Clinical features

The criteria for the diagnosis of personality disorders are that-:

The person’s characteristic and enduring patterns of behaviour deviate markedly from the cultural norm, with deviation in more than one area of-:

• Cognition (i.e. attitudes and ways of perceiving and interpreting),
• Affectivity,
• Control of impulses and gratification, and
• Ways of relating to others.

The deviation is pervasive and the behaviour is inflexible, maladaptive or dysfunctional in a broad range of situations.

There is personal distress or an adverse impact on others.

The deviation is stable and long-lasting, beginning usually in late childhood or adolescence.

The deviant behaviour is not caused by brain injury, disease or dysfunction (e.g. depression, intoxication, organic brain disease).

People with personality disorders may present in various ways; many never present to health services with personality disorder as the index condition. However, the behaviour and attitude of someone with a personality disorder can cause considerable problems for the sufferer and for others. They may be particularly inflexible, vulnerable, difficult to talk to, irrational, or have limited and fragile coping mechanisms.

Some behaviour may be overt (e.g. extreme aggression) but others may be subtle (e.g. lack of assertiveness or avoidance behaviour).

Some of the most common presentations of personality disorders include self-harm, self-neglect, aggression, alcohol or substance misuse and eating disorders. Continuous low-grade depression, or depressive episodes unresponsive to treatment, may also indicate underlying personality disorder. Brief psychotic spells (for example, hearing voices) or dissociative episodes (such as odd behaviour they cannot explain) are less common, but can occur with a primary personality diagnosis. Many people also present with a history of unexplained physical symptoms.

Most people diagnosed with a personality disorder fit the criteria for at least two different types of personality disorder.

Danger to others is most often associated with antisocial personality disorder.

People with a borderline emotionally unstable or paranoid personality disorder are at higher risk of self harm and suicide.

Antisocial personality disorder is included in the Mental Health Act 1983, and if thought to be treatable, can be the basis for compulsory admission to hospital.

Each type of personality disorder has characteristic associated features.

• Cluster A
• Cluster B
• Cluster C

Cluster A

Paranoid personality disorder

The following features tend to be predominant in people diagnosable with paranoid PD-:

• Being extremely sensitive to experiencing failure or rejection.
• Holding grudges against people and refusing to forgive insults, injuries or slights.
• Being very suspicious and often misconstruing the friendly or neutral behaviour of others as being unfriendly or hostile.
• Being constantly suspicious about the fidelity of sexual partners.
• Having a preoccupation with personal rights and a sense of these being infringed even when this is not so.
• Being self centred and self important.
• Believing in conspiracy theories about events affecting their own lives, and in the world at large.

Schizoid personality disorder

The following features tend to be predominant in people diagnosable with schizoid PD-:

• Finding pleasure in few, if any aspects of life.
• Being unemotional, cold and unfeeling and finding it very difficult to express, for example, anger or warmth.
• Being unaffected by the praise or criticism of others and noticeably insensitive to the norms and conventions held by society.
• Preferring to be on their own and having little interest in relationships (including close relationships or sexual partners).
• Being introspective and preoccupied with fantasy.

Schizotypal personality disorder

The following features tend to be predominant in people diagnosable with schizotypal PD-:

• Behaviour that is cold and aloof, and in other respects is regarded as strange and eccentric.
• Difficulty in maintaining relationships with a tendency to be socially withdrawn.
• Holding unusual beliefs, such as magical thinking (“if I think this, I can make that happen”) which influence behaviour.
• Holding ideas that are irrational and often feeling misunderstood.
• Thinking obsessively about a subject without being able to ‘let go’; this will often be of a sexual or violent nature.
• Reporting unusual perceptions such as voices, visions and bodily experiences.

Cluster B

Antisocial personality disorder

(Also known as ‘dissocial PD’, ‘ASPD’ and previously called ‘psychopathy’, ‘psychopathic disorder’ or ‘psychopathic PD’)

The following features tend to be predominant in people diagnosable with antisocial PD-:

• Disregarding social norms, rules and obligations.
• Acting in ways that are regarded as unacceptable or grossly irresponsible.
• Appearing to be callous and unconcerned about how their behaviour makes others feel.
• Feeling neither guilt nor profit from, for example, punishment.
• Blaming other people for their problems.
• Trying to find ways of rationalising abnormal or unacceptable behaviour.
• Inability to maintain long-term stable relationships.
• Inability to tolerate frustration.
• Proneness to outbursts of aggression and violence.

Borderline personality disorder

(Also known as ‘emotionally unstable personality disorder’ in the ICD classification, then divided into ‘impulsive’ and ‘borderline’)

The following characteristics tend to be predominant in people diagnosable with borderline personality disorder-:

• Acting impulsively without considering the consequences of actions. For example, engaging in unprotected sex or substance abuse.
• Self-harm without an intention to commit suicide.
• Vigorous attempts to avoid perceived abandonment (frequently with sense of desperation).
• Unstable mood – frequent swings between intense emotions.
• Transient psychotic symptoms (typically, hearing unpleasant voices).
• History of intense and unstable relationships.
• Feelings of chronic emptiness.
• Poor sense of personal identity (including life aims and sexual preferences).
• Low self-esteem.

Histrionic personality disorder

(Previously also known as ‘hysterical personality disorder’)

The following features tend to be predominant in people diagnosable with histrionic PD:

• • Being given to theatricality, self dramatisation and exaggerating the expression of emotions.
• • Suggestibility and being easily influenced by others or by circumstances.
• • Constantly needing to find activities offering excitement and the opportunity to be the centre of attention.
• • Longing to be appreciated by other people.
• • Overconcern with physical attractiveness.
• • Acting or appearing in an inappropriately seductive way.
• • Being persistently manipulative to achieve what is wanted.
• • Being easily hurt if obstructed.

Narcissistic personality disorder

The following features tend to be predominant in people diagnosable with narcissistic PD-:

• Appearance of arrogance and self importance.
• Fantasies about unlimited success, power and achievements.
• Belief that they are special and can only be understood by other special people.
• Having a constant need for attention and admiration.
• Exploiting others to achieve their own ends.
• Lacking empathy: unwilling to recognise or identify with the feelings and needs of others.
• Being envious of others.
• Believing that others are envious of them.

Cluster C

Avoidant personality disorder

(Also known as ‘anxious personality disorder’)

The following features tend to be predominant in people diagnosable with avoidant PD-:

• Avoidance of activities that involve other people.
• Reluctance to get involved in relationships unless certain of being liked.
• Over-concerned by the fear of being criticised or rejected in social or work situations.
• Persistent and pervasive feelings of shyness, insecurity, apprehension and tension.
• Believe that they are unlikeable, undeserving, socially inept and less important than other people.
• Restriction in general functioning and lifestyle.

Dependent personality disorder

(Previously known as ‘inadequate personality disorder’)

The following features tend to be predominant in people diagnosable with dependent PD-:

• Limited ability to make everyday decisions without excessive reassurance and advice.
• Encouraging or allowing others to make important life decisions.
• Unwillingness to make any demands on others, especially those people who play an important part in their life.
• Being compliant and subordinate to other people’s wishes.
• Inability to help themselves.
• Feeling helplessness and discomfort when alone.
• Anxiety about being abandoned by loved ones.
• Fear of being unable to care for themselves.

Obsessive compulsive personality disorder

(Called ‘anankastic personality disorder’ in the ICD-10 classification and also known as ‘obsessional PD’)

The following features tend to be predominant in people diagnosable with obsessive-compulsive PD-:

• A need to adhere strictly to rules, lists and orders.
• Degree of perfectionism which often interferes with the successful completion of tasks.
• Expectation of the same dedication of others.
• Seeking to prevent others from doing things in a different way.
• Difficulty maintaining close relationships.
• Difficulty enjoying normally pleasurable activities.
• Feelings of excessive doubt and caution.
• Rigid and stubborn in outlook.
• Pedantic about doing the right thing.

Other diagnoses, such as ‘multiple personality disorder’ or ‘split personality’ have no formal diagnostic recognition, and people with them are usually also able to be diagnosed within the official classification. ‘Passive-aggressive personality disorder’ was described in a previous Diagnostic and Statistical Manual (DSM) classification but is no longer used. ‘Complex post-traumatic stress disorder’ and ‘attachment disorder’ are sometimes used as explanatory diagnoses, but are not recognised as formal categories.

Cluster A disorders should be differentiated from psychotic mental illnesses; Cluster B disorders commonly present with aggressive behaviour; Cluster C disorders have to be differentiated from anxiety and depression.

However, personality disorders commonly co exists with mental disorders and the person may exhibit symptoms of both.

Amended June 2008