What are Personality Disorders?
An individual’s personality is a set of characteristics that defines how they perceive the world around them. It is made up of features that cause them to think, feel, and act in a particular way. Our style of behavior, how we react, our worldview, thoughts, feelings, and the way we interact in relationships are all part of what makes up our personality. Having a healthy personality enables a person to function in daily life. Everyone experiences stress at some time in life, but a healthy personality helps us to face the challenges and move on. Genetic make-up, biological factors, and environmental surroundings all help to shape personality. Personality makes each of us different…makes each of us an individual.
A personality disorder is officially described as “A deeply ingrained, inflexible pattern of relating, perceiving, and thinking that is serious enough to cause distress or impaired functioning.” In order to receive a diagnosis of a personality disorder, an individual must meet certain criteria, which are discussed below.
For someone with a personality disorder, the features of everyday life that most of us take for granted can become a challenge. When an individual has a personality disorder, it becomes harder for them to respond to the changes and demands of life, and to form and maintain relationships with others. These experiences can lead to distress and social isolation, and can increase the risk of depression and other mental health issues.
There are ten types of personality disorders, and The Psychiatric DSM-5 (Diagnostic and Statistical Manual, 5th edition) groups these ten personality disorders into three broad clusters, referred to as A, B, and C.
Cluster A personality disorders involve behavior that seems unusual and eccentric to others.
Paranoid personality disorder
Schizoid personality disorder
Schizotypal personality disorder
Cluster B personality disorders feature behavior that is emotional, dramatic, or erratic.
Antisocial personality disorder
Borderline personality disorder
Histrionic personality disorder
Narcissistic personality disorder
Cluster C personality disorders feature behaviors that are motivated by anxiety and fear.
Avoidant personality disorder
Dependent personality disorder
Obsessive-Compulsive personality disorders
Ten Types of Personality Disorders
1. Paranoid Personality Disorder
Affects approximately 2% – 4% of the general population. A person with paranoid personality disorder finds it hard to trust others. They might think that people are lying to them or manipulating them, even when there is no evidence of this happening. The inability to trust others can make it hard for people with paranoid PD to maintain relationships with those around them.
People with this may exhibit
– Mistrust and suspicion
– Anxiety about others taking advantage of them
– Anger over perceived abuse
– Concern about hidden meanings or motives
2. Schizoid Personality Disorder
Affects fewer than 1% of the population. A person with schizoid personality disorder may feel more comfortable with a pet than with another person, and in fact may form attachments with objects or animals rather than people, because they feel very uncomfortable when they are required to relate to others. Others may see the person as aloof, detached, cold, or as a “loner.” Note that schizoid personality disorder shares some features with schizophrenia, but they are not the same, as psychosis and hallucinations that are required for the diagnosis of schizophrenia are not part of schizoid personality disorder. However, individuals with schizoid personality disorder may have relatives of with schizophrenia or schizotypal personality disorder.
The person will tend to:
– Avoid close social contact with others
– Have difficulty forming personal relationships
– Seek employment that involves limited personal or social interaction
– React to situations in ways that others consider inappropriate
– Appear withdrawn and isolated
3. Schizotypal Personality Disorder
People with this disorder may have few close relationships outside their own family, because they have difficulty understanding how relationships develop, and how their behavior affects others. They may also find it hard to understand or trust others. A person with this condition has a higher risk of developing schizophrenia in the future.
For diagnosis, the person must exhibit or experience five or more of the following behaviors:
– Ideas of reference; example, when a minor event happens, they believe it has special significance for them.
– Odd beliefs or magical thinking that influences their behavior; such as superstitious thinking, beliefs in telepathy, or bizarre fantasies or preoccupations
– Unusual perceptual experiences, including bodily illusions and odd thinking and speech; example, metaphorical thinking, minute detail, and overelaboration.
– Suspiciousness or paranoia
– Inappropriate or bizarre facial expressions
– Behaviors that seem odd, eccentric, or peculiar
– Lack of close friends or confidants, other than first-degree relatives
– Extreme social anxiety
4. Antisocial Personality Disorder
A person with antisocial personality disorder (ASPD) acts without regard to right or wrong, or without thinking about the consequences of their actions on others. It is more likely to affect men than women. Approximately 1% – 3% of the general population have ASPD, but is found in approximately 40% – 70% of the incarcerated (jailed) population. When found in children under 15, commonly referred to as conduct disorder, which significantly increases the risk of having ASPD later in life. Researchers studied specific genetic features in 543 participants with ASPD. They found similar genetic features, as well as low levels of grey matter in the frontal cortex area of the brain. They determined that genetic, biological, and environmental factors are all likely to play a role.
This can result in:
– Irresponsible/ delinquent behavior
– Novelty-seeking behavior
– Violent behavior
– High risk for criminal activity
5. Borderline Personality Disorder
A person with borderline personality disorder will have trouble controlling their emotions.
They may experience:
– Mood swings
– Shifts in behavior and self-image
– Impulsive behavior
– Periods of intense anxiety, anger, depression, and boredom
These intense feelings can last for only a few hours or for much longer periods, even up to weeks. They can lead to relationship difficulties and other challenges in daily life, resulting in:
– Rapid changes in how the person relates to others, for example: swift shifts from closeness to anger
– Risky behaviors, ie dangerous driving and spending sprees
– Self-harming behavior
– Poor anger management
– Sense of emptiness
– Difficulty trusting others
– Recurrent suicidal behaviors, gestures, threats, or self-mutilation, such as cutting
– Feelings of apathy, detachment, or dissociation
6. Histrionic Personality Disorder
A person with histrionic personality disorder feels a need for others to notice them and reassure them that they are significant. This can affect the way the person thinks and acts. It is considered to be one of the most ambiguous (ie non-specific) diagnostic categories in mental health. The person may feel a strong need to be loved, and they may also feel as if they are not strong enough to cope with everyday life alone. The person may function well in social and other environments, but they may also experience high levels of stress, and this can lead to them having depression and anxiety. The features of histrionic personality disorder can overlap with, and be similar to, those of narcissistic personality disorder.
It may lead to behavior that appears:
– Provocative and flirtatious
– Excessively emotional or dramatic
– Emotionally shallow
– Insincere, as likes and dislikes shift to suit the people around them at the given moment
– Risky, as the person constantly seeks novelty and excitement
7. Narcissistic Personality Disorder
This disorder features a sense of self-importance and power, but it can also involve feelings of low self-esteem and weakness. These features can make it hard for them to maintain healthy relationships and function in daily life.
A person with this condition may show the following personality traits:
– An inflated sense of their own importance, attractiveness, success, and power
– Craving for admiration and attention
– Lacking regard for others’ feelings
– Overstatement of their talents or achievements
– Expectation of deserving the best of everything
– Experiencing hurt and rejection easily
– Expecting others to go along with all of their plans and ideas
– Experiencing jealousy
– Believing they should have special treatment
– Believing they should only spend time with other people who are as special as they are
– Appearing arrogant or pretentious
– Being prone to impulsive behavior
People with narcissistic PD may also have a higher risk of:
– Mood, substance, and anxiety disorders
– Low self-esteem and fear of not being good enough
– Feelings of shame, helplessness, anger at themselves
– Impulsive behavior
– Using lethal means to attempt suicide
8. Avoidant Personality Disorder This personality disorder can make it hard to form friendships. A person with it avoids social situations and close interpersonal relationships, mainly due to a fear of rejection and the feeling that they are not good enough. There may also be a higher risk of substance abuse, eating disorders, or depression, and the person may think about or attempt suicide. A person with avoidant personality disorder may want to develop close relationships with others, but they lack the confidence and ability to form relationships. They generally appear extremely shy and socially inhibited.
They often exhibit:
– Feelings of inadequacy
– Low self-esteem
– Distrustfulness of others
9. Dependent Personality Disorder
People with dependent PD often lack confidence in themselves and their abilities. It is difficult for them to undertake projects independently or to make decisions without help, and they may find it hard to take personal responsibility. They are especially vulnerable to ill-treatment from others, including emotional, verbal, physical, domestic abuse. Any mistreatment can lead to further complications, such as depression and anxiety.
A person with this condition may have the following characteristics:
– Having an excessive need to be taken care of by others
– Being overly-dependent on others
– Having a deep fear of separation and abandonment
– Investing a lot of energy and resources in trying to please others
– Going to great lengths to avoid disagreement and conflict
– Being vulnerable to manipulation by others.
– A willingness to tolerate mistreatment to keep a relationship
– A preference to not be alone
Others may see their behavior as:
10. Obsessive-Compulsive Personality Disorder
A person with OCPD can find it difficult to accept when something is not perfect. Obsessive-compulsive personality disorder (OCPD) is not the same as obsessive-compulsive disorder (OCD). OCD relates to everyday tasks, while OCPD focuses specifically on following procedures. In addition, OCD can interfere with the way a person functions in everyday life, whereas OCPD can enhance a person’s professional performance, while also potentially interfering with their personal life outside of work. Some people may experience both OCD and OCPD, and research has shown that there appears to be a link between them. An excessive concern with perfectionism and hard work dominate the life of a person with OCDP. The individual may prioritize these ideals of perfectionism and hard work to the detriment of close personal relationships. In fact, others may see the individual as sanctimonious, stubborn, uncooperative, and obstinate.
A person with OCPD may:
– Appear inflexible
– Feel an overwhelming need to be in control
– Find that concerns about rules and efficiency make it hard to relax
– Find it hard to complete a task for fear that it is not perfect
– Be uncomfortable when things are messy
– Have difficulty delegating tasks to others
– Be extremely frugal, even when it is not necessary
– Hoard items
Personality Disorders: Treatment and Outlook
People with personality disorders often don’t feel there is anything wrong with their behavior, but they may seek help because they are experiencing social isolation and fear. Regardless, depression, anxiety, and other mental health issues can result from living with a personality disorder. For this reason, it is important for them to seek help early. Personality disorders often share features, and it can be hard to distinguish between them, but there are sufficient criteria for an appropriate diagnosis. Following that diagnosis, treatment can help people with the various types of personality disorders. The physician may prescribe medication, and will often recommend therapy or counseling. Individual, group, and family counseling can help. One type of counseling is cognitive behavioral therapy (CBT). CBT helps a person to see their behavior in a new way and to learn alternative ways of reacting to situations. In time, this can make it easier for the person to function in everyday life and to maintain healthy relationships with others. So overall, the outlook is positive if the person with the personality disorder is willing to dedicate themselves to diligent work.
PsyCom has several online tests you can take for yourself or for someone else in your life, and then submit for results. Just for funsies, below are links to some tests related to this week’s topic, personality disorders.
Do you have antisocial personality disorder, commonly referred to as sociopathy? Use this quiz to determine whether you or someone you know may be a sociopath.
Do you have narcissistic personality disorder? Use this quiz to determine whether you or someone you know may be a narcissist or have a more severe case of Narcissistic Personality Disorder (NPD).
If you enjoyed this blog, please comment and share. For more information and stories on personality disorders, please check out my book, Tales from the Couch, available on Amazon.com.Learn More
A Coronavirus PSA
Before we get to this next blog on suicide, I must say something related to Coronavirus transmission, because I’m tired of yelling it at my television when I see people doing it or talking about it, how “safe” it is. What is it? It’s “elbow love,” bumping elbows with someone to say hello, goodbye, good job, whassup, whatever. Think about this, people: during this viral outbreak, what have we been asking people to do when they sneeze or cough? Ideally, to do so in a tissue, but that’s not realistic, it rarely happens, so we ask them to sneeze or cough into their bent arm, at the elbow. Get the picture? The droplets they expell during that sneeze or cough are deposited everywhere surrounding that area, including the part you bump, so if your “bumpee” has Coronavirus, even if they have no symptoms, you, the “bumper” get those bijillions of virions on your elbow, and you can take them home with you. Then maybe your spouse or partner welcomes you home by putting their hands on your arms to give you a kiss… and now half a bijillion virions may be on one of their hands, just waiting to be deposited everywhere. Bottom line: for as long as this virus is around, use your words, not your body, to say whassup. So pass this knowledge on…not the virus.
Suicide is always a very difficult topic for every family, and in thirty years as a psychiatrist, it’s never gotten much easier to broach this subject. What motivated me to write this blog is a recent conversation I had with the father of one of my young patients, a fourteen-year-old named Collin, who in fact had just made what I believed was a half-hearted suicide attempt; the proverbial ‘cry for help.’ Understand that half-hearted does not mean it’s totally safe to blow it off, but we’ll get to an explanation about that later. His father, Lawrence, who prefers to be called Law, was a single parent, a widower after metastatic melanoma devastated the family of three about eighteen months before. Shortly after the mother, Sharon, passed away, Law brought Collin to my office. It was clear from the first appointment that Collin was depressed, and had been for some time. Psychotherapy was difficult with him, and it took about five appointments to establish more than a tenuous relationship and for him to begin to open up to me. I had tried him on a couple of medications, but they never seemed to do the job. I strongly suspected that it was due to a compliance issue. Actually, I’m certain that it was. He just didn’t take them regularly or as directed. That always mystifies me, patients who are miserable, anxious and depressed, but they take their meds haphazardly, at best; meds that could turn their worlds around…not because they’re inconvenient, and not because of side effects, just because. So, the tenuous connection made for less than optimal psychotherapy sessions, and that, combined with the absence of appropriate meds, put Collin on a path that led here, my office, 22 hours after his attempt. I was a little shocked by his attempt, but very shocked at how effectively, how deeply, he was able to hide the monumental amount of pain that he had obviously been feeling. His father Law looked exhausted, shellshocked, and was having such difficulty talking about it for a number of reasons, but he told me that one of the main reasons was shame. He was ashamed that Collin was so ill, and even ashamed that he was ashamed of it. He was ashamed that he could do nothing to help him, and ashamed that he had possibly caused or contributed to his son’s illness. I told him repeatedly and in several different ways that I understood, that his feelings weren’t unusual among parents of children like Collin, that he absolutely was helping him, and that while mental illness does have a familial component, he was not responsible in any way for his sons illness or attempt. Unfortunately, I don’t think he really heard a word I said. In my experience, suicidal ideation, thoughts of suicide, suicide attempts, and the actual act of suicide affects everyone it touches in a way that no other psychiatric illness does. But in this situation, I think Law was thinking about what his life would be like if Collin tried again and succeeded. It would be very sad, alone, and lonely.
Facts and Figures
Suicide is the 10th leading cause of death in the United States, claiming 47,173 lives in 2019. Montana and Alaska have the highest suicide rates, which is interesting because both of those states have very high gun ownership rates. Believe it or not, New Jersey is the lowest. I have no clue why that would be the case. There were 1.4 million suicide attempts last year in the US. Men are 3.54 times more likely than women to commit suicide. Of all the suicides in the United States last year, 69.67% were white men; they don’t seem to be doing so well. The most common way to commit suicide is by firearm, at about 50%; suffocation is 27.7%, poisoning is 13.9%, and other would be the rest, things like jumping from a tall building or bridge, laying on train tracks or jumping in front of a subway car or a bus. Among US citizens, depression affects 20 to 25% of the population, so at any given point, 20% of the population is a bit more prone to suicide, as obvi people must first be depressed (chronically or acutely) before attempting suicide. There are 24 suicide attempts for every 1 completed suicide. The most disturbing statistic is that suicide rates are up 30% in the past 16 years, with a marked increase in adolescent suicides, and suicide is now the second leading cause of death in people ages 10 to 24.
You would think the US would have the highest suicide rates in the world, but in fact, Russia, China, and Japan are all higher.
Suicide Risk Factors
What are some factors that may put someone at higher risk of suicide?
– Family history of completed suicide in first-degree relatives
– Adverse childhood experiences, ie parental loss, emotional/ physical/ sexual abuse
– Negative life situations, ie loss of a business, financial issues, job loss
– Psychosocial stressors, ie death of loved one, separation, divorce, or breakup of relationship, isolation
– Acute and chronic health issues, illness and/ or incapacity, ie stroke, paralysis, mental illness, diagnoses of conditions like HIV or cancer, chronic pain syndromes
But, understand there’s no rule that someone must have one or more of these factors in order to be suicidal.
Mental Illness and Suicidality
In order to make a thorough suicide risk assessment, mental illness must be considered. There seem to be 6 mental health diagnoses that people who successfully complete suicide have in common:
– Bipolar disorder
– Schizoaffective disorder
– Post-traumatic stress disorder
– Substance abuse
Suicidal ideation refers to the thoughts that a person may have about suicide, or committing suicide. Suicidal ideation must be assessed when it is expressed, as it plays an important role in developing a complete suicide risk assessment. Assessing suicidal ideation includes:
– Determining the extent of the person’s preoccupation with thoughts of suicide, ie continuous? Intermittent? If so, how often?
– Specific plans; if they exist or not; if yes, how detailed or thought out?
– Person’s reason(s) or motivation(s) to attempt suicide
Assessment of Suicide Risk
Assessing suicide risk includes the full examination/ assessment of:
– The degree of planning
– The potential or perceived lethality of the specific suicide method being considered, ie gun versus overdose versus hanging
– Whether the person has access to the means to carry out the suicide plan, ie a gun, the pills, rope
– Access to the place to commit
– Note: presence, timing, content
– Person’s reason(s) to commit suicide; motivated only by wish to die; highly varied; ie overwhelming emotions, deep philosophical belief
– Person’s motivation(s) to commit suicide; not motivated only by wish to die; motivated to end suffering, ie from physical pain, terminal illness
– Person’s motivation(s) to live, not commit suicide
What is a Suicide Plan?
A suicide plan may be written or kept in someone’s head; it generally includes the following elements:
– Timing of the suicide event
– Access to the method and setting of suicide event
– Actions taken toward carrying out the plan, ie obtaining gun, poison, rope; seeking/ choosing/ inspecting a setting; rehearsing the plan
The more detailed and specific the suicide plan, the greater the level of risk. The presence of a suicide note suggests more premeditation and typically greater suicidal intent, so an assessment would definitely include an exploration of the timing and content of any suicide note, as well as a thorough discussion of its meaning with its author.
I spent years teaching suicide assessment to other physicians, medical students, nurses, therapists, you name it. It all seems super complicated when you look at all the above factors written out, but as I always taught, it becomes clearer when you put it into practice. What are we doing when we embark on a suicide assessment? We’re determining suicidality, the likelihood that someone will committ suicide. You’re deciding how dangerous someone is to themselves using the factors discussed above. You’re either looking at how lethal they could be, how lethal they are at this time, or how lethal they wereduring a previous episode of suicidal ideation or previous suicide attempt.
When we put this all into practice, we look at statements and actions to determine how dangerous a person is. Did someone say, ‘if so and so does this, I’ll kill myself’ or, did someone act but just scratched their wrist? Those would be low level lethality, and they would not be very dangerous. Did someone buy a gun, load the ammunition, learn how to shoot it, go to the place where they planned to kill themselves at the time they planned, and then practice putting the gun to their head…essesntially a dry run? That would be the most lethal; that person would be the most dangerous. Those are the two poles of lethality and danger, but there are variant degrees and many shades of gray, so you really have to discuss it very thoroughly with each individual.
Let’s say a 15-year-old is in the office after taking a big handful of pills in a suicide attempt. I ask him if he realized that taking those pills could have actually killed him, and he says no. He’s not that lethal, not that dangerous, because even though his means (pill overdose) was lethal, he didn’t know it was, so lacking that knowledge mitigates the risk, making him less dangerous. Example: acetominophen is actually extremely lethal. People who truly overdose on it don’t die immediately, but it shuts down the liver, killing them two days later. A person that takes a bunch of it thinking it’s a harmless over the counter drug is not that dangerous, because even though their method was lethal, they didn’t know it. In a similar manner, I’ve had people mix benzos with alcohol, which is another very lethal method. It’s a very successful way to kill yourself, but a lot of people don’t realize it, so it’s not that lethal to them. In the reverse case, people who know about combining alcohol and benzodiazepines, who know how dangerous it is, are dangerous, highly lethal to themselves.
People who play with guns, like Russian Roulette-type stuff; or people who intentionally try asphyxiating or suffocating themselves, as for sexual pleasure; or people who tie a rope to a rafter and then test their weight…these people are very dangerous, very lethal, very scary to psychiatrists.
Where someone attempts suicide is also very telling, very instructive in determining their lethality, how suicidal, how dangerous they are. If they do it in a place where there is no chance of being found, of being interrupted, they are very suicidal, very dangerous. Contrast that to doing it in a place where there are people walking by, or in a house where someone is, or could be coming home, then they are not as suicidal, not as dangerous. As an exaple, let’s say someone leaves their car running in a garage when they know that no one will be around for 2 days. That is very dangerous, they are very suicidal. If someone takes an opiate overdose at night when everyone’s in bed so they won’t find them for many hours, they are dangerous. If someone takes the overdose during the day, when people are awake at home, they are less dangerous.
A change in somone’s behaviors and/ or outlook can also help determine lethality. When people start giving away their possessions, that is a sign that they are very lethal, very dangerous. Another factor that can be informative is if an unnatural calm comes over them, and they say that they have no more problems, and everything is great. That is an indicator of serious lethality, major danger. These people have a sense of ease because they know that they’ll be dead very soon, and they don’t have to worry about things anymore. These are ominous signs.
Giving information about an attempt also informs a person’s level of lethality. If someone makes a statement of intent to commit suicide, they are not very dangerous. For example, a spouse saying ‘if you leave me, I’ll kill myself’ or ‘you broke my heart, I can’t live without you, I’m going to kill myself’ those statements alone do not indicate a very dangerous person. Not telling anyone and hiding when they plan to attempt is much more dangerous. There are many cases when people don’t come out and tell, but they aren’t being very secretive, intentionally or not, possibly even subconsciously. They leave clues, almost giving people a road map. This is very common, and these people are typically discovered. The discovery can either totally abort the act before it’s attempted, or can abort after the attempt, but in enough time to get the person help. This is why for every 1 “successfully” completed suicide, there are 24 failed suicide attempts. Similarly, someone who says ‘if this thing (interview, event) goes my way, I’ll be good, but if it doesn’t, I swear I’ll kill myself’ is not that dangerous, not very suicidal, because they’re bargaining, which means they’re still living in the real world. But, someone who does not want to negotiate, doesn’t care to affect things one way or another, may not be living in the real world, and they’re dangerous, they may be high risk to enter the world of the dead.
There are a couple other things to be considered in assessing risk of suicide, determining how dangerous someone might be. If someone is impaired, using drugs and/ or alcohol when they attempt or consider suicide, and if they are not suicidal when they’re clean and sober, they are generally not that suicidal, not that dangerous, they just have a drug or alcohol problem. When they get clean and sober for good, the risk is essentially zero, barring anything else. In a similar way, if someone is suffering from a mental illness when they attempt or consider suicide, but when you correct that mental illness they are not suicidal, they are not a huge danger.
So during suicide risk assessment, you can be looking at someone having a nebulous thought and/ or making a statement that a lot of people may have or make, and you know that they’re not very dangerous; or looking all the way to the opposite side, someone who thinks about it, formulates a thorough plan, picks the place and time, aquires all the things needed to commit the act, writes a suicide letter, and practices the complete act soup to nuts, and you know that they are very, very dangerous. And all the shades in between.
So that’s my primer on suicidal thinking and assessing suicide risk. There are lots of factors to keep in mind, and sometimes it’s a little like reading minds, but you get more proficient as the years go by…it’s easier to tell when someone is misleading or being honest and open. If you enjoy a humorous approach to character studies in all sorts of diagnoses, you would enjoy my book, Tales from the Couch, available on Amazon. I mean, most of you are isolating, sheltering in place anyway, right? Might as well entertain yourself! Check it out. – Dr. Mark AgrestiLearn More
Borderline personality disorder (BPD) is a personality disorder described as a prolonged disturbance of personality function in a person (generally over the age of eighteen years, although it is also found in adolescents), characterized by depth and variability of moods. The disorder typically involves unusual levels of instability in mood; black and white thinking, or splitting; the disorder often manifests itself inidealization and devaluation episodes, as well as chaotic and unstable interpersonal relationships, self-image, identity, and behavior; as well as a disturbance in the individual’s sense of self. In extreme cases, this disturbance in the sense of self can lead to periods of dissociation.
BPD splitting includes a switch between idealizing and demonizing others. This, combined with mood disturbances, can undermine relationships with family, friends, and co-workers. BPD disturbances also may include self-harm. Without treatment, symptoms may worsen, leading (in extreme cases) to suicide attempts.
There is an ongoing debate among clinicians and patients worldwide about terminology and the use of the word borderline, and some have suggested that this disorder should be renamed. The ICD-10 manual has an alternative definition and terminology to this disorder, calledEmotionally unstable personality disorder. There is related concern that the diagnosis of BPD stigmatizes people and supports pejorative and discriminatory practices.Learn More