There are some people we meet and know whose traits and behaviors astound us. They may appear isolated, eccentric, manipulative or even abusive. It could be a friend, colleague, teacher, parent or even yourself. This is simply an introduction into how DSM V characterizes personality disorders and the behaviors these people display. I shall develop on each cluster and disorder in more posts over time. As you read through, it is highly possible that you’ll recognize some traits in yourself and those around you, but it’s important to remember that each exists on a spectrum and if you believe that you or a close one exhibit similar behaviors, I would advise you seek clinical advice before jumping to any conclusions.
There are four defining features to the 10 personality disorders:
- Distorted thinking patterns
- Problematic emotional responses
- Over/Under-regulated impulse control
- Interpersonal difficulties
As mentioned in the Issues of Mental Diagnostics post, clinicians must attempt to determine the etiology of the condition as a personality disorder diagnosis is not applicable if the symptoms can be better explained by:
- Substance Abuse (Alcohol Dependence, Cannabis Use etc…)
- Anxiety Disorders (Social Anxiety etc..)
- Depression (Clinical Depression etc..)
- Dissociative Disorders (Dissociative Identity Disorder…)
- Post Traumatic Stress Disorder
The patient must be at least 18 years of age, although the behaviors typically emerge in adolescence and continue into adulthood.The patient must meet the minimum number of criteria that characterize the disorder for diagnosis (e.g 5/9), symptoms must be repeatedly observed without regard to time, place, or circumstance and precipitate significant distress and functional impairment.
The DSM classifies them into three clusters:
- Cluster A: ‘Odd, eccentric’
- Cluster B: ‘Dramatic, emotional, erratic’
- Cluster C: ‘Anxious, fearful’
Co-morbidity is not unusual and the individual may be diagnosed with more than one personality disorder. A study found that all three clusters were significantly comorbid with a wide range of DSM-IV Axis I disorders (Psychotic, Mood, Eating, Dissociative, Anxiety and Substance Abuse disorders) and significant associations of personality disorders with functional impairment were largely accounted for by Axis I comorbidity.
Cluster A: Paranoid, Schizoid and Schizotypal Personality disorders
Disorders in this cluster are specified by distorted thinking, social awkwardness and social withdrawal.
Paranoid: Characterized by a pervasive distrust and suspiciousness of other people. These individuals believe others are out to get them in one way or another and will endeavour to protect themselves and keep their distance from others. They have a propensity to hold grudges and display pathological jealously. Their emotional life tends to be dominated by distrust and hostility.
Schizoid: Characterized by a pervasive pattern of social detachment and a restricted range of emotional expression. These individuals do not take pleasure in social interaction and are generally isolated. They may come across as aloof, detached and cold and tend to appear indifferent to praise and criticism.
Schizotypal: Characterized by a pervasive pattern of social and interpersonal limitations. Similar to Schizoid PD, they also have a reduced capacity for social relationships, hence inclined to social isolation. Though, these individuals will also experience perceptual and cognitive distortions and/or eccentric behavior e.g. seeing a shadow in peripheral vision that is infact not there. They may hold superstitious or odd beliefs systems and are prevalent in families where someone has been diagnosed with Schizophrenia.
Cluster B: Antisocial, Borderline, Histrionic and Narcissistic Personality disorders
Disorders in this cluster are specified by impulse control and emotional dysregulation.
Antisocial (Sociopathy): Characterized by a pervasive pattern of disregard for the rights of other people that often manifests as hostility and/or aggression. Deceit and manipulation are also central features and relative behaviors tend to spring up in childhood. These children may engage in theft, arson, bullying, hurt or torment animals or people. Conduct disorder is usually an appropriate diagnosis at this time. As they continue into adulthood, these individuals are prone to risky and dangerous situations, often acting on impulses and displaying high levels of irresponsibility that can result in legal difficulties, accidents, unemployment etc. Yet, often blame others for their wrong-doings.
Borderline: Characterized by emotional dysregulation, self harm and impulsive behavior. Typically female, they tend to experience intense and rapidly shifting moods, that require a considerable amount of time before they calm down. Consequently, they frequently have angry outbursts and engage in impulsive and self destructive behaviors (i.e. substance abuse, risky sexual liaisons, self-injury, overspending, binge eating etc) in order to soothe or self-medicate. Harsh judgements/criticisms are applied to themselves and others which causes them to vacillate back and forth between ‘all good’ and ‘all bad’ standpoints (Splitting), or have an ‘all or nothing’ mentality. Inside is an unstable sense of self, manifested in numerous ways including frequent career, life goals or partner changes that can be quite sudden, radical and lacking preparation. You could call them ‘Women of Extremes’.
Histrionic: Characterized by a pattern of excessive emotionality and attention seeking. Uncomfortable in situations where they aren’t the centre of attention, these ‘drama queens’ tend to be seductive, flirtatious and dress in a manner that draws attention to them. They can be flamboyant and theatrical, yet simultaneously display vague and shallow emotions, causing some to view them as insincere. They feel depressed when the spotlight isn’t on them and are uncomfortable being alone, especially within an intimate relationship.
Narcissistic: Characterized by excessive preoccupation with personal adequacy, power, prestige and vanity. These individuals possess a powerful sense of entitlement and believe they deserve special treatment which leads them to act in ways that fundamentally disregard and disrespect the worth of those around them. They may come across as arrogant and exploitative and are highly frustrated or even enraged when others don’t admire them as much as they believe they deserve. Narcissists typically lack empathy and their relationships with colleagues, friends partners and even their own children tend to be superficial and devoid of intimacy and true love. They are able to use and/or discard anyone who does not conform to their way. Status and image are of utmost importance, yet the roots of these behaviors link back to their own fragile self-esteem. They can be quite manipulative and use many different strategies to gain control over others. There is a lot to say, but I shall refrain for now.
Cluster C: Avoidant, Dependent and Obsessive-Compulsive Personality disorders
These three personality disorders share a high level of anxiety.
Avoidant: Characterized by a pervasive pattern of social inhibition, feelings of inadequacy, and a hypersensitivity to negative evaluation.They predominantly believe they are not good enough which can bring forth intense anxiety of rejection, criticism and ridicule, so they avoid social situations and interactions such as parties, speaking up in class or meetings etc. Some may perceive them as distant and shy or stiff and restricted. This perpetuates their belief and further limits their ability to develop social skills, make friends and progress professionally.
Dependent: Characterized by a strong need for others to take care of them. They are prone to ‘clingy’ behavior and submit to the desires of other people in order to avoid conflict. This is usually due to an emotional void they are trying to fill (typically unmet emotional needs from childhood) and the fear of being alone. Hence, a dependent individual is more vulnerable to manipulation, abuse and repetition compulsion (cycle of relationships that result in disappointment again and again).
Obsessive-Compulsive: Characterized by preoccupation with rules, regulations and orderliness. As a result, flexibility, openness, and efficiency are sacrificed in the chase for perfectionism as they become rigid, controlling, stubborn and inflexible. They love lists and schedules, and are often devoted to work to the extent that they often neglect social relationships. They have perfectionist tendencies, and are so driven in their work to be the best and get it right that they become unable to complete projects or specific tasks because they get lost in the details. A ‘sub-standard’ job is never acceptable, which leaves them hesitant to delegate tasks for fear that another person will not deliver.