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The following article is intended to provide an overview of the main features of personality disorders, their symptoms, etiology and treatment approaches. The diagnosis and personality disorder therapy are considered as challenging, because it is not straightforward to distinguish such “disorders of personality” from “normal”, though sometimes problematic, personality traits.
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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 severe subjective complaints in the personal sphere and in interpersonal relationships.
Psychological instabilities and stresses represent burdens not only for those affected but often also for those close to them. With regards to personality disorders, this is particularly true for borderline personality disorder and especially dissocial (antisocial) personality disorder.
The most important features and diagnostic criteria of some specific personality disorders are presented below. 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, e.g. 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 some personality accentuations might also incorporate advantages: For example, people with an 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:
Until 2027, the ICD-10 can still be applied, and it can be differentiated between several – partially overlapping – distinct personality disorders (PD), e. g.:
marked by excessive sensitivity to setbacks and rejections, tendency to hold lasting grudges, distrust and tendency to distort experiences (by misinterpreting neutral and friendly attitudes of others as hostile or contemptuous).
characterized by dependent living, lack of assumption of personal responsibility, feeling of constant dependence on support, and fear of separation and being alone.
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. Affected individuals quickly feel criticized, which leads to great problems in professional and social environments.
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.
The potential causes of personality disorders are still not completely understood and 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, can 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.
The therapeutic procedure is challenging, since any personality disorder manifests itself in a heterogeneous disturbance pattern. Both psychoanalytically oriented and behavioral therapy approaches have become established as effective treatment options.
The treatment of borderline personality disorder is considered a 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 different therapy methods have the following common features:
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:
Training emotional competencies to deal with stress and reduce acute tension, and especially to stabilize affect and emotion regulation.
Personality disorders are relatively stable, socially inflexible, and poorly adapted behaviors. A thorough clinical-psychological/psychiatric diagnosis is required to differentiate merely difficult 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.
The ICD-11, to be compulsory applied from 2027, represents a paradigm shift to a dimensional classification – except for borderline personality disorder, the previous personality disorder categories will be abolished.
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.
The classification of personality disorders as distinct categories presented in this article will be replaced in the forthcoming ICD-11 by a dimensional classification with levels of severity. Whether a personality disorder is present or not will be defined by impairments of self-related and interpersonal personality functions.
All personality disorder diagnoses, except for borderline personality disorder, are abolished, so that the ICD-11 now only has the category “personality disorder” (ICD-11 code 6D10), which can be supplemented by a so-called “trait qualifier” if the criteria for borderline PD are met.
All other forms of personality disorder are characterized by specific profiles of the five pathological personality traits outlined below.
Range of burdened emotions such as anxiety, vulnerability, irritability, emotional instability and depression – often as an oversensitive reaction to even minor stressors.
Disregard for social norms and the feelings of others, characterized by a lack of or little empathy, ruthless behavior with a focus on one’s own advantage, and even manipulation and aggression.
Disregard for social norms and the feelings of others, characterized by a lack of or little empathy, ruthless behavior with a focus on one’s own advantage, and even manipulation and aggression.
Tendency to react impulsively to immediate internal or environmental stimuli without considering longer-term consequences – often with irresponsibility, impulsiveness without regard to risk or consequences, distractibility and recklessness.
Focus on control and the regulation of one’s own and others’ behavior to ensure that things are done according to the person’s particular vision or ideal – with perfectionism, perseveration, restrictive emotionality, stubbornness and orderliness.
In summary, it can be stated that in the ICD-11 the dimensional diagnosis of personality disorder is made first via severity and then the trait domains.