Chapter 30. Personality Disorders

Essentials of Diagnosis

DSM-IV-TR Diagnostic Criteria

1. 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:

   1. cognition (i.e., ways of perceiving and interpreting self, other people, and events)

2. affectivity (i.e., the range, intensity, lability, and appropriateness of emotional response)

3. interpersonal functioning

4. impulse control

2. The enduring pattern is inflexible and pervasive across a broad range of personal and social situations.

3. The enduring pattern leads to clinically significant distress or impairment in social, occupational, or other important areas of functioning.

4. The pattern is stable and of long duration and its onset can be traced back at least to adolescence or early adulthood.

5. The enduring pattern is not better accounted for as a manifestation of another mental disorder.

6. 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.)

General Considerations

Epidemiology

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.

Etiology

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 ...