NEUROPSYCHOLOGY: WHAT ARE PERSONALITY DISORDERS?
Medically Reviewed by Dr. Sony Sherpa (MBBS)
It is truly hard to define what personality is in essence as no person is identical from moment to moment. Personality may be described as a habitual tendency to behave, think and feel in a specific way that persists through time, which dictates how one relates on a personal level to others. Psychologists may refer to personality as one’s interpersonal style.
When someone’s personality is dysfunctional or has a detrimental effect on the well-being of the person or people the person is in contact with, then it is likely that the person suffers from a personality disorder. The main consequences include an inability to maintain relationships and some degree of harm to either the self or others.
Nobody is perfect and everyone’s personality tends to have undesirable traits. While undesirable traits may overlap with those seen in personality disorders, it does not mean that every person with them has a disorder. Furthermore, some personality traits arise temporarily as a natural response to various life situations. For example, extended periods of social isolation may make any person become anxious or withdrawn; traits that would otherwise vanish after social integration.
Historically, personality disorders are known to be the least scientific of all psychological conditions, characterized by societal observations. Each case of personality is unique and it is rare that a person with a dysfunctional personality matches the precise textbook description of the disorder. In this sense, personality disorders may be the hardest to diagnose and the easiest to misdiagnose.
Personality disorders are broken down into three main categories: Cluster A, Cluster B, and Cluster C. Those with these disorders tend to have combinations of traits from the cluster their disorder falls under, but may also exhibit traits from any group.[1]
Cluster A
Cluster A personality disorders (PDs) are known for personality traits that are odd or eccentric.
1. Paranoid PD
As the name suggests, this is a personality characterized by severe paranoia or distrust of others that persists through time, even in the face of evidence to suggest otherwise. This paranoia is present in the absence of a mental condition that predisposes the individual to paranoid delusions or hallucinations, such as schizophrenia. People with paranoid PD often cannot have close relationships with others as they trust no one and are always trying to prove that their suspicions of others are true.
Being overly guarded, suspicious, withdrawn, and using any situation to validate their fears, even to the extent that it unfairly frames other individuals, are common manifestations of this disorder. Unfounded grudges, an inability to forgive and let go, hostility, jealousy, shame and humiliation, defensiveness, and excessive denial in the face of contrary evidence are other common themes. Extreme cases of Paranoid PD may result in acts of violence from the paranoid person. [2]
An unrealistic projection of underlying fears onto others is often seen to perpetuate the persistent distrust. Instead of giving the benefit of the doubt to others or to circumstances, these people have mistrusting thoughts that they hold a suspect accountable for to make up for lacking evidence.
2. Schizoid PD
Those with Schizoid PD are unusual in that they are withdrawn and reclusive[3], choosing social isolation over social interaction. Some have no desire to form relations with others, whether in friendship or partnership, and prefer their internal worlds over reality. Others with Schizoid PD long for intimate relationships but find the reality too difficult or stressful, also preferring their internal world over the lived reality. This type of social avoidance is not typically related to social anxiety or being fearful of others.
These individuals are often indifferent to societal norms and conventions, and lack emotionality, coming off as disengaged, cold, aloof, and distant. None of these personality traits necessarily hinder these people in the workplace, however, they naturally choose vocations where they can work alone or remotely. Many with this type of personality are quite comfortable with their eccentricity.
3. Schizotypal PD
This PD is like a combination of paranoid PD, Schizoid PD, and Schizophrenia. Those with Schizotypal PD tend to be odd overall in their appearance, mannerisms, behavior, expression, use of language, and the way in which they think. They may have frequent experiences and perceptions that fall outside of the realm of the ordinary, similar to those with Schizophrenia. Strong-held superstitious beliefs, suspiciousness, repetitive or obsessive thoughts, social anxiety, and paranoid thinking are common.[4]
Persons with Schizotypal PD tend to think others are harmful and thus avoid social interactions out of fear. As a result, they may also believe or feel that events involving others are related to them when they are not.
Previously known as Latent Schizophrenia, people with this personality type are at a higher risk of developing actual Schizophrenia.
Cluster B
Cluster B personality types are grouped together for the tendency to be overly dramatic, erratic, and unpredictable.
1. Histrionic PD
The term histrionic derives its roots from the Latin word histrionicus, which means “pertaining to the actor.” Those with histrionic PD have little to no self-worth and as a result, they tend to put on a show to attract attention and approval from others. As natural actors, much in their lives quickly become over-dramatized.
Other common themes may include being overly concerned with their appearance, being inappropriately charming or seductive (even with those they are not attracted towards), indulging in risk-taking behaviors, being impulsive, and having difficulty accepting rejection, criticism, or loss. They are classically the “life of the party” in social settings, or try their best to be and steal the spotlight. All their behavior, from the clothes they wear to the way they express themselves are all designed to remain at the center of attention. When attention shifts off them, they may feel unappreciated and even totally disregarded.[5]
If they feel unaccepted by others, it tends to promote more histrionic behavior to compensate, which creates a catch 22 cycle as most people do not condone such behavior from them. Many with this PD are prone to manipulation, exploitation, and accidental injuries, all of which further reinforces the way they dramatically derive attention from others.
2. Borderline PD
Borderline PD is sometimes referred to as emotionally unstable PD, which alludes to the often turbulent manifestations of the disorder. It describes a person who lacks a sense of self to the point that they feel empty, depressed, and fear abandonment. Emotional volatility and irrationality, extreme moods, intensely unstable relationships, highly impulsive behavior, acts of self-harm, threats of suicide and angry or even violent outbursts are common for those with this PD.
It was named as such for the way it appears to sit on the fence between an anxiety disorder and a psychotic disorder (e.g. bipolar disorder). Stressful situations, particularly those that may result in some kind of emotional rejection for those with borderline PD may trigger their typical emotional outbursts.[6]
3. Narcissistic PD
One of the most well-known PDs, narcissism takes its roots from the Greek God Narcissus, who was exceptionally beautiful and could not stop fawning over his reflection. Unfortunately, that was precisely his downfall and he died because he could do nothing else[7]. In a similar way, those with narcissistic PD have an extremely inflated sense of self-importance, entitlement, a lack of empathy[8] and an intense need to be admired. These tendencies derive from an extreme lack of self, self-worth, and self-esteem. Someone with narcissism is often unable to perceive how they truly are as the reality is too threatening. To others, they can come off as self-obsessed, intolerant, rude, selfish, insensitive, cruel, manipulative and controlling.
A narcissist is often comfortable with lying to others, especially to manage other people’s perceptions of them as they do not always stand up to their grand ideas of themselves. Exploitation of others, competing with others, and being jealous or envious of others are common narcissistic behaviors. These individuals feel entitled to everything they set their sights on and have no issue manipulating others to get their way. If someone stands in their way, fails to admire them, or pulls them down, they may become excessively angry and enact revenge – a phenomenon known as “narcissistic rage.” This depends on the context and situation, as a narcissist will never do something they feel is beneath them. Furthermore, it can be difficult to insult a narcissist as they often choose to see others as inferior and blind to their superiority, depending on the circumstance.
4. Antisocial PD
Antisocial PD is perhaps the most infamous of the PDs and often describes the personality of a villain. As the name suggests, this PD encompasses behavior that is against society and all its social norms, such as criminal behavior.[9] One of the diagnostic criteria for this PD is having been diagnosed with conduct disorder by the age of 15[10] and the main characteristic of someone with antisocial PD is an utter disregard for others (that is often acted upon to the other’s detriment).
Unlike a narcissist, those with antisocial PD tend to be ruthless (perhaps sadistic) in the way they lie, manipulate and control other people. A lack of empathy and guilt, an inability to learn from their mistakes, an aggressive or irritable emotional disposition, impulsive and risk-taking behavior, and a disregard for any social convention including laws, rules, obligations, and agreements are common manifestations of antisocial PD. Those with this condition often enjoy harming or deceiving other people, deriving pleasure from such activity and many even feel justified in doing so. It can be difficult to recognize someone with antisocial PD as they tend to be deceptively charming at first.
This disorder used to be divided into psychopaths and sociopaths, but in recent years they have been grouped into one category due to significant overlap.
Cluster C
Cluster C personality disorders are characterized by intense underlying fear or anxiety.
1. Avoidant PD
This PD is basically a type of social anxiety disorder, with some sources arguing that it is a more intense version and others arguing that it is less intense.[11] [12] Avoidant PD people feel fundamentally inept, unappealing, and inferior. Fear of embarrassment, criticism, judgment, and rejection drive their avoidant behavior. Many with this PD only engage in social contact if they can be 200% sure they will be accepted for who they are. Even in their close relationships they feel restrained and act with great caution as a result of their fearful disposition. Extreme cases avoid all forms of social contact, never setting foot outside of the house unless they can be sure they will encounter no one.
Those with Avoidant PD tend to overly monitor their internal reactions and the reactions of others, which contributes to making all social interaction unnatural, forced, and stressful for them. These are perhaps the people with the loudest inner critics, being highly self-judgmental which continues to reinforce the social anxiety. This often correlates with being overly judged or rejected by parents or peers in childhood.
2. Dependent PD
This describes the personality of someone who lacks self-confidence to the point that they have no faith in their ability to make decisions or do anything, even the most basic of tasks. They depend heavily on others for help on a daily basis and only feel secure when there is someone there to do so. These people lack and often fear their own independence and autonomy, fail to assert themselves, and tend to suffer from an attachment disorder [13]. They may go to great lengths to secure their relationships and may unrealistically idolize those who constantly help or protect them – even if doing so places them at a detriment or is harmful. Dependent PD types often behave in a way that undermines themselves and are, naturally, the most vulnerable towards abuse and exploitation. The domineering personality types in Cluster B often partner with this type as the dynamic tends to be securing for both involved.
3. Anankastic PD (Obsessive-Compulsive PD)
Anankastic PD is a personality type that has its roots set in obsessive-compulsive disorder. These people have a strong need to exert control over the world, having an underlying anxiety that results from a perceived lack of control. They tend to do so through being perfectionistic and establishing order as much as possible, being obsessed with structure, details, lists, organization, time, or schedules. Sadly, the more they try to exert control, the more out of control they feel, which perpetuates the problem.
Extreme dedication to work supersedes relaxation and socializing for these individuals. Often they struggle to complete a task as they can never reach the unrealistic expectations of perfectionism they set for themselves or others. Excessive skepticism or doubtfulness, caution, rigidity, controlling tendencies, a lack of humor, and a need to hoard are common manifestations. Relationships of any kind are strained for those with this PD as they are often inflexible and attempt to impose unreasonable demands on others. This PD is often present in those with eating disorders and autistic spectrum disorders.[14]
Dissociative Identity Disorder
In some individuals with Dissociative Identity Disorder (also known as multiple or split personality disorder), multiple discrete personalities or personality disorders may be present at once. Individuals with this condition switch personalities and become completely different people at the drop of a hat, with no recollection of what they do when embodying another personality type. This is often a neurological coping mechanism in response to severe trauma where the brain compartmentalizes information in order to avoid remembering the stressful event(s) that give rise to a separate personality.
While this condition pertains to personality, it falls under a different category of disorder known as dissociative disorders. [15]
Risk Factors
Abuse, trauma, neglect, and substance misuse are common factors that may create a dysfunctional personality, particularly if they coincide with one’s formative years and biologic development.
Other risk factors include:
- Neurotransmitter imbalances, particularly serotonin and dopamine
- Hormone imbalances
- Chronic severe stress
- Depression and other neuropsychological diseases such as bipolar disorder and schizophrenia
- Chronic exposure to somebody with a personality disorder
Treatment Options
With the above in mind, it should be noted that personality disorders cannot be “cured” as they do not typically fall within the realm of disease. Moreover, those with personality disorders very rarely seek medical help and often fail to understand the nature of the dysfunction. Some people with personality disorders fall on the milder side of the spectrum and may not require any treatment if they can integrate successfully into society without harming themselves or others.
Recent research reveals that there might be a neurobiological component to some personality disorders, yet no case is the same; a phenomenon that has been highlighted time and time again by brain imaging technology. Brain scans may give insight into treatment options for an underlying neurological disease that may be contributing, such as a demyelination condition or brain tumor.
On a psychological level, fear, anxiety, lack of self-worth, anger, sadness, frustration, and other consistent emotional states may predispose one to personality disorders. If an underlying psychological trigger can be pinpointed for dysfunctional behavior, tackling the trigger may help abate the dysfunction, yet this has not worked in every case. Psychotherapy and cognitive behavioral therapy may also help to improve functionality by moderating the behavior of the person. These interventions do not work for several personality disorders, particularly those in which the person is inclined to lie to their therapist or where they fail to acknowledge they have a problem.
Psychiatric treatment options for personality disorders revolve around treating symptoms, such as psychosis, aggression, anxiety, and depression. Sedatives, antipsychotics, antidepressants, and other similar pharmaceuticals may be prescribed to tackle such symptoms. These measures often do nothing for the personality traits and can make matters worse by eliciting unintended side effects, such as insomnia.
Some individuals with personality disorders require incarceration or institutionalization to minimize the harm they inflict on others or themselves.
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