Personality disorders are a class of mental disorders characterized by enduring maladaptive patterns of behavior, cognition, and inner experience, exhibited across many contexts and deviating markedly from those accepted by the individual's culture. These patterns develop early, are inflexible, and are associated with significant distress or disability.[1]The definitions may vary somewhat, according to source.[2][3]
Official criteria for diagnosing personality disorders are listed in the Diagnostic and Statistical Manual of Mental Disorders, published by the American Psychiatric Association, and in the mental and behavioral disorders section of the International Statistical Classification of Diseases and Related Health Problems, published by the World Health Organization. The DSM-5 published in 2013 now lists personality disorders in exactly the same way as other mental disorders, rather than on a separate 'axis' as previously.[4]
Personality, defined psychologically, is the set of enduring behavioral and mental traits that distinguish human beings. Hence, personality disorders are defined by experiences and behaviors that differ from societal norms and expectations. Those diagnosed with a personality disorder may experience difficulties in cognition, emotiveness, interpersonal functioning, or control of impulses. In general, personality disorders are diagnosed in 40–60 percent of psychiatric patients, making them the most frequent of all psychiatric diagnoses.[5]
These behavioral patterns in personality disorders are typically associated with substantial disturbances in some behavioral tendencies of an individual, usually involving several areas of the personality, and are nearly always associated with considerable personal and social disruption. A person is classified as having a personality disorder if their abnormalities of behavior impair their social or occupational functioning. Additionally, personality disorders are inflexible and pervasive across many situations, due in large part to the fact that such behavior may beego-syntonic (i.e. the patterns are consistent with the ego integrity of the individual) and are, therefore, perceived to be appropriate by that individual. This behavior can result in maladaptive coping skills, which may lead to personal problems that induce extreme anxiety, distress, or depression.[6] These patterns of behavior typically are recognized in adolescence and the beginning of adulthood and, in some unusual instances, childhood.[1]
Many issues occur with classifying a personality disorder.[7] There are many categories of definition,[clarification needed] some mild and some extreme.[7] Because the theory and diagnosis of personality disorders occur within prevailing cultural expectations, their validity is contested by some experts on the basis of invariable subjectivity. They argue that the theory and diagnosis of personality disorders are based strictly on social, or even sociopolitical and economic considerations.[8][9][10][11]
Classification[edit]
The two major systems of classification, the ICD and DSM, have deliberately merged their diagnoses to some extent, but some differences remain. For example, ICD-10 does not include narcissistic personality disorder as a distinct category, while DSM-5 does not include enduring personality change after catastrophic experience or after psychiatric illness. ICD-10 classifies the DSM-5 schizotypal personality disorder as a form of schizophrenia rather than as a personality disorder. There are accepted diagnostic issues and controversies with regard to distinguishing particular personality disorder categories from each other.[12] ICD classifies Transsexualism as a personality disorder;[13] while the DSM-5 instead addresses Gender dysphoria.[14]
Effect on social functioning[edit]
Social function is affected by many other aspects of mental functioning apart from that of personality. However, whenever there is persistently impaired social functioning in conditions in which it would normally not be expected, the evidence suggests that this is more likely to be created by personality abnormality than by other clinical variables.[39] The Personality Assessment Schedule[40] gives social function priority in creating a hierarchy in which the personality disorder creating the greater social dysfunction is given primacy over others in a subsequent description of personality disorder.
Attribution[edit]
Many who have a personality disorder do not recognize any abnormality and defend valiantly their continued occupancy of their personality role. This group have been termed the Type R, or treatment-resisting personality disorders, as opposed to the Type S or treatment-seeking ones, who are keen on altering their personality disorders and sometimes clamor for treatment.[37] The classification of 68 personality disordered patients on the caseload of an assertive community team using a simple scale showed a 3 to 1 ratio between Type R and Type S personality disorders with Cluster C personality disorders being significantly more likely to be Type S, and paranoid and schizoid (Cluster A) personality disorders significantly more likely to be Type R than others.[41]
Signs and symptoms[edit]
In the workplace[edit]
Depending on the diagnosis, severity and individual, and the job itself, personality disorders can be associated with difficulty coping with work or the workplace - potentially leading to problems with others by interfering with interpersonal relationships. Indirect effects also play a role; for example, impaired educational progress or complications outside of work, such as substance abuse and co-morbid mental diseases, can plague sufferers. However, personality disorders can also bring about above-average work abilities by increasing competitive drive or causing the sufferer to exploit his or her co-workers.[42][43]
In 2005 and again in 2009, psychologists Belinda Board and Katarina Fritzon at the University of Surrey, UK, interviewed and gave personality tests to high-level British executives and compared their profiles with those of criminal psychiatric patients at Broadmoor Hospital in the UK. They found that three out of eleven personality disorders were actually more common in executives than in the disturbed criminals:
- Histrionic personality disorder: including superficial charm, insincerity, egocentricity and manipulation
- Narcissistic personality disorder: including grandiosity, self-focused lack of empathy for others, exploitativeness and independence.
- Obsessive-compulsive personality disorder: including perfectionism, excessive devotion to work, rigidity, stubbornness and dictatorial tendencies.[44]
According to leading leadership academic Manfred F.R. Kets de Vries, it seems almost inevitable these days that there will be some personality disorders in a senior management team.[45]
Relationship with other mental disorders[edit]
The disorders in each of the three clusters may share some underlying common vulnerability factors involving cognition, affect and impulse control, and behavioral maintenance or inhibition, respectively, and may have a spectrum relationship to certain syndromal mental disorders:[46]
- Paranoid or schizotypal personality disorders may be observed to be premorbid antecedents of delusional disorders or schizophrenia.
- Borderline personality disorder is seen in association with mood andanxiety disorders and with impulse control disorders, eating disorders, ADHD, or a substance use disorder.
- Avoidant personality disorder is seen with social anxiety disorder.
Diagnosis[edit]
Diagnostic Criterion[edit]
In the most recent edition of the DSM, DSM-V, the diagnostic criteria of a personality disorder have been revised. The general criterion for a personality disorder specifies that an individual's personality must deviate significantly from what is expected within their culture. [47] Also, particular personality features must be evident by early adulthood.
In order to diagnose a personality disorder, the following criteria must be met:
- "Significant impairments in self (identity of self-direction) and interpersonal (empathy or intimacy) functioning." [48]
- "One or more pathological personality traits domains or trait facets."[48]
- "The impairments in personality functioning and the individual's personality trait expressions are relatively stable across time and consistent across situations." [48]
- "The impairments in personality functioning and the individual's personality trait expressions are not better understood as normative for individual's developments stage or sociocultural environment."[48]
- "The impairments in personality functioning and the individual's personality trait expressions are not solely due to the direct physiological effects of a substance (e.g., a drug of abuse, medication) or a general medical condition (e.g., severe head trauma)." [48]
The ICD-10 'clinical descriptions and diagnostic guidelines' introduces its specific personality disorder diagnoses with some general guideline criteria that are similar. To quote:[49]
- Markedly disharmonious attitudes and behavior, generally involving several areas of functioning; e.g. affectivity, arousal, impulse control, ways of perceiving and thinking, and style of relating to others;
- The abnormal behavior pattern is enduring, of long standing, and not limited to episodes of mental illness;
- The abnormal behavior pattern is pervasive and clearly maladaptive to a broad range of personal and social situations;
- The above manifestations always appear during childhood or adolescence and continue into adulthood;
- The disorder leads to considerable personal distress but this may only become apparent late in its course;
- The disorder is usually, but not invariably, associated with significant problems in occupational and social performance.
The ICD adds: "For different cultures it may be necessary to develop specific sets of criteria with regard to social norms, rules and obligations."
In clinical practice, individuals are generally diagnosed by an interview with a psychiatrist based on a mental status examination, which may take into account observations by relatives and others. One tool of diagnosing personality disorders is a process involving interviews with scoring systems. The patient is asked to answer questions, and depending on their answers, the trained interviewer tries to code what their responses were. This process is fairly time consuming.
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