult mental health disorders to understand and treat. Personality disorders are frequently misdiagnosed or underdiagnosed as anxiety and depression become the focus of treatment (2). To correctly diagnose and provide accurate treatment a thorough assessment should be performed.

A contributing factor to the difficulty of diagnosing personality disorders is that those with the disorder usually do not think there is a problem with their thinking or behavior. As a result, they are reluctant to seek treatment or help. When they do reach out for help, it is frequently due to problems related to anxiety, depression, substance abuse, or issues created by the personality disorder (2).

The DSM-5 gives healthcare providers guidance in assessing and diagnosing personality disorders. According to the DSM-5, to be diagnosed with a personality disorder, the individual must meet the following criteria (4):

• Must have chronic and pervasive patterns of behavior that affect social functioning, school, work, and relationships.
• Must have symptoms that affect two or more of the following areas: thoughts, interpersonal functioning, emotions, or impulse control.
• The onset of patterns of behavior can be traced back to adolescence or early adulthood.
• The patterns of behaviors cannot be explained by any other mental disorders, substance abuse, or medical conditions.

A complete assessment should include:

• A thorough interview, discussing past and present symptoms
• A review of personal and family medical history
• A medical exam to rule out potential causes of symptoms.
• If needed, interviews with family and friends

Determining the type of personality disorder can be challenging. This is due to the possibility of overlap between the types of personality disorders. In addition, other mental health disorders may be present such as depression, anxiety, post-traumatic stress disorder, eating disorders, or substance abuse (17). Additional exams may be required including (17):

• A physical exam
• A mental health exam
• Using standard guidelines to compare symptoms to
• Neuropsychological testing

Screenings and Tests

While there is not a single definitive test for personality disorders, there are some tools that are helpful in screening for personality disorders. Specifically borderline personality disorder (BPD). These include (5, 6).

• The McLean Screening Instrument for BPD (MSI-BPD)
• The Personality Diagnostic Questionnaire 4th ed-BPD Scale (PDQ-4)
• Structured Clinical Interview for DSM-5 Personality Disorders (SCID-5-PD)
• Zanarini Rating Scale for Borderline Personality disorder (ZAN-BPD)

While these tests help identify the probability of a personality disorder, they do not determine a diagnosis but indicate the need for further evaluation (6).

DSM-5 Diagnostic Criteria for Personality Disorders

The DSM-5 is published by the American Psychiatric Association (APA) and provides the official diagnostic criteria for personality disorders (6). Each of the ten personality disorders has specific criteria that must be met to be assigned a specific personality disorder.

Paranoid Personality Disorder

According to the DSM-V, this disorder begins by early adulthood with behaviors that are pervasive and suspicious of others. For a diagnosis of paranoid personality disorder to be given four or more of the following must be present (7).

1. Suspects for no reason that others are attempting to harm, exploit, or deceive them.
2. Is doubtful that friends or associates are loyal or can be trusted and become preoccupied with these thoughts.
3. They are hesitant to confide in others as they fear the information they share will be used against them.
4. Misinterprets benign remarks or events, finding hidden threatening or demeaning meanings in them.
5. Does not forgive others and holds grudges.
6. Feels that others are attacking their character or reputation which causes them to react in anger or counterattack.
7. Is suspicious of their spouses, or sexual partners, fidelity with no justification.

Schizoid Personality Disorder

According to the DSM-V, this disorder begins by early adulthood with a pervasive pattern of detachment from social relationships and limited expression of emotions. To receive a diagnosis of schizoid personality disorder four or more of the following must be present (8).

1. Does not enjoy or desire having close relationships or being part of a family.
2. Prefers being alone and doing solitary activities.
3. Does not have interest in having sexual relationships.
4. Finds little pleasure in any activity.
5. Has few friends.
6. Shows indifference when others give criticism or praise.
7. Appears to have a flat affect or be detached and emotionally cold.

Schizotypal Personality Disorder

According to the DSM-V, this disorder begins by early adulthood with a pattern of social and interpersonal deficits that include cognitive and perceptual distortions and eccentricities. For a diagnosis of schizotypal personality disorder to be given five or more of the following must be present (9).

1. Ideas of reference
2. Odd beliefs or magical thinking. May have bizarre fantasies or believe they are clairvoyant or telepathic.
3. Unusual perceptual experiences, such as body illusions.
4. Odd thinking and speech.
5. Will be suspicious or have paranoid ideations.
6. Inappropriate affect.
7. Odd, peculiar, or eccentric appearance or behavior.
8. Lack of friends.
9. Social anxiety and paranoid fears, which is not relieved with familiarity.

Antisocial Personality Disorder

According to the DSM-V, this disorder occurs since the age of 15 years and is a disregard for the rights of others and a violation of the rights of others. For a diagnosis of antisocial personality disorder to be given three or more of the following must be present (10).

1. Does not respect the law and is frequently arrested. Does not conform to social norms or have respect for lawful behaviors.
2. Is deceitful with repeated lying. Cons and manipulates others for personal pleasure or profit.
3. Very impulsive.
4. Displays aggressive behavior and irritability. Is assaultive and frequently gets in physical fights.
5. Displays reckless behavior with no regards to personal safety or safety of others.
6. Consistently irresponsible, has difficulty holding a job or meeting financial obligations.
7. No remorse for hurting or mistreating others.

Borderline Personality Disorder

According to the DSM-V, this disorder begins in early adulthood and consists of impulsivity and instability in interpersonal relationships and self-image. For a diagnosis of borderline personality disorder to be given five or more of the following must be present (11).

1. Extreme effort to avoid abandonment that may be real or imagined.
2. There is a pattern of unstable interpersonal relationships.
3. Unstable self-image or sense of self.
4. Impulsivity in at least two areas that are self-damaging such as spending, substance abuse, binge eating, sex, or reckless driving.
5. Suicidal behaviors or self-harming behaviors that are reoccurring.
6. Irritability, anxiety, and dysphoria that last several hours and rarely more than several days.
7. Ongoing feelings of emptiness
8. Intense anger, constant anger that is inappropriate. Has difficulty controlling anger.
9. Displays dissociative symptoms and stress-related paranoid ideation.

Histrionic Personality Disorder

According to the DSM-V, this disorder begins in early adulthood and consists of extreme emotionality and attention-seeking behavior. For a diagnosis of histrionic personality disorder to be given five or more of the following must be present (12).

1. Desires to be the center of attention and is uncomfortable in situations in which they are not.
2. Displays inappropriate sexually provocative or seductive behavior.
3. Has a shallow expression of emotions.
4. Frequently will use physical appearance to gain attention.
5. Speech is very impressionistic and lacks in detail.
6. Has exaggerated expression of emotions and demonstrates self-dramatization.
7. Is easily influenced by others.
8. Believes that relationships are more intimate than they are.

Narcissistic Personality Disorder

According to the DSM-V, this disorder begins by early adulthood and consists of a pervasive pattern of grandiosity, with a need for admiration. There is a lack of empathy. For a diagnosis of narcissistic personality disorder to be given five or more of the following must be present (13):

1. Is grandiose with a sense of self-importance. Exaggerates their achievements and talents. Expects to be recognized as superior.
2. Has a preoccupation with fantasies of success, beauty, love, brilliance, and power.
3. Believes they are special and unique. Believes they should associate with other special or high-status people and institutions.
4. Seeks constant and excessive admiration.
5. Has a sense of entitlement and believes they should receive special treatment.
6. Will take advantage of others to meet their needs and is interpersonally exploitative.
7. Cannot recognize or acknowledge the feelings and needs of others and lacks empathy.
8. Is envious of others, and believes they are envious of them.
9. Displays haughty behaviors and arrogant attitudes.

Avoidant Personality Disorder

According to the DSM-V, this disorder begins by early adulthood and consists of social inhibition, feelings of inadequacy, and hypersensitivity to negative feedback. For a diagnosis of avoidant personality disorder to be given four or more of the following must be present (14).

1. Fears criticism, rejection, and disapproval. Will avoid occupational activities that involve interpersonal contact.
2. Has a fear of not being liked and will avoid getting involved with people because of this.
3. Will avoid intimate relationships for fear of being shamed or ridiculed.
4. Is preoccupied with rejection or being criticized in social situations.
5. Displays inhibition in new interpersonal situations or relationships because of feelings of inadequacy.
6. Has feelings of inferiority, and views self as unappealing and socially inept.
7. Does not engage in new activities or take personal risks for fear of being embarrassed.

Dependent Personality Disorder

According to the DSM-V, this disorder begins by early adulthood and consists of the need to be taken care of. This is demonstrated by submissive and clinging behavior and the fear of separation. For a diagnosis of dependent personality disorder to be given five or more of the following must be present (15).

1. Needs advice and reassurance from others and has difficulty making everyday decisions.
2. Will not disagree with others as they fear they will lose their support or approval.
3. Lacks confidence to initiate projects or do things on their own.
4. Will go to excessive lengths or volunteer to do unpleasant things or tasks to gain the support of others.
5. Has exaggerated fears of being unable to care for themselves. Feels helpless when left alone.
6. When a close relationship ends, they desperately seek another to replace the source of care and support.
7. They are preoccupied with the fear of being left alone and having to take care of themselves.

Obsessive-Compulsive Personality Disorder

According to the DSM-V, this disorder begins by early adulthood and consists of a preoccupation with orderliness, perfectionism, and mental and interpersonal control. For a diagnosis of obsessive-compulsive personality disorder to be given four or more of the following must be present (16).

1. There is a preoccupation with details, order, organization, rules, lists, or schedules. This can be to an extent where the major point of the task or activity is lost.
2. They are unable to complete a task or project because their own standards of perfectionism interfere.
3. Forfeits leisure activities, friendships, and relationships due to excessive devotion to work and productivity.
4. Is overconscientious, rigid, and inflexible regarding matters of ethics, values, and morality
5. Has difficulty discarding useless or worthless objects, including those that have no sentimental value.
6. Insists others submit to doing things exactly their way and is reluctant to delegate tasks to others.
7. Is miserly towards self and others, and views money as something to be hoarded for future needs or emergencies.
8. Very stubborn and rigid.

Symptoms and Causes

We have determined that the signs and symptoms of each personality disorder are different. The common factor shared among them is the problem and uncertainty in which these individuals see themselves. All these disorders cause problems in relationships with other people.

While symptoms and treatments are better understood, the cause of personality disorders continues to be vague. It is known that the factors below contribute to the development of personality disorders (2).

• Genetics
• Brain changes
• Childhood trauma
• Verbal abuse
• Cultural factors

Genetics

A malfunctioning gene has been identified that may contribute to obsessive-compulsive personality disorder. Other research is focusing on genetic links to aggression, anxiety, and fear. All of which are traits of personality disorders (2).

Brain changes

There have been brain changes noted in those with personality disorders. Altered amygdala functioning has been linked to paranoid personality disorder and changes in the frontal lobe have been linked to schizotypal personality disorder (2).

Childhood trauma

Studies have linked childhood trauma to the development of personality disorders. There is a correlation between borderline personality disorder and childhood sexual trauma. Those with borderline personality disorder and antisocial personality disorder experience issues with trust and intimacy. Trust and intimacy both have been linked to childhood abuse and trauma (2).

Verbal abuse

A study indicated that people who were exposed to childhood verbal abuse were three times as likely to experience borderline, narcissistic, obsessive-compulsive, or paranoid personality disorders (2).

Cultural factors

There are varying rates of personality disorders in different countries. It is thought that cultural factors may play a role in this (2).

Management and Treatment

The treatment of personality disorders is most effective when it focuses on the specific personality disorder. The severity of the disorder and current life situation are also considered. Treatment can be lifelong and should address medical, social, and mental needs.

The most effective approach to treatment is a multidisciplinary approach, with a treatment team that includes (16):

• Psychiatrist
• Psychologist or Therapist
• Psychiatric nurse
• Social Worker
• Pharmacist

While personality disorders are difficult to diagnose, they can also be challenging to treat. As mentioned previously, those suffering from personality disorders are often reluctant to seek treatment. Also, there are currently no medications that are approved to treat personality disorders specifically. All these factors contribute to making personality disorders one of the most difficult mental health disorders to treat (2).

Psychotherapy does help treat and manage personality disorders and is considered the gold standard of treatment (19). Psychotherapy focuses on thoughts, emotions, and behaviors. The goals of psychotherapy are (2).

• Reducing anxiety and depression
• Reducing immediate stress
• Assisting the individual in understanding their problems are internal and not caused by other people or situation
• Decreasing socially undesirable behavior
• Decreasing unhealthy behavior
• Modifying the personality traits that are causing individual difficulties

Treatment Modalities

Those with personality disorders may lack motivation to change. The behaviors they experience could take years to change. The primary treatment modalities for personality disorders are pharmacological and psychosocial. All treatment modalities for these disorders should involve an intensive long-term plan of care. The following therapies have proven to be effective in the treatment of personality disorders (18).

• Individual psychotherapy
• Interpersonal therapy (IPT) (20)
• Milieu or group therapy
• Cognitive behavior therapy (CBT)
• Dialectical behavior therapy (DBT)
• Psychoanalytical therapies
• Family therapy (4)

Individual psychotherapy

Individual psychotherapy may be time-limited, or it may include long-term psychoanalytical therapy. This therapy is appropriate for personality disorders as it focuses on interpersonal relationship problems and developing interpersonal relationship skills. This therapy focuses on understanding and addressing maladjusted behaviors, cognition, and moods that affect the personal lives and relationships of those with personality disorders (18).

Interpersonal therapy

The focus of interpersonal therapy explores how those with personality disorders interact with others, family, and friends. This is usually done on a one-to-one basis but can also be used in a group setting. It addresses current problems and relationships. It is structured, time-limited, focuses on interpersonal relationships and communication, focuses on present relationships, and attempts to improve interpersonal functioning and support (20, 21).

Milieu or group therapy

Group therapy consists of supportive groups that focus on the development of social skills. It is also helpful in the development of interpersonal trust. It is based on support and feedback from peers. It is very effective in helping those with antisocial personality disorder and social anxiety (18).

Cognitive behavior therapy (CBT)

CBT assists those with personality disorders to recognize and change their inaccurate perceptions about themselves, other people, and the world in which they function. The goal is to replace unhealthy thoughts with healthier and more positive thoughts and perceptions (20). These strategies assist the person in recognizing and correcting distorted and irrational thought patterns (18).

Dialectal Behavior Therapy (DBT)

DBT was originally developed by Marsha Linehan, as a specific type of psychotherapy used for the treatment of chronic self-injurious behaviors in BPD. It is based on the belief that those with personality disorders suffer from emotional dysregulation. DBT has become a popular treatment for those suffering from BPD. This therapy consists of four primary modes (18).

• Group skills training
  • People are taught skills addressing those problems specific to BPD. This includes core mindfulness skills, interpersonal effectiveness skills, emotion modulation skills, and distress tolerance skills (18).
• Individual psychotherapy
  • The sessions are held weekly on an individual basis and address dysfunctional behavioral patterns, personal motivation, and skills strengthening (18).
• Telephone contact
  • The therapist remains available to the person by telephone. This provides the person with help and support in applying the skills they are learning, and to help with real-life situations. This also focuses on avoiding self-injury (18).
• Therapist consultation/team meeting
  • Therapists meet regularly to review their progress and work. They provide motivation and support for each other (18).

Psychoanalytical therapies

This consists of two types of approaches that have proved beneficial in the treatment of BPD. These are mentalization therapy and transference therapy (18). Mentalization therapy focuses on teaching people with personality disorders to notice and reflect on their internal states of mind and those of others (4). Transference therapy is based on the transference that occurs between the therapist and the patient. The goal is to improve self-perception and relationship skills (18).

Family therapy

Involving the family in therapy allows them to address and change unhealthy reactions to each other and to learn communication skills (18).

Psychopharmacology

As mentioned previously, medications do not influence the direct treatment of personality disorders. However, medications may be helpful in some circumstances and provide relief for associated symptoms (18). Medications may be prescribed based on the symptoms being displayed. A healthcare provider may prescribe one or more from the following group of medications (4).

• Antianxiety medications
• Antidepressant medications
• Antipsychotic medications
• Mood stabilizers

Prevalence of Personality Disorders

While anyone can be affected by a personality disorder, everyone will be affected differently. The majority of personality disorders surface during the teenage years. People afflicted with antisocial personality disorder will start to display symptoms as early as 11 years old (2). Males are more likely to develop antisocial personality disorder, and females are more likely to be affected by borderline, histrionic, and dependent personality disorders (2). Of the universal population, the prevalence of personality disorders is 10-13%.

It is also important to recognize the following statistics related to the prevalence of personality disorders (22):

• In the United States, approximately 9% of adults have at least one personality disorder.
• Personality disorders are one of the most common psychiatric diagnoses, they are diagnosed in 40-60% of all psychiatric patients.
• Risk factors that significantly increase the chances of an individual developing a personality disorder are traumatic childhood experiences, including abuse and neglect.
• Studies indicate that 60-90% of individuals treated for substance abuse have at least one personality disorder.

Awareness of specific prevalence rates provides information on how common each personality disorder is in different populations and geographical locations. It can also assist in understanding and researching different treatment methods (22).

Paranoid personality disorder

In the United States statistics indicate the prevalence of paranoid personality disorder is 2-10% in people receiving outpatient treatment and 10-30% in people receiving inpatient treatment (22).

Schizoid personality disorder

Statistics on schizoid personality disorder are difficult to determine as these individuals seldom seek treatment. It is estimated that approximately 3-4% of the general population suffers from this disorder (22).

Schizotypal personality disorder

The estimated prevalence rate of schizotypal personality disorder is approximately 1-3.9% of the overall United States population, with a global prevalence of 0.6-4.6%. Prevalence is higher among people with lower socioeconomic status, and people who are divorced or widowed, and men (26).

Antisocial personality disorder

Statistics for antisocial personality disorder indicate that approximately 3% of the United States population has this disorder. Approximately 80% of individuals with this disorder will show symptoms by the age of 11 (22).

Borderline personality disorder

Statistics show that approximately 1.6 % of the United States population suffers from bipolar personality disorder. There is an indication that this number may is higher, but it is known that over five million people experience this. Of those individuals diagnosed with bipolar personality disorder 75% are women. Those with borderline personality disorder have a high risk of suicide, with approximately 75% of these people attempting suicide at least once in their lives and 10% eventually completing suicide (22).

Histrionic personality disorder

Histrionic personality disorder presents in approximately 2.1% of the general population (22).

Narcissistic personality disorder

Narcissistic personality disorder occurs in approximately 0.5% of the United States population. Between 2-16% of people receiving treatment from a mental health provider will receive this diagnosis. This disorder has been diagnosed in 6% of the forensic population, 20% of the military population, and 17% of first-year medical students (22).

Avoidant personality disorder

While approximately 40% of the population experiences feelings of shyness, the symptoms of avoidant personality disorder are significantly more intense than general shyness. Approximately 2.5% meets the criteria for this disorder (22).

Dependent personality disorder

Statistics for dependent personality disorder indicate that less than 1% of the United States population has this disorder. Some studies indicate this disorder is more prevalent in women (22).

Obsessive-compulsive personality disorder

Obsessive-compulsive personality disorder occurs in nearly 8% of the population. This disorder is twice as prevalent in men than in women (22).

The Most Common Types of Personality Disorders

All personality disorders are significant and should be diagnosed and treated accordingly. However, there are types of personality disorders that are more common and that are diagnosed more frequently.

A major study identified obsessive-compulsive personality disorder as the most prevalent personality disorder (23, 24). The second most common is narcissistic personality disorder and the third most common is borderline personality disorder (23).

While obsessive-compulsive, narcissistic, and borderline personality disorders have been identified as the most prevalent of the personality disorders, they are not the most diagnosed. Borderline personality disorder and antisocial personality disorder are the most frequently diagnosed personality disorders (25).

The reason that borderline personality disorder and antisocial personality disorders are more frequently diagnosed but are not identified as more prevalent than the others is that they frequently go undiagnosed. Many individuals who suffer from certain personality disorders deny having any problems and refuse to seek treatment. This results in the personality disorder being underdiagnosed (25).

Borderline Personality Disorder and Antisocial Personality Disorder

Borderline personality and antisocial personality disorders have been identified as the personality disorders most frequently diagnosed. Nurses working in different settings will likely encounter people with borderline personality or antisocial personality disorder.

Individuals with borderline personality disorder will usually be hospitalized because of attempts at self-harm. Whereas the person with antisocial personality disorder may be hospitalized because of a judicially ordered evaluation (18). These two disorders have very distinct characteristics that nurses should be aware of.

Borderline Personality Disorder

A borderline personality disorder is characterized by chaotic relationships, affective instability, and fluctuating attitudes. These individuals frequently seem to be in a state of crisis, with recurrent mood swings. This is sometimes referred to as “thriving on chaos” (18). The key characteristics of borderline personality disorder include (18).

• Chronic depression:
  • Depression is very common in this disorder. It has been linked to feelings of abandonment in early childhood.
• Inability to be alone:
  • This is related to the chronic fear of abandonment. Those suffering from this disorder have difficulties being left alone.
• Clinging and distancing:
  • Clinging behavior involves the person appearing helpless or even childlike. They are very dependent on others and seek constant reassurance. If they feel rejected, they can exhibit self-harming behaviors. Distancing behaviors involve hostility, anger, and devaluing others.
• Splitting:
  • This is a defense mechanism very common in those with this disorder. They view others, situations, and even themselves in an all-or-nothing term. Their thinking consists of “You are either with me or you are against me.”
• Manipulation:
  • Individuals experiencing this disorder are skilled at manipulation. They will exhibit behaviors to achieve their desired results. Playing one person against another is common behavior.
• Self-destructive behaviors:
  • Repetitive self-destructive behaviors are common and are classic manifestations of borderline personality disorder. While this behavior can result in suicide, the intent is more of a manipulative one. The behavior is intended to get a rescue response from others. Suicide attempts are also common and are a result of feelings of abandonment.
• Impulsivity:
  • Individuals with this disorder have poor impulse control. Impulsive behaviors include gambling, substance abuse, reckless driving, promiscuity, and binging and purging.

Antisocial Personality Disorder

In the past, antisocial personality disorder was referred to as sociopathic or psychopathic (18). When these individuals are seen in a healthcare setting, it is usually because of legal consequences. Frequently, they are encountered in jails, prisons, and rehabilitation facilities. Those with this disorder will exhibit a pattern of socially irresponsible, exploitative, and guiltless behavior. One of the key characteristics of this disorder is the tendency to disregard authority and rules (18). The clinical picture of someone with antisocial personality disorder includes (18).

• Disregard for the rights of others.
• Exploit and manipulate others for personal gain.
• Unconcerned about obeying the law.
• Difficulty holding a job.
• Difficulty having relationships.
• Appear to be cold.
• Will be argumentative, cruel, and malicious.
• Lack of warmth and compassion.
• Have low tolerance and easily frustrated
• Impulsivity
• They are restless and easily bored
• They often take chances and seek thrills.

Nursing Management of Personality Disorders

Nursing management of personality disorders involves the nursing process and includes the following (27).

• Nursing Assessment
• Nursing Diagnosis
• Nursing Care Planning
• Nursing Interventions
• Evaluation
• Documentation

Nursing Assessment

The assessment of the individual with a personality disorder should include (27):

• History
  • Many people suffering from a personality disorder report difficult relationships with their parents that begin in early childhood.
  • Many have experienced childhood physical, verbal, or sexual childhood abuse.
• Mood and affect
  • People with personality disorders will experience a pervasive mood of dysphoria. This includes unhappiness, restlessness, and malaise. They will also report intense loneliness, boredom, frustration, and feelings of emptiness.
• Thought process and content
  • Thoughts about self and others are often extreme. Some will adore and idolize others only to diminish them if they do not meet their expectations.
• Intellectual and sensorium process
  • This assesses the person’s orientation to reality, and if their intellectual capacities are intact.

Nursing Diagnosis

A nursing diagnosis for a person with a personality disorder can include the following (27):

• Ineffective coping:
• This is related to failure to learn or change their behaviors based on past experiences.
• Social isolation:
• This is related to ineffective interpersonal relationships.
• Risk for suicide:
• This is related to low frustration tolerance.
• Risk for self-mutilation:
• This is related to impulsive behavior.
• Risk for other-directed violence:
• This is related to the lack of feelings or remorse.

Nursing Care Planning

Nursing care plans for a person with a personality disorder may include the following (27).

• The person will be safe and free from significant injury.
• The person will not harm others or destroy property.
• The person will verbalize greater satisfaction with relationships.
• The person will demonstrate problem-solving skills.
• The person will demonstrate increased control of impulsive behavior.
• The person will take steps to meet their own needs.

Nursing Interventions

People with personality disorders often require long-term psychotherapy. The following nursing interventions should be a priority (27).

• Promotion of client safety
  • The nurse should always consider suicidal ideation. Self-harm should also be a serious consideration.
• Promotion of therapeutic relationships:
  • The nurse should assist in providing structure and limit setting in therapeutic relationships.
• Establishing boundaries in relationships:
  • The nurse should be clear about the boundaries of the therapeutic relationship. This will ensure that no boundaries are violated.
• Teaching effective communication skills:
  • The nurse should assist in basic communication skills. This should include making eye contact, active listening, taking turns talking, validating the meaning of others’ communication, and using ‘I’ statements.
• Assisting with coping skills and controlling emotions:
  • The nurse should help the person with the personality disorder to identify their feelings and learn to accept them without exaggerated responses, such as self-harm or property destruction. The nurse could encourage the person to keep a journal to assist in gaining awareness of feelings.
• Reshaping thinking patterns:
  • The nurse could use a technique such as cognitive restructuring. This is used to change patterns of thinking by assisting the person to identify negative thoughts and replace them with positive ways of thinking. Another technique is thought stopping. This alters the process of negative or self-critical thought patterns.
• Structuring daily activities of living:
  • The nurse should minimize unstructured time, assist in planning activities, and encourage the person to develop a written schedule.

Evaluation

The nurse should evaluate the effectiveness of the care plan and goals.

Progress towards goals would be evidenced by the following (27):

• The person with a personality disorder will be safe and free of significant injury.
• The person with a personality disorder will not harm others or destroy property.
• The person with a personality disorder will demonstrate increased control of impulsive behavior.
• The person with a personality disorder will take appropriate steps to meet their own needs.
• The person with a personality disorder will demonstrate problem-solving skills.
• The person with a personality disorder will verbalize greater satisfaction with relationships.

Documentation

Documentation is an important part of monitoring the progress, or lack of progress, in the treatment of an individual with a personality disorder. Documentation should include the following (27).

• Individual findings include social exchanges, factors that affect interactions, and specifics of the individual’s behavior.
• The individual’s cultural and religious beliefs and expectations.
• The individual’s specific plan of care should include a teaching plan.
• How the individual is responding to the plan of care, interventions, teaching, and actions performed.
• The individual’s progress toward or attainment of the desired outcomes.

Special Considerations

It is evident that personality disorders are not uncommon, and approximately 15% of all psychiatric patients will have a personality disorder (27). While some are treated on psychiatric units, there is a possibility that all nurses will encounter an individual with a personality disorder. It is essential to recognize these disorders and specific risks associated with the care of these individuals.

Those with personality disorders have a higher death rate, higher rates of suicide attempts, higher rates of suicide completion, accidents, and emergency department visits (26). They also have higher separation rates, divorce, and involvement in legal proceedings (26).

Personality disorders have also been linked with criminal behaviors, and it is estimated that 70-85% of criminals have a personality disorder. Those with personality disorders also have higher rates of alcoholism and drug abuse (27).

Self-Harm and Suicide Risk

There is a significant risk for suicide, suicide attempts, and self-harm in those with personality disorders (28). Cluster B personality disorders, including borderline personality disorder and antisocial personality disorder, are strongly associated with suicide risk and self-injurious behaviors (29). Suicidal ideations and self-injurious behaviors are critical characteristics of borderline personality disorders (29).

Nurses should be vigilant regarding suicidal behaviors and self-injurious behaviors when caring for those with personality disorders.

Self-harm, self-injurious, or self-mutilation can be a difficult concept to understand. This behavior consists of the individual deliberately inflicting harm and pain on themselves. The injuries can be minor or severe. Certain personality disorders can place individuals at increased risk for these behaviors, specifically borderline personality disorder.

It is essential to realize that self-harm is not a mental health disorder but a behavior (30). Self-injurious behaviors can consist of the following (30).

1. Cutting self
2. Burning self
3. Breaking bones
4. Bruising self
5. Punching self
6. Pulling out hair

Self-harm is also referred to as non-suicidal self-injury behavior. This behavior intends to hurt themselves but not to cause death. The reasons for self-injurious behavior include (31).

• To assist with coping:
  • This behavior makes some people feel good, that they can feel pain or decrease negative feelings (31). 
• To direct emotion inward:
  • Some people self-harm to take out anger on themselves or to punish themselves (31).
• To communicate with others:
  • This behavior is a way to communicate distress or ask for help or support (31).

Conclusion

Personality disorders are complex mental health disorders, and those who suffer from them encounter frequent and significant challenges. This course has provided information on each personality disorder and treatment modalities that have been proven to help treat these disorders. Nurses working in all areas are likely to encounter individuals with a personality disorder. Therefore, all nurses need to be aware of these disorders, diagnostic criteria, and how to manage the symptoms to provide the best care possible and improve the quality of life for these people.

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