DSM-IV-TR Diagnostic Criteria
An enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual's culture. This pattern is manifested in two (or more) of the following areas:
cognition (i.e., ways of perceiving and interpreting self, other people, and events)
affectivity (i.e., the range, intensity, lability, and appropriateness of emotional response)
The enduring pattern is inflexible and pervasive across a broad range of personal and social situations.
The enduring pattern leads to clinically significant distress or impairment in social, occupational, or other important areas of functioning.
The pattern is stable and of long duration and its onset can be traced back at least to adolescence or early adulthood.
The enduring pattern is not better accounted for as a manifestation of another mental disorder.
The enduring pattern is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., head trauma).
(Reprinted, with permission, from the Diagnostic and Statistical Manual of Mental Disorders. 4th edn. Text Revision. Washington, DC: American Psychiatric Association, 2000.)
The prevalence of diagnosable personality disorders in the general population has been estimated at 10–20%. This rate is much higher in mental health treatment settings, with as many as 50% of psychiatric patients meeting criteria for one or more personality disorders.
Some personality disorders are diagnosed more frequently in men, and some are more prevalent in women. Thus, for example, borderline personality disorder appears to be more common in women. Antisocial personality disorder predominates in men.
The causes of personality disorders are not well understood. As with essentially every other type of psychiatric disorder, they probably involve various combinations of biologic, temperamental, and social etiologies. Historically, classic psychoanalytic theory suggests that personality disorders occur when a person fails to progress through the usual stages of psychosexual development. Fixation at the oral stage (i.e., the infantile stage) is considered to cause a personality characterized by demanding and dependent behavior, the current parallel being the dependent personality disorder. Fixation at the anal stage (i.e., the stage of toilet training) is thought to lead to obsessionality, rigidity, and emotional aloofness. The current diagnostic parallel is obsessive–compulsive personality disorder. Fixation at the phallic stage (early childhood) is thought to lead to shallowness and difficulty sustaining intimate relationships, the diagnostic parallel being histrionic personality disorder.
Related to the above, developmental and environmental problems have been a major focus of interest to scholars of personality. This is in part because onset occurs early in life and is frequently associated with real and perceived disruptive childhood experiences. Of particular interest has been the extremely high rate of reported neglect and childhood sexual, physical, or emotional abuse in patients with certain personality disorders, especially borderline personality disorder and histrionic personality disorder.
Genetic factors are often influential in the etiology of personality disorders. For example, family, twin, and adoption studies suggest that schizotypal personality disorder is linked to a family history of schizophrenia. Similar studies have delineated genetic factors related to antisocial and borderline disorders.
In the United States of America, Personality disorders are coded on Axis II of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR), so as to separate them from the major mental disorders (i.e., bipolar disorder, schizophrenia, panic disorder), which are coded on Axis I. Both Axis I and Axis II disorders can and frequently do coexist.
Personality disorders as currently described in DSM-IV-TR are described as “an enduring manifestation of inner experience and behavior that deviates markedly from the expectations of the individual's culture, is pervasive and inflexible, has an onset in adulthood, is stable over time, and leads to distress or impairment.” DSM-IV-TR Personality disorders are representative of long-term functioning and are not limited to episodes of illness.
For purposes of DSM-IV-TR classification, there are 10 personality disorders and these are grouped into three major categories or clusters. Cluster A (paranoid, schizoid and schizotypal) is composed of individuals who are generally odd or eccentric. They may have abnormal cognitions, such as being overly suspicious or exhibiting peculiar expressions or odd speech. Cluster B personality disorders (antisocial, borderline, histrionic, and narcissistic) consist of individuals with dramatic, acting-out behaviors. Cluster C disorders (avoidant, dependent, obsessive–compulsive) include those personality disorders generally marked by prominent anxiety and avoidance of novelty.
Co-occurrence of several personality disorders in a given individual within a given cluster is common, as is co-occurrence across clusters. Furthermore, a patient meeting criteria for a particular personality disorder will also often exhibit some features of other disorders within the same cluster, as well as across clusters. In addition to the 10 personality disorders, DSM-IV-TR includes criteria for two additional disorders, these being the passive–aggressive and the depressive personality disorder. There is also a category entitled personality disorders, not otherwise specified.
As a group, the personality disorders are one of the most difficult and complicated emotional disorders to diagnose and to treat. Diagnosis is difficult in part because the disorders are often difficult to differentiate from each other, due to overlapping symptoms, and because the boundary between normality and psychopathology for each diagnosis is not distinct. Treatment of personality disorders is also difficult. Almost by definition, they are well-established behaviors and/or ways of thinking that are not perceived by the afflicted individual as abnormal or aberrant.
Manifestations of personality disorders are frequently evident early in life. Some behaviors in children such as aggressiveness and stealing predict later personality problems, such as ...