Personality Disorders: Types, Incidence, and Impact

Portraits of the Self Turned Against Itself

Since the beginning of recorded history societies have employed strategies for understanding the distinguishing differences among people. Even primitive and ancient cultures developed methods for determining and recognizing the distinctive characteristics of the individual within the collective. One of the earliest systems for classifying and explaining personality was that of the Greek philosophers Hippocrates and Galen who suggested that the four basic bodily fluids, known as humors, were associated with an element and a corresponding personality type: yellow bile is related to fire and a choleric or irritable personality; black bile (melancholia) is related to earth and a melancholic or depressed personality; blood is related to air and a sanguine or optimistic personality; phlegm is associated with water and a phlegmatic or calm personality. In this model, personality disorders and emotional problems were conceptualized as imbalances in bodily fluids (Corsini, 1994; Phillips & Gunderson, 1994).

The body fluid model of temperament established a precedent for later models of personality and disorders of personality based on body type. In the early 1900s, Ernst Kretschmer, a German psychiatrist, reported an association between body type and diagnosis (i.e., manic-depressive patients more frequently had the pyknic, round body type whereas schizophrenic patients more frequently had the frail asthenic or the muscular athletic type). Subsequently, an American psychologist, William Sheldon, extended Kretschmer’s work, suggesting three basic body types each associated with a particular temperament and/or clinical tendency. Other early methods of personality assessment included techniques such as astrology, physiognomy (the practice of determining character from physical appearance), graphology (the practice of interpreting personality from handwriting) and phrenology (the practice of judging one’s faculties and personality through reading the bumps on the head) (Corsini, 1994; Phillips & Gunderson, 1994).

The first comprehensive system of personality disorder categorization is attributed to German phenomenologist Schneider who considered these pathologies to represent socially deviant and extreme variants of normally occurring personality traits. His system provided the template for the modern classifications in the American Psychiatric Association’s (2013) Diagnostic and Statistical Manual, 5th ed. (DSM-V) (Phillips & Gunderson, 1994).

Personality and Personality Disorders

The DSM-V defines personality traits as “enduring patterns of perceiving, relating to, and thinking about the environment and oneself exhibited in a wide range of important social and personal contexts” (APA, 2013, p. 782). Relatedly, personality disorders constitute “an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture and is manifested in at least two of the following areas: cognition, affectivity, interpersonal functioning, or impulse control (Criterion A). This enduring pattern is inflexible and pervasive across a broad range of personal and social situations (Criterion B) and leads to clinically significant distress or impairment in social, occupational, or other important areas of functioning (Criterion C). The pattern is stable and of long duration, and its onset can be traced back at least to adolescence or early adulthood (Criterion D). The pattern is not better explained as a manifestation or consequence of another mental disorder (Criterion E) and is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication, exposure to a toxin) or another medical condition (e.g., head trauma) (Criterion F)” (American Psychiatric Association, 2013, p. 647). Similarly, the International Classification of Diseases, Tenth Edition (ICD-10), defines personality disorders as “severe disturbances in the characterological constitution and behavioral tendencies of the individual, usually involving several areas of the personality, and nearly always associated with considerable personal and social disruption which tend to appear in late childhood or adolescence and continue to manifest into adulthood” (World Health Organization, 2003, p. F60).

Generally speaking, the pathological characteristics of these personality disturbances exhibit precursors of early developmental disturbances which persist as enduring qualities of the individual. The enduring nature of the behaviors, their impact on social functioning, the lack of clear boundaries between normality and illness and the patient’s perception of the symptoms as not being foreign make this group of conditions more difficult to conceptualize than the more typical episodic mental disorders (Rey, 1996).

Personality disorders differ qualitatively from other psychiatric disorders in several fundamental ways. Individuals with these disorders demonstrate alloplastic defenses which manifest through reactions to stress which attempt to change the external environment. For example, such patients often deal with a potential disappointment by threatening to retaliate and in that manner manipulate another person to gratify rather than disappoint them. In contrast, patients with neurotic disorders demonstrate autoplastic defenses, whereby they react to stress by changing their internal psychological processes. For example, neurotic patients would rationalize that a disappointment is really of no great importance.

Additionally, these disorders differ in the degree and nature of self-awareness manifested in the patients. Individuals with personality disorders typically perceive character deficits as ego-syntonic — acceptable, unobjectionable and an inherent part of the self. As such, these patients may disavow personal responsibility for hurting another person, have difficulty in appreciating the pain they have inflicted upon another and attribute blame to another person or set of circumstances. Conversely, personal shortcomings in individuals with neurotic disorders are perceived by the patient as ego-dystonic — unacceptable, objectionable and alien to the self. Therefore, patients with neurotic disorders tend to blame and chastise themselves for disappointing or hurting a valued person through their shortcomings (Goldman, 2000 Kaplan & Saddock, 2002).

Categories and Types of Personality Disorders

The Diagnostic and Statistical Manual of Mental Disorders (DSM-5), organizes personality disorders into three main categories, with several types in each category.

Eccentric personality disorders

People with these disorders often appear odd or peculiar. The eccentric personality disorders include:

• Paranoid personality disorder. Paranoia is the hallmark of this disorder. People with paranoid personality disorder have a constant mistrust and suspicion of others. They believe that others are trying to demean, harm, or threaten them.
• Schizoid personality disorder. People with this disorder are distant, detached, and indifferent to social relationships. They generally are loners who prefer solitary activities and rarely express strong emotion.
• Schizotypal personality disorder. People with this disorder display unusual thinking and behavior, as well as appearance. People with schizotypal personality disorder might have odd beliefs and often are very superstitious.

Dramatic personality disorders

People with these disorders have intense, unstable emotions and a distorted self-image. They also often tend to behave impulsively. These disorders include:

• Antisocial personality disorder. People with this disorder are sometimes called “sociopaths” or “psychopaths.” This disorder is characterized by rash, irresponsible, and aggressive behavior, which often is expressed by a disregard for others and an inability to abide by society’s rules. People with this disorder often commit serious crimes and have a lack of remorse for their actions.
• Borderline personality disorder. This disorder is marked by unstable moods, poor self-image, chaotic relationships, and impulsive behavior (such as sexual promiscuity, substance abuse, over-spending, and reckless driving).
• Histrionic personality disorder. People with this disorder are shallow and constantly seek attention. They often are very dramatic, possibly even childish, and overly emotional.
• Narcissistic personality disorder. This disorder is characterized by an exaggerated sense of superiority, and a preoccupation with success and power. However, this preoccupation is fueled by a fragile self-esteem. People with this disorder are very self-centered, tend to lack empathy, and require constant attention and admiration.

Anxious personality disorders

People with these disorders often are nervous or fearful. These disorders include:

• Avoidant personality disorder. People with this disorder tend to avoid social contacts. This behavior is not the result of a desire to be alone but due to excessive concern over being embarrassed or harshly judged. They often miss out on many valuable social experiences because of their fear of being rejected.
• Dependent personality disorder. This disorder is marked by dependency and submissiveness, a need for constant reassurance, feelings of helplessness, and an inability to make decisions. People with dependent personality disorder often become very close to another individual and spend great effort trying to please that person. They tend to display passive and clinging behavior, and have a fear of separation.
• Obsessive-compulsive personality disorder. This disorder is characterized by a pattern of perfectionism and inflexibility, control and orderliness, with a strong fear of making mistakes. This fear often results in an inability to make decisions, difficulty finishing tasks, and a preoccupation with details. (APA, 2013; Cleveland Clinic, 2021)

Incidence, Frequency and Impact

The measured prevalence of personality disorders in contemporary society depends on the validity of the classification system and diagnostic instruments used to establish the presence of a disorder. Available epidemiological data suggests that Personality Disorders, as diagnosed with the DSM-V criteria, affect approximately 10–13% of the adult world population. Individuals may manifest symptoms of more than one personality disorder. The following statistics represent estimates of the prevalence of specific personality disorders in the general population:

• Paranoid personality disorder — 2–10%
• Schizoid personality disorder — 3–4%
• Antisocial personality disorder — 3% of men, 1% of women
• Borderline personality disorder — 1.6%
• Histrionic personality disorder — 2.1%
• Narcissistic personality disorder — Less than .5%
• Avoidant personality disorder — 2.5%
• Obsessive-compulsive personality disorder — 2.1–7.9%
• Dependent personality disorder — .5%. (Hull, 2021)

The impact of personality disorders (PDs) on the individual, family, and society is virtually immeasurable. Ruegg and Francis (2005) summarized the extent of the impact stating,

PDs are associated with crime, substance abuse, disability, increased need for medical care, suicide attempts, self-injurious behavior, assaults, delayed recovery from medical illness, institutionalization, underachievement, underemployment, family disruption, child abuse and neglect, homelessness, illegitimacy, poverty, STDs, misdiagnosis and mistreatment of medical and psychiatric disorder, malpractice suits, medical and judicial recidivism, dissatisfaction with and disruption of psychiatric treatment settings, and dependency on public support. (pp. 16–17).

Patients with personality disorders present with problems that are among the most complex and challenging that clinicians encounter. This is due, in part, to the reality that the personality disorder characteristics do not simply represent a problem the patient has, but are in fact central to who that patient is. In this way, personality disorder patients often represent a population with limited capacity for complete eradication of symptoms and/or restoration of optimal adaptive functioning.

However, this population can make significant strides when their therapists are able to develop a sophisticated treatment plan guided by an accurate cognitive conceptualization that emphasizes using the therapeutic relationship to test assumptions about others and that achieves a reasonable balance between current problem-solving, restructuring dysfunctional beliefs originating in childhood and adopting new, more flexible behavioral strategies. Personality disorder patients can learn, in short, to think about themselves and others in more realistic, more functional ways and to act more adaptively in order to reach their goals and lead more fulfilling lives.

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author.

Corsini, R. J. (Ed.) (1994). Encyclopedia of Psychology — Volume 3, (2nd ed.). Itasca, IL: F. E.

Peacock Publishers, Inc.

Goldman, H. H. (2000). Review of general psychiatry, (5th ed.). New York, NY: McGraw-Hill Medical.

Hull, M. (2021). Personality Disorders Facts and Statistics. The recovery village. https://www.therecoveryvillage.com/mental-health/personality-disorders/personality-disorder-statistics/

Kaplan, H. I. & Saddock, B. J. (2002). Synopsis of Psychiatry, 9e. Baltimore: Lippincott, Williams & Wilkins.

Phillips, K. A., & Gunderson, J. G. (1994). Personality disorders. In R. E. Hales, S. C. Yudofsky, & J. A. Talbott (Eds.), The American Psychiatric Press textbook of psychiatry, (2nd ed.). (pp. 701–728). American Psychiatric Association.

Rey, J. M. (1996). Antecedents of personality disorders in young adults. Psychiatric Times, XIII, 2.

World health Organization. (2003). International classification of disorders,(10th ed.).