Understanding Personality Disorders in the DSM-5

Complex mental health conditions and personality disorders involve long-lasting patterns of thoughts, behaviors, and emotion regulation that differ from the expectations of the culture in which they occur.

These behavior patterns cause distress, impairment of interpersonal relationships, and failure to meet typical life demands. The conditions are diagnosed using the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5).

DSM-5’s insights on personality disorders are the result of greater insight into the nature of these complex mental health problems. The prevalence of personality disorders is striking, and an estimated 9% of the US population is affected^[1]. Mental health care professionals and those hoping to grasp how personality disorders influence individuals and society must have a basic understanding of the DSM-5 framework.

This article will examine the diagnostic criteria for personality disorders, address the clusters into which they are organized, and review recent changes from DSM-IV to DSM-5. It will also explore the alternative model of personality disorders and challenges to differential diagnosis – demystifying personality disorders and providing an accessible understanding of their appearance.

What Are Personality Disorders?

Personality disorders are marked, enduring ways of thinking and behavior brought about by inner experience and behavior that deviate from cultural norms. In adolescence or early adulthood, these patterns are pervasive and inflexible.

They can manifest in cognitive, emotional, interpersonal, and impulse control domains. Personality disorders, which are based on episodic or acute conditions, differ from most other mental health conditions and are identified by traits that persist across every part of life.

We divide personality disorders into ten distinct types that are grouped into three clusters (A, B, and C), each of which has its own characteristics. Personality disorders are relatively common — at least 6% of adults have personality disorders worldwide^[2]. Unlike other mental illnesses, they instead concentrate on maladaptive personality traits not present in other conditions such as anxiety disorders or depression.

Importantly, personality disorders occur in many forms and degrees of severity. For example, suppose you have Borderline Personality Disorder (BPD). In that case, you may find you fluctuate in emotional stability, or if you have Schizoid Personality Disorder, you might be totally detached from your relationships. Though the conditions are separate, both devastate quality of life and relationships and require long-term management.

The DSM-5 Diagnostic Criteria for Personality Disorders

To allow accurate diagnostic and treatment planning, the DSM-5 includes guidelines about how a personality disorder is diagnosed, specifically outlining the diagnostic criteria for each personality disorder. The general criteria demand the person exhibit a pattern of behavior and experience that is enduring, pervasive, and inflexible across societal and personal contexts.

In order to receive a diagnosis, these patterns must cause a person significant distress or impairment in critical areas of functioning and cannot be better accounted for by another mental concern, substance use, or medical condition^[3].

In addition, maladaptive traits must manifest in at least two of the following areas: a disorder that impairs cognition (the ability to perceive self, others, or events), affectivity (the range or appropriateness of emotions), interpersonal functioning, or impulse control. Symptoms must start in adolescence or early adulthood and be consistent over time.

Cumulatively, the DSM-5 stresses the necessity of perceiving personality disorders as exceptions to objectifiable cultural or developmental variations. Because an accurate diagnosis is essential, careful clinical assessment is required, including structured interviews and validated diagnostic tools. If this does not take place, an individual may receive ineffective treatment and continue to experience stress.

Cluster A Personality Disorders

Cluster A includes the “odd or eccentric” disorders: Paranoid, Schizoid, and Schizotypal Personality Disorders. These conditions include social withdrawal, mistrust, and unusual ways of thinking.

• Paranoid personality disorder involves pervasive distrust and an unwarranted suspicion of other people’s motives. Benign acts may be perceived as threatening or deceitful.
• Schizoid personality disorder involves a marked absence of the ability to connect with others—or even experience much emotional connection to others—through social means or emotional expression. Individuals with this disorder may seem unaffected by encouragement or disparagement and typically enjoy being alone.
• Schizotypal personality disorder causes someone to demonstrate eccentric behaviors, unusual perceptions, and trouble with close relationships. Magical thinking is also common.

Less commonly diagnosed than other clusters, these disorders disproportionately affect people in their relationships with others. Early management of symptoms depends significantly on early recognition and intervention.

Cluster B Personality Disorders

Cluster B encompasses the “dramatic, emotional, or erratic” disorders: Antisocial, Borderline, Histrionic, and Narcissistic. In these conditions, emotional dysregulation and impulsivity are often present.

• Antisocial personality disorder is associated with a disregard for others’ rights, including deceit, impulsive behavior, and absence of remorse. Antisocial personality disorder also may cause someone to have difficulty with authority, which can lead to legal trouble.
• Borderline personality disorder is defined by the instability of emotions, self-image, and relationships. People with BPD often have an intense fear of abandonment and behave impulsively.
• Histrionic Personality Disorder adults are described as highly emotional and attention-seekers.
• Narcissistic personality disorder is associated with grandiosity, a need for admiration, and a lack of empathy for others.

Because these disorders are often highly challenging relationally and have high rates of comorbidity with other mental health conditions,^[4] psychotherapy is generally effective. In some cases, medication is used to treat accompanying symptoms, such as anxiety or depression.

Cluster C Personality Disorders

Cluster C includes the “anxious or fearful” personality disorders: Avoidant, dependent, and obsessive-compulsive. These disorders are most often distinguished by ongoing fear, ongoing anxiety, and a preoccupation with control or dependency.

• Avoidant personality disorder is marked by extreme sensitivity to real or perceived rejection and feelings of inadequacy. Individuals often avoid social interactions because they fear criticism or embarrassment despite a desperate need or desire for connection^[1].
• Dependent personality disorder individuals have an excessive need to be taken care of, resulting in submissive behaviors. Individuals living with this condition may have trouble making decisions without the additional assurance of others^[2].
• Obsessive-compulsive personality disorder is different from obsessive-compulsive disorder (OCD). Its typical feature is obsessive concern for orderliness, perfectionism, and control, often to the detriment of flexibility and efficiency^[3].

These disorders commonly interfere with occupational, social, and personal functioning. Treatment is directed to the psychotherapy aspect, specifically cognitive behavioral approaches, to reverse the existing maladaptive thought patterns and underlying fears^[4].

Changes from DSM-IV to DSM-5

The shift from DSM-IV to DSM-5 featured significant changes in personality disorders. The DSM-5 further added the dimensional framework while keeping the categorical approach from the DSM-IV. The alternative model instead focuses on personality functioning and trait dimensions rather than rigid diagnostic categories^[2].

One important change was to reinforce clear and consistent diagnostic criteria. Interestingly, the multi-axial system was removed from the DSM-5, and personality disorders were moved away from being called “Axis II disorders.” This shift makes it possible to understand personality disorders within the broader spectrum of mental health conditions^[3].

Though the categorical model remains for clinical utility, the DSM-5 includes the alternative model for personality disorders in Section III. This addition reflects the ongoing debate among researchers on the limitations of category specificity and the requirement for a more flexible and individualized approach^[1].

The Alternative Model for Personality Disorders

Section III of the DSM-5 contains another model for personality disorders, which is a dimensional approach to diagnosis. This model focuses on two core elements: personality functioning impairments and pathological personality traits.

Personality functioning is assessed regarding self (identity and self-direction) and interpersonal relationships (empathy and intimacy). Pathological traits are grouped into five domains:

• negative affectivity
• detachment
• antagonism
• disinhibition
• psychoticism

Given this, personality pathology can be better understood on a spectrum regarding the degree and impact of maladaptive traits^[2].

This is unlike the categorical model, which categorizes individuals under particular labels, whereas the alternative model understands personality disorders as existing on a spectrum. The framework fits with research that personality traits are dimensional and overlap highly across disorders^[4]. Although this model isn’t fully integrated into clinical practice, it is a considerable step toward understanding personality disorders, as research dictates.

Differential Diagnosis and Comorbidities

Difficulties in diagnosing personality disorders exist because there are many overlaps of symptoms, and so often, personality disorders are comorbid with other mental health issues. For example, diagnosing borderline personality disorder may prove challenging because it nearly always occurs with mood disorders, substance use disorders, and/or posttraumatic stress disorder^[4]. Another example is social anxiety disorder, which shows similarities with avoidant personality disorder – distinguishing between the two requires a comprehensive clinical evaluation^[1].

Clinicians’ assessments must be comprehensive and account for symptoms’ duration, pervasiveness, and context. The diagnosis can be clarified by structured diagnostic interviews, self-report measures, and collateral information from close family or friends^[3].

Treatment planning is also affected by comorbidities. Examples include treating mood symptoms before maladaptive personality traits when a major depressive disorder coexists with a personality disorder. Treatments for distress in palliative care often target a single condition; however, recognizing and treating comorbid conditions is critical to improving outcomes and reducing distress.

Conclusion

The DSM-5 presents a thorough approach to diagnosing and understanding personality disorders. These disorders involve complex and chronic patterns of behavior and cognition that strongly influence individuals’ lives. The DSM-5 achieves this by categorizing personality disorders into clusters and creating a new, alternative dimensional model to help clinicians best recognize and treat them.

Despite recent advances, many personality disorders are challenging to differentiate from other mental disorders. Much more research and education are needed to refine diagnostic tools and to improve outcomes.