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What is a personality disorder?
What does it entail to live with a personality disorder? Here is a comprehensive overview of its understanding, symptoms, and treatment.
Photo: Kreated Media via Unsplash
Living with a personality disorder entails that your experiences of yourself, others, and your surroundings can cause significant internal distress that makes it difficult to function in everyday life. These difficulties can manifest in various ways. Today, there is effective treatment available, and many people manage to overcome the diagnostic criteria within a ten-year period.
The way typically think, feel, and behave towards ourselves and others over time is understood as our personality.
We are all different as human beings – some are extroverted, while others more reserved and cautious. Some are curious and enjoy new situations, while others prefer the familiar and comfortable.
People with personality disorders struggle from a young age to understand themselves, their surroundings, and close relationships. These difficulties can manifest in very different ways. You might isolate yourself from the outside world, struggle with a low or unstable self-image, regularly engage in self-destructive behaviour such as self-harm, substance abuse, or frequently find yourself in conflicts. Aggression towards others can also occur.
It may be a personality disorder if:
You have difficulties functioning in everyday life due to how you perceive yourself, others, and your surroundings
Additionally, the difficulties should:
Have negative consequences accross different areas of life, e.g., in school/work, leisure time, and in being with family and friends.
Have manifested in adolescence or persisted over several years.
Not be exclusively explained by other mental disorders such as substance abuse or other medical conditions.
The diagnosis provides insight into the challenges you may face and is important for receiving tailored treatment. It does not define who you are as a person.
Personality Functioning
Personality difficulties is a dimensional phenomenon, something we all have to varying degrees. In the future, we will therefore emphasise severity more than personality disorder categories, where the core of the issues lies in difficulties in our relationship with ourselves and our relationship with others. Assessing the severity is crucial for effective treatment planning.
Challenges Related to the Self
Identity: Your own self-perception negatively affects you.This can involve uncertainty about your own identity, or a low, fluctuating, or seemingly inflated self-image and self-esteem. You may struggle to regulate emotions – resulting in either too little or too much emotional expression.
Self-Direction: It can be difficult to set or achieve personal goals. The values guiding your goals may be unclear, unstable, or deviant. The ability for self-reflection may be limited.
Challenges Related to Functioning with Others
Empathy (Understanding others' perspectives): It can be difficult for you to understand or appreciate others' perspectives or motivations, especially when they differ from your own. You may also struggle to understand how others perceive you, what you say, or what you do.
Intimacy (Closeness to others): It may be difficult for you to trust and connect with others. Consequently, you may have trouble achieving close, secure, long-lasting, and reciprocal relationships with others.
Challenges related to oneself:
Low and/or unstable self-esteem and confidence.
Fluctuating and unstable experience of one’s own identity
Difficulties in finding meaning in life
Difficulties in pursuing long-term goals
Difficulties in adhering to societal norms for acceptable behaviour
Difficulties in managing and controlling emotions and impulses
Repeated self-harm
Repeated suicide attempts
Challenges related to others:
Difficulties trusting other people
Conflicts in close relationships, such as romantic, friendship, and family relationships
Frequent misunderstandings in relationships with others
Difficulties in establishing and maintaining close relationships
Difficulties in understanding others’ experiences, perspectives, and motives
A tendency towards social avoidance and social isolation
Difficulties in having multiple perspectives on social events
Difficulties in understanding how one’s own behaviour affects others
Difficulties with reciprocity and equality in relationships
Why Do Some People Develop a Personality Disorder?
Multiple factors come into play when a person develops a personality disorder. Think of it as a recipe where several ingredients are mixed together and influence each other. The two main ingredients are our genetic predisposition (temperament) and the interaction with the environment we grew up in (especially caregivers).
Genes: Our innate blueprint (temperament) can make us either vulnerable or resilient when facing stressful life events. Our temperament also influences the activation of specific emotions and reactions, making us more or less susceptible to developing a personality disorder.
Upbringing: From birth, we develop an emotional bond (attachment) to our closest caregivers. This attachment is crucial for our later personality functioning. The quality of this bond develops through the interplay between our innate temperament and the upbringing environment – how we were met and understood as we grew up. This includes relationships with family, friends, and how we experienced daily situations and specific events.
Many have also experienced negative childhood conditions such as:
Lack of stable caregivers.
Experiences of loss and disruption of emotional bonds.
Experiences of prolonged bullying and harassment.
Sexual abuse and other traumatic events.
Upbringing conditions characterised by insecurity, conflict, physical or psychological violence.
It is important to be aware that many children experience negative events in childhood without developing a personality disorder.
This is where individual differences come into play. Some are more vulnerable to developing a personality disorder than others. Events that might seem small or insignificant to some can be very difficult for others. While others may withstand greater stress before it impacts their personality development.
Most personality disorders manifest in adolescence and continue into adulthood. Some experience personality changes after being exposed to highly stressful life events in adulthood, where their vulnerability becomes apparent.
What is the Diagnostic Process and Criteria?
The diagnosis is based on a thorough assessment. This is usually conducted by a psychologist or psychiatrist who performs a clinical overall evaluation, typically involving structured interviews. Occasionally, information from informants (people who know the individual) is also needed.
In Norway, we use the official diagnostic system ICD-10. In practice, we often use the diagnostic criteria as outlined in the American diagnostic system DSM-5. The reason is that there is a corresponding diagnostic interview available (SCID-5-PF). The criteria for personality disorders are largely consistent in both DSM and ICD.
It is worth noting that significant changes are forthcoming in how we define and classify personality disorders, primarily moving towards a more dimensional understanding of personality disorders.
In ICD‐10, personality disorders are described as
A range of conditions and behaviour patterns that are persistent and seem to express the individual's typical lifestyle and way of relating to themselves and others.
These are deeply ingrained and persistent behaviour patterns that manifest through rigid reactions in personal and social situations. They represent significant or extreme deviations from how an average individual in a given culture perceives, thinks, feels, and, particularly, relates to others.
They are often, but not always, associated with varying degrees of subjective discomfort and deficits in social skills and functioning. The disorder cannot be directly attributed to major brain injury, brain disease, or another psychiatric disorder. Personality disorders typically manifest in late childhood or adolescence and continue to present until adulthood.
In ICD‐10, ten types of personality disorders (PD) are described; below you can read more about the various types.
Paranoid personality disorder is characterized by a pervasive distrust and suspiciousness of others. Other people's motives are interpreted as malevolent. This begins by early adulthood and presents in a variety of contexts. To receive the diagnosis, four (or more) of the following criteria must be met:
Suspects, without sufficient basis, that others are exploiting, harming, or deceiving him or her.
Is preoccupied with unjustified doubts about the loyalty or trustworthiness of friends or associates.
Is reluctant to confide in others because of unwarranted fear that the information will be used maliciously against him or her.
Reads hidden demeaning or threatening meanings into benign remarks or events.
Persistently bears grudges (i.e., is unforgiving of insults, injuries, or slights).
Perceives attacks on his or her character or reputation that are not apparent to others and is quick to react angrily or to counterattack.
Has recurrent suspicions, without justification, regarding the fidelity of a spouse or sexual partner.
Schizoid personality disorder is characterized by a pervasive pattern of detachment from social relationships and a restricted range of expression of emotions in interpersonal settings. This begins by early adulthood and presents in a variety of contexts. To receive the diagnosis, at least four (or more) of the following criteria must be met:
Neither desires nor enjoys close relationships, including being part of a family.
Almost always chooses solitary activities.
Has little, if any, interest in having sexual experiences with another person.
Takes pleasure in few, if any, activities.
Lacks close friends or confidants other than first-degree relatives (parents, siblings).
Appears indifferent to the praise or criticism of others.
Shows emotional coldness, detachment, or flattened affectivity.
Individuals with this personality disorder display behavior from the age of 15 in the form of a pervasive pattern characterized by disregard for and violation of the rights of others. In addition, there must be evidence of conduct disorder with onset before age 15, characterized by a persistent pattern of behavior where the basic rights of others or major age-appropriate societal norms are violated.
To receive the diagnosis (according to DSM-5), the individual must display at least 3 of the following 7 symptoms and signs:
Failure to conform to social norms with respect to lawful behaviors, as indicated by repeatedly performing acts that are grounds for arrest.
Consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or honor financial obligations.
Impulsivity or failure to plan ahead.
Deceitfulness, as indicated by repeated lying, use of aliases, or conning others for personal profit or pleasure.
Reckless disregard for the safety of self or others.
Lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another.
Irritability and aggressiveness, as indicated by repeated physical fights or assaults.
This personality disorder manifests as a pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity, beginning by early adulthood and presenting in a variety of contexts. To receive the diagnosis (according to DSM-5), at least 5 of the following 9 symptoms must be present:
Frantic efforts to avoid real or imagined abandonment.
A pattern of unstable and intense interpersonal relationships (characterized by alternating between extremes of idealization and devaluation).
Markedly and persistently unstable self-image or sense of self.
Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating).
Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior.
Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days).
Chronic feelings of emptiness.
Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights).
Transient, stress-related paranoid ideation or severe dissociative symptoms.
Histrionic personality disorder is characterized by a pervasive pattern of excessive emotionality and attention seeking, beginning by early adulthood and presenting in a variety of contexts. To receive the diagnosis, at least five of the following criteria must be met:
Is uncomfortable in situations in which he or she is not the center of attention.
Interaction with others is often characterized by inappropriate sexually seductive or provocative behavior.
Displays rapidly shifting and shallow expression of emotions.
Consistently uses physical appearance to draw attention to self.
Has a style of speech that is excessively impressionistic and lacking in detail.
Shows self-dramatization, theatricality, and exaggerated expression of emotion.
Is suggestible (i.e., easily influenced by others or circumstances).
Considers relationships to be more intimate than they actually are.
A personality disorder characterized by a pervasive pattern of preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness, and efficiency. To receive the diagnosis, at least 4 of the following 7 criteria must be met:
Is preoccupied with details, rules, lists, order, organization, or schedules to the extent that the major point of the activity is lost.
Shows perfectionism that interferes with task completion (e.g., is unable to complete a project because his or her own overly strict standards are not met).
Is excessively devoted to work and productivity to the exclusion of leisure activities and friendships (not accounted for by obvious economic necessity).
Is overconscientious, scrupulous, and inflexible about matters of morality, ethics, or values (not accounted for by cultural or religious identification).
Is unable to discard worn-out or worthless objects even when they have no sentimental value.
Is reluctant to delegate tasks or to work with others unless they submit to exactly his or her way of doing things.
Adopts a miserly spending style toward both self and others; money is viewed as something to be hoarded for future catastrophes.
Shows rigidity and stubbornness.
This personality disorder is the most common in the general population (approx. 4%), and reaches up to 25–40% in clinical samples. It is characterized by a pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation. The individual is often marked by anxiety and tension. To receive the diagnosis (according to DSM-5), at least 4 of the following 7 symptoms and signs must be present:
Avoids occupational activities that involve significant interpersonal contact, because of fears of criticism, disapproval, or rejection.
Is unwilling to get involved with people unless certain of being liked.
Shows restraint within intimate relationships because of the fear of being shamed or ridiculed.
Is preoccupied with being criticized or rejected in social situations.
Is inhibited in new interpersonal situations because of feelings of inadequacy.
Views self as socially inept, personally unappealing, or inferior to others.
Is unusually reluctant to take personal risks or to engage in any new activities because they may prove embarrassing.
Dependent personality disorder is characterized by a pervasive and excessive need to be taken care of that leads to submissive and clinging behavior and fears of separation. To receive the diagnosis, at least 5 of the following 8 criteria must be met:
Has difficulty making everyday decisions without an excessive amount of advice and reassurance from others.
Needs others to assume responsibility for most major areas of his or her life.
Has difficulty expressing disagreement with others because of fear of loss of support or approval (does not include realistic fears of retribution).
Has difficulty initiating projects or doing things on his or her own (because of a lack of self-confidence in judgment or abilities rather than a lack of motivation or energy).
Goes to excessive lengths to obtain nurturance and support from others, to the point of volunteering to do things that are unpleasant.
Feels uncomfortable or helpless when alone because of exaggerated fears of being unable to care for himself or herself.
Urgently seeks another relationship as a source of care and support when a close relationship ends.
Is unrealistically preoccupied with fears of being left to take care of himself or herself.
Narcissistic personality disorder is characterized by a pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy.
ICD-10 does not have a separate category for narcissistic personality disorder; here, the diagnosis is categorized under "Other specific personality disorders"—a designation for personality problems that do not fit any of the above-mentioned categories. In DSM-5, narcissistic personality disorder is listed as its own distinct category. There, at least 5 of the following 9 criteria must be met:
Has a grandiose sense of self-importance (e.g., exaggerates achievements and talents, expects to be recognized as superior without commensurate achievements).
Is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love.
Believes that he or she is "special" and unique and can only be understood by, or should associate with, other special or high-status people (or institutions).
Requires excessive admiration.
Has a sense of entitlement (i.e., unreasonable expectations of especially favorable treatment or automatic compliance with his or her expectations).
Is interpersonally exploitative (i.e., takes advantage of others to achieve his or her own ends).
Lacks empathy: is unwilling to recognize or identify with the feelings and needs of others.
Is often envious of others or believes that others are envious of him or her.
Shows arrogant, haughty behaviors or attitudes.
This is a residual category containing traits from several personality disorders without fulfilling sufficient symptoms to warrant a specific personality disorder category, but where the personality problems are severe enough to be classified as a personality disorder.
How is Personality Disorders Treated?
It is estimated that about one in ten meet the criteria for a personality disorder. This means that they have significant problems with self-esteem, identity, and relationships with others, leading to considerable social and health consequences.
Often, individuals seek treatment for recurring psychological symptoms such as anxiety or depression, rather than for the underlying personality issues. The main treatment for mild personality disorders is talk therapy over an extended period (possibly long-term psychotherapy). Supportive conversations with a general practitioner (GP) are also beneficial.
For more severe personality disorders, specialised treatment programmes may be necessary, this might include hospitalisation during severe crises.
Specialised Treatment for Personality Disorders
Knowledge about the development, diagnosis, and treatment of personality disorders has advanced significantly in recent decades. This has contributed to the development of several specialised treatment programmes:
In general, pharmacological treatment for personality disorders has little value, but sometimes it is possible to combine medication with psychotherapy when other mental disorders occur simultaneously, such as anxiety and depression.
Personality Disorders Over Time – Is it Possible to Get Better?
Can one recover from a personality disorder? Yes, there is hope! Treatment can help, and many also improve over time.
When does it start?
Signs of a personality disorder usually appear in adolescence. However, it is common for it not to be detected until adulthood.
Can it get worse?
If personality difficulties are overlooked, or if one goes through several rounds of treatment for symptoms without experiencing improvement, one may experience a worsening of the personality disorder.
Does it get better with time?
Yes, treatment can be very helpful. Even without treatment, many will find that the most challenging aspects of their personality become less prominent as they age.
What about treatment?
Treatment can be very helpful in regulating emotions, understanding oneself and others better, and improving the ability to get along with those around you. Overall, quality of life often improves with treatment, and one can receive help to change their developmental path.
What happens in tough times?
Just like everyone else, difficult life events, such as crises or stress, can exacerbate personality difficulties for a time. And sometimes, people may develop a personality disorder after very stressful events in adulthood.
Can you make a full recovery?
Personality difficulties are something we all have to a greater or lesser degree, and yes, you can get significantly better. It is entirely possible to have a good life where you feel secure in yourself, have stable and close relationships, and function well in work or other meaningful activities. Studies show that after ten years, only about nine out of ten still meet the criteria for the diagnosis. It is worth mentioning that many may struggle with reduced physical health as a result of the personality disorder.
