The Diagnosis of Personality Disorders

Personality disorders (PD) are a group of mental health conditions characterized by disruptive patterns of thinking, behavior, and inner experiences. Accurate diagnosis is key because it helps clinicians know what treatment to provide. However, because of various factors, such as overlapping symptoms and lack of awareness, diagnosing personality disorders is often more complicated than it should be.

What are Personality Disorders?

Personality disorders are a group of mental health conditions where long-term maladaptive patterns of behavior, thinking, and feeling are exhibited across many situations and deviate from the norm ^[1]. A personality is a unique combination of traits one has and how they are expressed, defining who we are as individuals. Someone with a personality disorder may have a distorted view of reality and a hard time relating to others.

Those with personality disorders tend not to realize their actions deviate from what’s considered ‘normal’ and that they may cause distress to people around them. Their view of the world differs from others, and, as a result, individuals with personality disorders may struggle with participating in social, educational, and family activities.

Personality disorders often stop individuals from relating to others, feeling emotions, or enjoying life. They can cause isolation, which can lead to depression and anxiety. People with personality disorders may feel their emotions are confusing and out of control, and may struggle to change negative behavioral patterns.

Types of Personality Disorders

There are 10 types of personality disorders ^[2]. The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) groups them into three main clusters, each with similar characteristics and symptoms.

Cluster A: Generally Suspicious

Cluster A personality disorders are characterized by odd, eccentric, or suspicious behaviors. Individuals in this cluster often struggle with social relationships and may appear distant, distrustful, or detached from reality. This group includes paranoid, schizoid, and schizotypal personality disorders.

Paranoid Personality Disorder: According to study evidence, Paranoid Personality Disorder affects approximately 1.2% to 4.4% of adults in the United States ^[3]. Many individuals with paranoid personality disorder distrust others without adequate reason and often believe people plan to demean, exploit, or harm them.

Schizoid Personality Disorder: Schizoid personality disorder features social isolation and a lack of caring about other people. Individuals with this disorder display minimal interest in forming personal relationships or engaging in social interactions, leading others to describe them as cold or withdrawn. Schizoid personality disorder slightly affects more men than women. People with the disorder are drawn towards introspection and fantasy rather than having close interpersonal relationships ^[4]. 

Schizotypal Personality Disorder: People with schizotypal personality disorder are paranoid and often have thought disorders, unconventional beliefs, and social anxiety. They have limited needs for close relationships, misinterpret behaviors, and respond irrationally ^[5]. 

Cluster B: Emotional, Dramatic, and Impulsive

Cluster B personality disorders are marked by emotional intensity, dramatic behavior, and impulsivity. Individuals with these disorders often experience unstable relationships and struggle with self-image and emotional regulation. This cluster includes antisocial, borderline, histrionic, and narcissistic personality disorders.

Antisocial Personality Disorder (ASPD): Unlike most personality disorders, ASPD usually begins to manifest in childhood as conduct disorder ^[6]. ASPD includes disregarding rules and social norms and having no respect for others. People with this disorder may physically or emotionally harm others and not feel guilty. They may also use substances heavily and act dishonestly ^[6]. 

Borderline Personality Disorder (BPD): People with borderline personality disorder often have difficulty regulating their emotions, which leads to mood swings, low self-esteem, and impulsive behaviors. They frequently feel empty and abandoned, no matter how much support they get from family and those around them. People with BPD have trouble handling stress and usually have paranoid episodes ^[7]. 

Histrionic Personality Disorder: Histrionic personality disorder features intense, unstable emotions and a twisted self-image. Those affected often try to seek attention by being dramatic or provocative. They may behave in socially inappropriate ways to achieve this and can be easily swayed by others. People with this disorder are sensitive to disapproval or perceived criticism, and their self-esteem depends on external approval ^[8]. 

Narcissistic Personality Disorder: This condition involves perceived superiority, self-absorption, and a lack of empathy for others. People with narcissistic personality disorder need excessive praise or admiration and tend to exaggerate their looks and achievements. Underlying low self-esteem and self-confidence drive these behaviors ^[9]. 

Cluster C: Severe Anxiety and Fear

High levels of anxiety, fearfulness, and behavioral inhibition characterize Cluster C personality disorders. Individuals with these disorders often appear overly cautious, dependent, or perfectionistic, which can significantly impact their relationships and daily functioning. This cluster includes avoidant, dependent, and obsessive-compulsive personality disorders.

Avoidant Personality Disorder: Avoidant personality disorder involves fears of inadequacy, inferiority, and criticism, leading to a pattern of social inhibition and avoidance. Those affected are highly sensitive to negative judgment; therefore, they frequently avoid new activities or making friends. The fear of rejection can prevent them from interacting with others ^[10]. 

Dependent Personality Disorder (DPD): Dependent personality disorder manifests as a fear of being alone and an excessive need for others to provide care. People with this condition depend on others for their emotional and physical needs, also involving submissiveness, an inability to make decisions, and a need for constant reassurance ^[11]. 

Obsessive-Compulsive Personality Disorder (OCPD): People with OCPD are preoccupied with orderliness, perfectionism, and control. They follow rules and feel incredibly uncomfortable when things aren’t perfect. They may even neglect personal relationships to make a project perfect ^[12]. This condition is not the same as obsessive-compulsive disorder (OCD).

Diagnostic Criteria for Personality Disorders

The DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition) has specific criteria a person must meet to be diagnosed with a personality disorder. The general criteria include:

1. The traits must cause significant impairments in self and interpersonal functioning.
2. The traits must affect two or more of the following four areas: cognition, emotions, interpersonal functioning, and impulse control ^[13].
3. The onset of behavior patterns can be traced back to early adulthood or adolescence.
4. Other mental disorders, medical conditions, or substance use cannot explain the patterns of behavior.
5. The traits are not better understood as normative for the individual’s developmental stage or sociocultural environment.

Key Characteristics of Personality Disorders:

• Chronic and pervasive nature: Unlike other mental health disorders, which may come and go or be episodic, personality disorders typically persist over time.
• Inner experience: Personality disorders involve outward behavior and deep-seated patterns in how a person experiences themselves and others.
• Cultural considerations: The DSM-5 emphasizes that personality disorders must be considered in the context of the person’s culture and age, as what is considered “deviant” behavior can vary widely across societies and age groups.

How are Personality Disorders Diagnosed?

Personality disorders can be hard to diagnose, as most affected individuals are not aware they have them. Diagnosing a personality disorder involves a process that requires a complete assessment of the person’s mental health, behavior, and functioning over time. The goal is to identify patterns of thoughts, emotions, and behavior that fit the diagnostic criteria and to rule out other mental health issues.

Initial Screening

The process starts with an initial screening to see if there are any obvious signs of personality disturbance. Mental health professionals will understand the patient’s presenting issues and background, including medical history, family dynamics, personal history, and current symptoms. They may ask questions about the patient’s work history, relationships, and emotional stability to assess for clues to a personality disorder.

The patient’s behavior during the interview is observed, and their reactions, interpersonal style, and communication patterns potentially indicate a disorder. Standardized questionnaires or self-report scales may also be used to identify red flags. Standard tools include the Personality Diagnostic Questionnaire-4 (PDQ-4) or the Millon Clinical Multiaxial Inventory (MCMI). These initial screens help determine if further evaluation is needed.

Comprehensive Psychological Evaluation

If the initial screen indicates a personality disorder may be present, the healthcare professional conducts a comprehensive psychological evaluation. This is just a more detailed version of the initial interview. The mental health professional digs deeper into the patient’s history, including childhood experiences, family relationships, educational and work history, significant life events, and any previous psychiatric or psychological treatment. They may also gather more information from family members, previous treatment providers, or others who know the patient well.

Structured and Semi-Structured Interviews

These are essential tools for diagnosing personality disorders. The Structured Clinical Interview for DSM-5 (SCID-5) is the most common structured interview format. It helps clinicians determine whether an individual meets the DSM-5 criteria and provides reliable and objective data on the presence and severity of personality disorder traits.

Other structured interviews are the International Personality Disorder Examination (IPDE), which assesses personality disorders in cross-cultural settings, and the Diagnostic Interview for Personality Disorders (DIPD), which is more flexible than the SCID.

Psychological Testing and Questionnaires

Psychological tests and self-report questionnaires help gain insight into an individual’s personality traits, behavior, and emotional functioning. They supplement clinical interviews and provide objective data. Examples include the Minnesota Multiphasic Personality Inventory (MMPI-2 or MMPI-3), the Millon Clinical Multiaxial Inventory (MCMI), and the Personality Disorder Inventory (PDI).

Differential Diagnosis

After gathering all the data, the clinician considers other differential diagnoses to rule out other disorders or conditions that may present similar symptoms. The clinician must also evaluate if the symptoms are better explained by a medical condition or substance use. Differential diagnoses are essential but can be tricky since personality disorders often co-occur with other mental illnesses.

Challenges In Diagnosing Personality Disorders

Clinicians find diagnosing personality disorders tricky for many reasons, including the complexity of the disorders and the fine details they must consider during assessment. Here are some of the challenges in diagnosing personality disorders:

• Symptom overlap: Personality disorders often share symptoms with other mental health conditions, which can make it difficult to differentiate between them. Some of the common symptoms include anxiety, paranoia, avoidance, and emotional dysregulation.
• Comorbidity with other conditions: Different disorders often affect those with personality disorders. This comorbidity complicates diagnosis because clinicians must carefully distinguish whether symptoms (like impulsivity, depression, or anxiety) are manifestations of a personality disorder or if they are due to an entirely separate disorder.
• Potential for misdiagnosis: Personality disorders often involve pervasive, enduring patterns of behavior, which makes them easily misunderstood or misdiagnosed. Lack of consistency in diagnostic criteria, biases, stigma, and focus on immediate symptoms are some of the reasons PDs are often misdiagnosed.
• Variability in presentations: Personality disorders manifest differently, making them harder to categorize. They may also develop over many years and may not fully emerge until adulthood, especially in cases like schizotypal personality disorder and avoidant personality disorder.

Conclusion

Personality disorders are complex mental health conditions that significantly impact a person’s thoughts, emotions, and behaviors, often leading to challenges in relationships, work, and daily life. Diagnosing these disorders is challenging due to symptom overlap, comorbidity with other conditions, and how symptoms appear differently from person to person. 

Despite these challenges, proper diagnosis of personality disorders is possible, and current diagnostic approaches are more comprehensive than ever. This means that treatment for personality disorders can be more accurately prescribed and implemented, leading to a better quality of life for those suffering from these conditions.