Characterization, causes and therapy of personality disorders

The following article is intended to provide an overview of the main features of the so-called “personality disorders”, their possible causes and the basic approaches to their therapeutic possibilities. Diagnosis and treatment of personality disorders are considered difficult, because it is not straight forward to distinguish such “disorders of personality” from “normal”, though sometimes problematic, personality traits.

  1. General characterization of personality disorders

Personality disorders have an estimated prevalence of 5-10 %. According to the current classification systems (DSM-V and ICD-10), they are characterized by a specific combination of persistent dysfunctional patterns of perception, relating, thinking, and behavior with pathological value. Personality disorders have disease value in that they are inflexible, maladaptive, and situationally generalized, leading to subjective complaints and distress in thinking, feeling, and behavior. The often deeply rooted and persistent behavioral patterns, which are manifested in rigid reactions to different personal and social life situations, result in impaired performance. Personality disorders with pathological value cause strong subjective complaints with considerable suffering in the personal sphere and in interpersonal relationships. Personality disorders have usually existed since childhood and adolescence, but because of the developmental process they should not be diagnosed until adulthood.

Psychological instabilities and stresses represent burdens not only for those affected but often also for those close to them. With regard to personality disorders, this is particularly true for borderline personality disorder and especially dissocial (antisocial) personality disorder.

  1. Overview of the specific personality disorders

The most important features and diagnostic criteria of some specific personality disorders are presented below in condensed tabular form. Diagnosis of personality disorders – or their milder forms, the so-called personality accentuations – requires a sound structured clinical diagnostic interview by experienced practitioners.

We all carry some traits of a “personality disorder” in the sense of problematic personality traits, are dependent to a certain degree, have some compulsive traits or also some narcissistic parts. In this respect, it is important to emphasize that problematic personality traits always lie within a spectrum and that personality disorders only manifest themselves in the extreme range of expression.

It should not be overlooked that personality traits lying on a continuum – in the case of a personality disorder that is not fully developed – also bring advantages: For example, people with obsessive-compulsive personality accentuation work accurately and are reliable, somewhat dependent people are capable of bonding and attachment, and people with a healthy degree of narcissism are interesting and entertaining.

According to the clinical psychological/psychiatric diagnostic systems (ICD-10 and DSM-V) currently still in use, personality disorders may be diagnosed as mental disorders only if the personality traits or personality styles carry the following characteristics:

  • when the individual exhibits a persistent pattern of perceiving, thinking, feeling, and behaving that is consistently rigidly inflexible and poorly adapted,
  • if these personality traits result in significant impairments, for example, in the academic, professional and/or private spheres, and/or
  • if a high level of suffering arises for the affected person due to the subjective complaints of their own personality.

 

The following overview shows in tabular form the most important classificatory features of individual personality disorders. Even though most people will not have a pathological personality disorder, but at best a “personality accentuation”, the tabular overview can serve to identify problematic and stressful personality traits. Problematic and stressful personality traits or – if present – personality disorders can then be worked on in a naturally longer therapy and modified in a stress-reducing direction.

Paranoid

PD
  • Excessive sensitivity to setbacks and rejections.
  • Tendency to hold lasting grudges (insults, hurts, and distrust are not forgiven)
  • Distrust and a persistent tendency to distort experiences (by misinterpreting neutral and friendly attitudes of others as hostile or contemptuous)
  • Persistent insistence on one’s own rights
  • Unjustified suspicion of the sexual fidelity of a spouse or sexual partner
  • Constant self-centeredness, especially in combination with strong arrogance

The term paranoid (= delusional) is inappropriate because there is no proximity to paranoid schizophrenia. Older terms such as “querulous” or “fanatical” are a more apt description of this disorder.
Antisocial

PD
  • Callous lack of concern for the feelings of others
  • Irresponsible attitude and disregard for social norms
  • Inability to maintain lasting relationships, although there is no difficulty in entering into them
  • Very low frustration tolerance and low threshold for aggressive, including violent, behavior

– Lack of guilt or inability to learn from negative consequences
Emotionally

unstable

PS

 Central to the disorder, also known as borderline personality disorder, is an affective regulation disorder and impulse control disorder, whereby a distinction is made between the impulsive and borderline types.

Impulsive Type: At least three of the following diagnostic criteria must be present:

  • Tendency to act unexpectedly and without consideration of consequences
  • Clear tendency to quarrel and conflict (especially when impulsive actions are stopped or reprimanded)
  • Tendency to outbursts of anger or violence – with inability to control explosive behavior
  • Difficulty in maintaining actions that do not receive immediate rewards
  • Volatile and moody mood.

Borderline Type: At least three of the following diagnostic criteria must be present:

  • Disturbance and insecurity regarding self-image, goals, and “internal preferences” (including sexual)
  • Instability regarding self-image and interpersonal relationships, self-parts are perceived as alien and tormenting
  • Tendency to engage in intense but unstable relationships, often resulting in emotional crises
  • Excessive efforts to avoid being abandoned
  • Repeated threats or acts of self-harm
  • Persistent feelings of emptiness.
Aanancastic

PD

 Inflexibility, pedantry and rigidity are the main criteria for the disorder – sufferers also show high perfectionism and conscientiousness. This often makes the timewise fulfillment of professional and social tasks considerably more difficult.

Patients suffer considerably from the conflict of striving for perfection and a life according to strict standards on the one hand, and almost never achieving it on the other.

  • Feeling of strong doubt and excessive caution.
  • Constant preoccupation with details, rules, lists, order, organization or plans
  • Perfectionism that interferes with the completion of tasks
  • Excessive conscientiousness and scrupulousness
  • Disproportionate focus on performance to the neglect of pleasure and interpersonal relationships
  • Excessive pedantry and adherence to social conventions
Anxious-

avoidant

PD

 Symptoms of this disorder are feelings of insecurity, fear of rejection, of being judged negatively, as well as shyness, tension and avoidance of social contacts. Sufferers quickly feel criticized, which leads to great problem in professional and social environment.

  • Persistent and extensive feelings of tension and anxiety.
  • Conviction of being socially awkward, unattractive, or inferior to others themselves
  • Excessive worry about being criticized or rejected in social situations
  • Restricted lifestyle because of the need for physical security
  • Avoidance of occupational and social activities that require intense interpersonal contact – for fear of criticism, disapproval, or rejection (fear of rejection).
Dependent

PD

 This is characterized by dependent living, lack of assumption of personal responsibility, feeling of constant dependence on support, and fear of separation and being alone continue to characterize the disorder.

  • Encouragement or permission to others to make most of the important decisions for one’s own life
  • Subordination of one’s own needs to those of others with whom there is dependence, with disproportionate compliance to their wishes
  • Unwillingness to express even reasonable demands to persons on whom one depends
  • Feeling uncomfortable or helpless when alone (due to exaggerated fear of not being able to care for oneself alone)
  • Frequent preoccupation with fear of being abandoned and dependent on oneself
  • Limited ability to make everyday decisions without numerous advice and reassurance from others….
Narcissistic

PD

 Narcissistic personality disorder carries the main diagnostic features of arrogance and inability to be criticized. Affected individuals exhibit a persistent pattern of inner experience and behavior characterized by a need for admiration, a lack of empathy, fantasies of boundless success, power, and beauty, and a sense of one’s own importance. In addition, there is a sense of entitlement, feelings of envy toward others, arrogant behavior, and exploitative relationships.

  • Sense of grandeur in relation to one’s own achievement
  • Preoccupation with fantasies of unlimited success, power, possessions, beauty, or ideal love
  • Conviction of being “special” and unique
  • Need for excessive admiration
  • Entitlement attitude; unfounded expectations of especially favorable treatment or automatic fulfillment of expectations.
Combined

PS

 Here, the diagnostic features of various personality disorders are fulfilled, but there is no predominant symptom picture that would allow a specific diagnosis.

A combination of features of borderline, dissocial and histrionic personality disorder is common.

  1. Causes of personality disorders

The potential causes of personality disorders are still not completely understood and, in particular, there are hardly any studies on possible neurobiological/genetic factors.

There is evidence for the relevance of psychological influences on socialization. According to this, childhood experiences – especially in the form of a problematic parent-child relationship – are seen as a risk factor for personality disorder development.

Further risk factors for a personality disorder represent stressful and traumatic experiences in childhood. According to this, evidence exists that emotional neglect in childhood and traumatic experiences, i.e., especially physical and sexual abuse, favor the onset of dissocial and borderline personality disorder.

Finally, a lack of social integration is a risk factor. Critical fractures in family development, lack of social-societal integration, migration but also rapid social and societal change are the main aspects of a lack of or insufficient social integration.

  1. Therapy of personality disorders

The therapeutic procedure is complex and difficult, since a personality disorder manifests itself in a heterogeneous disturbance pattern. The close positive influence of the personality traits, which are considered to be relatively stable and enduring, often requires intensive and long treatment due to their nature. Thus, the efficient treatment of a diagnosed personality disorder is not amenable to short-term therapy. Since there are hardly any efficient treatments with psychotropic drugs – except for short-term intervention in acute crises – psychotherapy is considered the most important and effective treatment option. Both psychoanalytically oriented and behavioral therapy approaches have become established.

The therapy of borderline personality disorder is considered a great challenge for therapists, since problematic behaviors and symptoms of unstable affect of the patient also show up within the therapeutic setting, which can partly undermine an efficient treatment.

As an important principle, it is not the personality disorder as such that should be treated, but:

  • The resulting disturbances in interpersonal interaction.
  • disturbances in experiencing (often unstable and negativistic)
  • disturbances of self-perception and self-regulation
  • disorders of impulse control.

The different therapy methods have the following common features:

  • the multimodal approach
  • a detailed (differential) diagnosis at the beginning of the therapy, from which the individual treatment modalities are derived
  • the definition of therapy priorities and the time frame of the therapy
  • the making of binding agreements (such as, for example, that in the case of borderline patients, repeated cutting will lead to the termination of therapy).

Despite these similarities, the individual therapy procedures differ in terms of both concept and methodology in the treatment of personality disorders, and only two procedures are concisely presented here.

Kernberg & Clarkin’s Transference Focused Therapy is a modified psychoanalytic method that focuses on the analysis of transference and countertransference in the therapeutic relationship.

It is primarily suitable for the treatment of borderline, narcissistic and histrionic personality disorder. The goal of transference-focused psychotherapy is to change the structure of those areas of the patient’s inner experience that lead to repeated destructive behavioral and relational patterns by identifying and interpreting the transference patterns that emerge in the therapeutic process between patient and therapist.

Dialectical-behavioral therapy (Linehan, 1983) views borderline personality disorder primarily as a disorder of affect regulation and incorporates behavioral therapy elements into the therapeutic approach:

  • Social skills training to improve interpersonal interaction.
  • Mindfulness-based meditative techniques to focus attention on the momentary inner experience
  • Training of emotional competencies to deal with stress and reduce acute tension, and especially to stabilize affect and emotion regulation.

  1. Summary and Résumé

Personality disorders are relatively stable, socially inflexible, and poorly adapted behaviors. A thorough clinical-psychological/psychiatric diagnosis is required to differentiate merely stressful personality traits from pathological personality disorders. Personality disorders lead to considerable reductions in performance in the private and professional spheres and to a high degree of subjective suffering for those affected.

There is a variety of specific personality disorders such as the prevalent dependent, the dissocial and the emotionally unstable personality disorder.

Possible causes of personality disorders include emotional neglect and traumatic experiences (physical violence and sexual abuse) in childhood.

Effective therapies – especially for borderline personality disorder – have been shown to be the transference-focused psychotherapy and, moreover, the dialectical-behavioral therapy.

 

Prospects for the paradigm shift in ICD-11 – Dimensional classification of personality disorders.

The classification of personality disorders as distinct categories presented in this paper will be replaced in the forthcoming ICD-11 by a dimensional classification with severity gradations. Whether a personality disorder is present or not will be defined by impairments in self-related and interpersonal personality functions.

All personality disorder diagnoses, with the exception of borderline personality disorder, are abolished, so that in ICD-11 there is now only the category “personality disorder” (ICD-11 code 6D10), which can be supplemented by a so-called “trait qualifier” if the criteria of borderline PS are present.

All other forms of personality disorders are characterized by specific profiles of five pathological personality traits. The most central change from the perspective of child and adolescent psychiatry is that the age limit for the diagnosis of personality disorders  has been removed, so that the disorder and its development are now seen in a perspective across the lifespan comparable to other psychiatric disorders.

Reference: Klaus Schmeck & und Marc Birkhölzer; Published Online:12 Aug 2020;

https://doi.org/10.1024/1422-4917/a000747)