Personality disorders (PDs) are enduring patterns of inner experience and behavior that deviate markedly from the expectations of the individual’s culture, are pervasive and inflexible, have an onset in adolescence or early adulthood, are stable over time, and lead to distress or impairment.
General Diagnostic Criteria
The DSM-5 defines personality disorder as an enduring pattern of inner experience and behavior that:
| Criterion | Description |
|---|---|
| A. Enduring pattern | Deviates markedly from cultural expectations in two or more: cognition (ways of perceiving/understanding self, others, events), affectivity (range, intensity, lability, appropriateness), interpersonal functioning, impulse control |
| B. Pervasive and inflexible | Pattern is inflexible and pervasive across broad range of personal and social situations |
| C. Distress or impairment | Causes clinically significant distress or impairment |
| D. Stable and long duration | Pattern is stable and of long duration; onset traced to adolescence or early adulthood |
| E. Not better explained | Not better explained as manifestation or consequence of another mental disorder |
| F. Not substance/medical | Not attributable to physiological effects of substance or medical condition |
Cluster A: Odd, Eccentric
Paranoid Personality Disorder
Pervasive distrust and suspiciousness of others, interpreting their motives as malevolent.
| Criterion | Description |
|---|---|
| Prevalence | ~2-4% |
| Gender | More common in males |
| Core features | Suspects others exploit/harm them without basis; preoccupied with unjustified doubts about loyalty/trustworthiness; reads hidden meanings; bears grudges; perceives attacks to character; suspects infidelity |
| Functioning | May be hostile, argumentative; difficulty with close relationships |
| Comorbidity | Avoidant PD, schizoid PD, substance use disorders |
Schizoid Personality Disorder
Pervasive pattern of detachment from social relationships and restricted range of emotional expression.
| Criterion | Description |
|---|---|
| Prevalence | ~3-5% |
| Gender | More common in males |
| Core features | Neither desires nor enjoys close relationships; chooses solitary activities; little or no interest in sexual experiences; takes pleasure in few activities; lacks close friends; appears indifferent to praise/criticism; emotional coldness, detachment, flattened affectivity |
| Functioning | May function well in solitary occupations; minimal social drive |
| Comorbidity | Schizotypal PD, avoidant PD; increased risk for schizophrenia spectrum disorders |
Schizotypal Personality Disorder
Pervasive pattern of social and interpersonal deficits marked by acute discomfort with, and reduced capacity for, close relationships as well as cognitive/perceptual distortions and eccentricities of behavior.
| Criterion | Description |
|---|---|
| Prevalence | ~3-5% |
| Gender | Slightly more common in males |
| Core features | Ideas of reference; odd beliefs/magical thinking; unusual perceptual experiences; odd thinking/speech; suspiciousness/paranoia; inappropriate/constricted affect; odd/eccentric behavior/appearance; lack of close friends; excessive social anxiety |
| Functioning | Odd, eccentric appearance and behavior; social isolation |
| Comorbidity | Paranoid PD, schizoid PD, avoidant PD; genetic link to schizophrenia spectrum |
| Treatment response | Poorer than other PDs; some response to low-dose antipsychotics |
Cluster A Differential Diagnosis
| Condition | Key Distinguishing Feature |
|---|---|
| Schizophrenia (prodromal) | Prominent psychotic symptoms; functional decline |
| Autism spectrum disorder | Social communication deficits; restricted interests; sensory issues |
| Avoidant personality disorder | Desires relationships but is inhibited by fear of rejection |
| Obsessive-compulsive personality disorder | Preoccupation with orderliness, control |
Cluster B: Dramatic, Emotional, Erratic
Antisocial Personality Disorder (ASPD)
Pervasive pattern of disregard for and violation of the rights of others since age 15.
| Criterion | Description |
|---|---|
| Prevalence | ~1-4% |
| Gender | Male:female ~3:1 |
| Core features | Failure to conform to social norms (arrestable behavior); deceitfulness; impulsivity; irritability/aggressiveness; reckless disregard for safety; consistent irresponsibility; lack of remorse |
| Age requirement | Must be at least 18 |
| Conduct disorder | Evidence of conduct disorder with onset before age 15 |
| Functioning | High rates of incarceration; substance use; early mortality |
Subtype: Psychopathy:
- Factor 1: Interpersonal/affective deficits (callousness, grandiosity, lack of empathy/superficial charm)
- Factor 2: Antisocial lifestyle (impulsivity, irresponsibility, early behavioral problems)
- Assessed by Psychopathy Checklist-Revised (PCL-R)
Borderline Personality Disorder (BPD)
Pervasive pattern of instability in interpersonal relationships, self-image, affect, and marked impulsivity.
| Criterion | Description |
|---|---|
| Prevalence | ~1.6-6% |
| Gender | Female:male ~3:1 (clinical samples); ~1:1 (community) |
| Core features | Frantic efforts to avoid real/imagined abandonment; unstable, intense relationships; marked identity disturbance; impulsivity in two+ areas; recurrent suicidal behavior/self-harm; affective instability; chronic emptiness; inappropriate anger; transient stress-related paranoia/dissociation |
DSM-5 requires 5+ of 9 criteria:
| No. | Criterion | Manifestation |
|---|---|---|
| 1 | Fear of abandonment | Panic at even brief separations; frantic efforts to maintain contact |
| 2 | Unstable relationships | Idealization-devaluation cycles (splitting) |
| 3 | Identity disturbance | Markedly unstable self-image; frequent changes in goals, values, career |
| 4 | Impulsivity | Reckless spending, sex, substance use, binge eating, reckless driving |
| 5 | Suicidal/self-harm behavior | Self-mutilation (cutting, burning), suicidal gestures and attempts |
| 6 | Affective instability | Emotional reactions lasting hours to a few days; intense reactivity |
| 7 | Chronic emptiness | Feelings of emptiness, boredom |
| 8 | Inappropriate anger | Intense, poorly controlled anger; physical fights |
| 9 | Transient paranoia/dissociation | Stress-related paranoid ideation or dissociative symptoms |
Suicide risk in BPD:
- Lifetime suicide attempts: ~50-80%
- Completed suicide: ~5-10%
- Self-harm is common (usually for emotion regulation, not always suicidal intent)
Histrionic Personality Disorder (HPD)
Pervasive pattern of excessive emotionality and attention-seeking.
| Criterion | Description |
|---|---|
| Prevalence | ~1.8% |
| Gender | More diagnosed in females (may reflect referral bias) |
| Core features | Discomfort when not center of attention; sexually seductive/inappropriate behavior; rapidly shifting, shallow emotions; uses physical appearance to attract attention; self-dramatization, theatricality; suggestibility; considers relationships more intimate than they are |
| Functioning | May function well socially; difficulty with sustained intimacy |
Narcissistic Personality Disorder (NPD)
Pervasive pattern of grandiosity, need for admiration, and lack of empathy.
| Criterion | Description |
|---|---|
| Prevalence | ~1-6% |
| Gender | More common in males (~50-75%) |
| Core features | Grandiose sense of self-importance; fantasies of unlimited success/power/brilliance; believes they are special; requires excessive admiration; sense of entitlement; interpersonally exploitative; lacks empathy; envious of others or believes others envy them; arrogant attitudes/behaviors |
Narcissistic subtypes:
| Subtype | Characteristics |
|---|---|
| Grandiose (overt) | Exhibitionistic, self-aggrandizing, entitled, aggressive, low sensitivity to rejection |
| Vulnerable (covert) | Hypersensitive to criticism, socially inhibited, needy, self-doubt, defensively grandiose |
| Malignant | Grandiose NPD + ASPD + paranoia + sadism |
Cluster B Comorbidity
| Disorder | Common Comorbid Conditions |
|---|---|
| ASPD | Substance use disorders, ADHD, other PDs, mood disorders |
| BPD | PTSD (30-60%), MDD (50-80%), substance use (50-70%), eating disorders (15-30%), other PDs |
| HPD | Other Cluster B PD, somatic symptom disorder, conversion disorder |
| NPD | MDD, substance use, anorexia nervosa, other PDs |
Cluster C: Anxious, Fearful
Avoidant Personality Disorder (AvPD)
Pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation.
| Criterion | Description |
|---|---|
| Prevalence | ~2-4% |
| Gender | Equal |
| Core features | Avoids occupational activities involving significant interpersonal contact; unwilling to get involved unless certain of being liked; restraint in intimate relationships; preoccupied with criticism/rejection; inhibited in new situations; views self as socially inept/unappealing; reluctant to take personal risks |
AvPD vs. Social Anxiety Disorder:
| Feature | AvPD | Social Anxiety |
|---|---|---|
| Pervasiveness | Enduring, pervasive pattern | May be more situational |
| Identity | Poor self-concept, feelings of inadequacy as core identity | Anxiety specific to performance/social situations |
| Onset | Insidious, adolescence | May be acute or gradual |
| Avoidance | General, pervasive | More specific to feared situations |
| Treatment | Slower, longer-term | Often responds to brief CBT |
| Comorbidity | High with other PDs | Lower with PDs |
Dependent Personality Disorder (DPD)
Pervasive and excessive need to be taken care of, leading to submissive and clinging behavior and fears of separation.
| Criterion | Description |
|---|---|
| Prevalence | ~1-2% |
| Gender | More diagnosed in females |
| Core features | Difficulty making decisions without advice/reassurance; needs others to assume responsibility for major life areas; difficulty expressing disagreement; difficulty initiating projects; excessive efforts to obtain nurturance/support; discomfort being alone; urgently seeks alternative relationship when one ends; unrealistic preoccupation with fears of being left to care for self |
Obsessive-Compulsive Personality Disorder (OCPD)
Pervasive pattern of preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness, and efficiency.
| Criterion | Description |
|---|---|
| Prevalence | ~2-8% |
| Gender | More common in males (~2:1) |
| Core features | Preoccupation with details/rules/lists; perfectionism that interferes with task completion; excessive devotion to work/productivity (excluding leisure/friendships); overconscientious, scrupulous, inflexible about morality/ethics; hoarding (without distress — not same as hoarding disorder); reluctance to delegate; miserly spending; rigidity and stubbornness |
OCPD vs. OCD:
| Feature | OCPD | OCD |
|---|---|---|
| Ego-syntonic | Symptoms seen as reasonable | Symptoms ego-dystonic (unwanted) |
| Nature | Personality style/inflexibility | Obsessions and compulsions |
| Insight | Low (I’m correct) | Variable (usually recognizes absurdity) |
| Time | Life-long | Episodic (can wax/wane) |
| Distress | Low (mostly others distressed) | High |
Dimensional Model (DSM-5 Alternative Model)
The DSM-5 Section III proposes an alternative dimensional model for personality disorders:
Criterion A: Level of personality functioning (self + interpersonal):
| Level | Self | Interpersonal |
|---|---|---|
| 0 (Little/no impairment) | Stable identity; good self-reflection | Capacity for intimacy; empathy |
| 1 (Some impairment) | Identity somewhat dependent on others | Some difficulty with intimacy |
| 2 (Moderate impairment) | Poor identity; limited self-reflection | Limited intimacy; impaired empathy |
| 3 (Severe impairment) | Fragile identity; lacks self-direction | No meaningful relationships; severe empathy deficits |
| 4 (Extreme impairment) | Identity confusion; no self-direction | Dangerously impaired relationships |
Criterion B: Pathological personality traits (5 domains):
| Domain | Facets |
|---|---|
| Negative affectivity | Emotional lability, anxiousness, separation insecurity, submissiveness, hostility, perseveration, depressivity, suspiciousness |
| Detachment | Withdrawal, intimacy avoidance, anhedonia, depressivity, restricted affectivity, suspiciousness |
| Antagonism | Manipulativeness, deceitfulness, grandiosity, callousness, attention-seeking, hostility |
| Disinhibition | Irresponsibility, impulsivity, risk-taking, distractibility, rigid perfectionism (low) |
| Psychoticism | Unusual beliefs/experiences, eccentricity, cognitive/perceptual dysregulation |
Etiology
Biological Factors
| Disorder | Heritability | Neurobiological Findings |
|---|---|---|
| Paranoid PD | ~30-40% | Unknown |
| Schizoid PD | ~20-30% | Similar to schizophrenia spectrum |
| Schizotypal PD | ~50-60% | Temporal lobe abnormalities; reduced gray matter |
| Antisocial PD | ~50-60% | Reduced amygdala volume; reduced prefrontal activity; low arousal |
| Borderline PD | ~40-60% | Amygdala hyperreactivity; reduced prefrontal/ACC volume; impaired fronto-limbic connectivity |
| Histrionic PD | ~50% | Unknown |
| Narcissistic PD | ~50-60% | Reduced prefrontal cortex; altered empathy circuitry |
| Avoidant PD | ~30-40% | High behavioral inhibition; bias toward threat |
| Dependent PD | ~30-40% | Unknown |
| OCPD | ~25-35% | Possibly related to frontal lobe function |
Psychosocial Factors
Childhood adversity and trauma:
- BPD: Strong link to childhood trauma (physical/sexual abuse ~40-70%, emotional neglect)
- ASPD: Associated with early conduct problems, harsh parenting, abuse
- Avoidant PD: Peer rejection, criticism
- Dependent PD: Overprotective parenting
Attachment theory:
- Secure attachment: Adaptive personality development
- Insecure (anxious/preoccupied): Associated with BPD, dependent PD
- Avoidant/dismissing: Associated with schizoid, narcissistic, antisocial
- Disorganized: Associated with BPD, particularly with trauma history
Treatment Approaches
Psychotherapy
| Modality | Primary Indications | Key Features |
|---|---|---|
| Dialectical behavior therapy (DBT) | BPD | Emotion regulation, distress tolerance, interpersonal skills, mindfulness |
| Mentalization-based treatment (MBT) | BPD | Enhancing capacity to understand mental states of self and others |
| Transference-focused therapy (TFP) | BPD, NPD | Use of transference in structured treatment |
| Schema therapy | BPD, other PDs | Early maladaptive schemas, limited reparenting, mode work |
| Cognitive-behavioral therapy (CBT) | Avoidant, dependent, OCPD | Cognitive restructuring, behavioral activation, exposure |
| Cognitive analytic therapy (CAT) | Various PDs | Reformulation, recognition, revision |
| Psychodynamic psychotherapy | Cluster C, some Cluster B | Insight into unconscious patterns, defense analysis |
Pharmacotherapy
| Symptom Target | Medication Options | Evidence |
|---|---|---|
| BPD: affective dysregulation | SSRIs, mood stabilizers (lamotrigine, valproate), atypical antipsychotics | Moderate |
| BPD: impulsive-behavioral dyscontrol | Mood stabilizers, low-dose antipsychotics | Moderate |
| BPD: cognitive-perceptual symptoms | Low-dose antipsychotics | Moderate |
| Schizotypal PD: psychotic-like symptoms | Low-dose antipsychotics | Moderate |
| Cluster C: anxiety | SSRIs, benzodiazepines (short-term) | Limited |
| ASPD: aggression | Mood stabilizers (lithium), antipsychotics | Limited |
General Principles
- Treatment is typically longer-term than for Axis I disorders
- Therapeutic alliance is critical and often more difficult to establish
- Clear boundaries and structure are essential
- Supervision and support for therapists (especially with Cluster B)
- Crisis management and safety planning (especially BPD)
- Many patients benefit from combined individual + group therapy
- Pharmacotherapy targets specific symptom domains, not the disorder itself
Prognosis
| Disorder | Course | Improvement with Treatment |
|---|---|---|
| Paranoid PD | Chronic; limited data | Limited |
| Schizoid PD | Chronic; stable | Limited, most do not seek treatment |
| Schizotypal PD | Chronic; ~10% develop schizophrenia | Moderate (symptom reduction) |
| Antisocial PD | Improves somewhat after age 40 | Limited; treatment retention poor |
| Borderline PD | 50% remission at 10 years; improved functioning over time | Good with DBT, MBT, schema therapy |
| Histrionic PD | Chronic but may improve | Moderate |
| Narcissistic PD | Chronic; limited change | Guarded (insight poor) |
| Avoidant PD | Chronic but may improve with treatment | Good with CBT, social skills training |
| Dependent PD | Chronic; may improve | Good with CBT, assertiveness training |
| OCPD | Chronic; stable | Moderate with CBT, psychodynamic therapy |
References
- American Psychiatric Association. (2022). Diagnostic and Statistical Manual of Mental Disorders (5th ed., text rev.). Arlington, VA: APA.
- Leichsenring, F., & Leibing, E. (2003). The effectiveness of psychodynamic therapy and cognitive behavior therapy in the treatment of personality disorders. American Journal of Psychiatry, 160(7), 1223-1232.
- Paris, J. (2015). Treatment of Borderline Personality Disorder (2nd ed.). Guilford Press.
- Linehan, M. M. (2015). DBT Skills Training Manual (2nd ed.). Guilford Press.
- Bateman, A., & Fonagy, P. (2016). Mentalization-Based Treatment for Personality Disorders. Oxford University Press.
- Widiger, T. A., & Trull, T. J. (2007). Personality disorders. Annual Review of Clinical Psychology, 3, 257-280.
- Zanarini, M. C., et al. (2012). The 10-year course of borderline personality disorder. Archives of General Psychiatry, 69(8), 834-842.