Personality disorder

General Diagnostic Requirements for Personality Disorder

Essential (Required) Features:

• An enduring disturbance characterized by problems in functioning of aspects of the self (e.g., identity, self-worth, accuracy of self-view, self-direction), and/or interpersonal dysfunction (e.g., ability to develop and maintain close and mutually satisfying relationships, ability to understand others’ perspectives and to manage conflict in relationships).
• The disturbance has persisted over an extended period of time (e.g., lasting 2 years or more).
• The disturbance is manifest in patterns of cognition, emotional experience, emotional expression, and behaviour that are maladaptive (e.g., inflexible or poorly regulated).
• The disturbance is manifest across a range of personal and social situations (i.e., is not limited to specific relationships or social roles), though it may be consistently evoked by particular types of circumstances and not others.
• The symptoms are not due to the direct effects of a medication or substance, including withdrawal effects, and are not better accounted for by another mental disorder, a Disease of the Nervous System, or another medical condition.
• The disturbance is associated with substantial distress or significant impairment in personal, family, social, educational, occupational or other important areas of functioning.
• Personality Disorder should not be diagnosed if the patterns of behaviour characterizing the personality disturbance are developmentally appropriate (e.g., problems related to establishing an independent self-identity during adolescence) or can be explained primarily by social or cultural factors, including socio-political conflict.

Severity of Personality Disorder:

The areas of personality functioning shown in Table 6.18 should be considered in making a severity determination for individuals who meet the general diagnostic requirements for Personality Disorder.

Table 6.18. Aspects of Personality Functioning That Contribute to Severity Determination in Personality Disorder

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• Degree and pervasiveness of disturbances in functioning of aspects of the self:
  • Stability and coherence of one's sense of identity (e.g., extent to which identity or sense of self is variable and inconsistent or overly rigid and fixed).
  • Ability to maintain an overall positive and stable sense of self-worth.
  • Accuracy of one’s view of one’s characteristics, strengths, limitations.
  • Capacity for self-direction (ability to plan, choose, and implement appropriate goals).
• Degree and pervasiveness of interpersonal dysfunction across various contexts and relationships (e.g., romantic relationships, school/work, parent-child, family, friendships, peer contexts):
  • Interest in engaging in relationships with others.
  • Ability to understand and appreciate others’ perspectives.
  • Ability to develop and maintain close and mutually satisfying relationships.
  • Ability to manage conflict in relationships.
• Pervasiveness, severity, and chronicity of emotional, cognitive, and behavioural manifestations of the personality dysfunction:

  Emotional manifestations:

  • Range and appropriateness of emotional experience and expression.
  • Tendency to be emotionally over- or underreactive.
  • Ability to recognize and acknowledge emotions that are difficult or unwanted by the individual (e.g., anger, sadness).

  Cognitive manifestations:

  • Accuracy of situational and interpersonal appraisals, especially under stress.
  • Ability to make appropriate decisions in situations of uncertainty.
  • Appropriate stability and flexibility of belief systems.

  Behavioural manifestations:

  • Flexibility in controlling impulses and modulating behaviour based on the situation and consideration of the consequences.
  • Appropriateness of behavioural responses to intense emotions and stressful circumstances (e.g., propensity to self-harm or violence).
• The extent to which the dysfunctions in the above areas are associated with distress or impairment in personal, family, social, educational, occupational or other important areas of functioning.

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Additional Clinical Features:

• Personality Disorder tends to arise when individuals’ life experiences provide inadequate support for typical personality development, given the person’s temperament (the aspect of personality that is considered to be innate, reflecting basic genetic and neurobiological processes). Thus, early life adversity is a risk factor for later development of Personality Disorder, as it is for many other mental disorders. However, it is not determinative. That is, some individuals’ temperament allows typical personality development despite an extremely adverse early environment. Nonetheless, in the context of a history of early adversity, ongoing behavioural, emotional, or interpersonal difficulties suggest that a Personality Disorder diagnosis should be considered.
• Personality Disorder often complicates and lengthens treatment of other clinical syndromes. Thus, poor or incomplete response to standard treatments of, for example, Depressive Disorders and Anxiety or Fear-Related Disorders, may suggest the presence of Personality Disorder. Relatedly, persistent functional impairment after resolution of the clinical syndrome(s) being treated may suggest the presence of Personality Disorder,
• There is often considerable variability in the degree to which individuals and those around them agree that the individual’s behaviours reflect a particular trait. If there is a marked discrepancy between an individual’s self-description and the kinds of problematic behaviours exhibited, it often is helpful to interview someone who knows the person well. Marked differences between the individual’s self-description and the informant’s description may be suggestive of Personality Disorder.

Boundary with Normality (Threshold):

• Personality refers to an individual’s characteristic way of behaving, experiencing life, and of perceiving and interpreting themselves, other people, events, and situations. Personality is manifested most directly in how individuals think and feel about themselves and their interpersonal relationships, how they behave in response to those thoughts and feelings and in response to others’ behaviours, and how they react to events in their lives and changes in the environment. An important characteristic of non-disordered personality is sufficient flexibility to react appropriately and adapt to other people’s behaviours, life events, and changes in the environment. In Personality Disorder, patterns of cognition, emotional experience, emotional expression, and behaviour are sufficiently maladaptive (e.g., inflexible or poorly regulated) that they result in substantial distress or significant impairment in personal, family, social, educational, occupational or other important areas of functioning.
• To warrant a diagnosis of Personality Disorder, personality disturbance must be manifest across a range of personal and social situations over an extended period of time (e.g., lasting 2 years or more). Behaviour patterns that are apparent only in the context of specific relationships, social roles, or environmental circumstances, or that have lasted for a shorter period of time, are not a sufficient basis for a diagnosis of Personality Disorder. Instead, the possibility that such behaviour patterns are a response to environmental circumstances must be considered. A focus on problems in the relevant relationship or in the environment (e.g., with family or school) may be more appropriate than a diagnosis of Personality Disorder in such cases.

Course Features:

• Manifestations of personality disturbance tend to appear first in childhood, increase during adolescence, and continue to be manifest into adulthood, although individuals may not come to clinical attention until later in life. Caution should be exercised in applying the diagnosis to children because their personalities are still developing.
• Overt behavioural manifestations of certain traits (Dissociality, Disinhibition) tend to decline over the course of adulthood. Other traits (Detachment, Anankastia) are less likely to do so. In both cases, functional impairment in broad areas of life (e.g., employment, interpersonal relationships) among people with Personality Disorder is often persistent.
• Personality Disorder is relatively stable after young adulthood, but may change such that a person who had Personality Disorder during young adulthood no longer meets the diagnostic requirements by middle age.
• Much less commonly, a person who earlier did not have a diagnosable Personality Disorder develops one later in life. Emergence of Personality Disorder in older adults may be related to the loss of social supports that had previously helped to compensate for personality disturbance.
• When there is a change in personality during middle adulthood or later in life, in the absence of change in the individual’s environment, the possibility that the change is due to an underlying medical condition (i.e., Secondary Personality Change) or to an unrecognized Disorder Due to Substance Use should be considered.

Developmental Presentations:

• Personality Disorder is not typically diagnosed in pre-adolescent children. Over the course of their development, children integrate knowledge and experience about themselves and other people into a coherent identity and sense of self, as well as into individual styles of interacting with others. Different children vary substantially in the rate at which this integration occurs, and there is also substantial variation in the rate of integration within individuals over time. Therefore, it is very difficult to determine whether a pre-adolescent child exhibits problems in functioning in aspects of the self, such as identity, self-worth, accuracy of self-view, or self-direction, because these functions are not fully developed in children. This is also true of interpersonal functions such as the ability to understand others’ perspectives and to manage conflict in relationships.
• However, prominent maladaptive traits may be observable in pre-adolescent children and may be precursors to Personality Disorder in adolescence and adulthood. For example, individual differences in Negative Affectivity and Disinhibition, as well as more specific features such as lack of empathy (an aspect of Dissociality) and perfectionism (an aspect of Anankastia) may be observed in very young children. However, such traits are also associated with the development of other mental disorders (e.g., Mood Disorders, Anxiety or Fear-Related Disorders) and should not be interpreted as childhood forms of Personality Disorder.
• Features of Personality Disorder manifest in similar ways in adolescents and in adults. However, in evaluating adolescents, it is important to consider the developmental typicality of the relevant behaviour patterns. For example, risk-taking behaviour, self-harm, and moodiness are more common during adolescence than during adulthood. Therefore, thresholds for evaluating whether such behaviour patterns are indicative of Personality Disorder or of elevations in trait domains such as Disinhibition and Negative Affectivity among adolescents should be correspondingly higher. The wide variability in normal adolescent development that may affect the expression of these behaviours or characteristics should also be considered.

Culture-Related Features:

• Assessment of personality across cultures is challenging, requiring knowledge of normative personality function for the sociocultural context, variations in cultural concepts of the self, and evidence for consistent traits and behaviours across time and multiple social contexts.
• Culture shapes modes of self-construal, social presentation, and levels of insight about behaviours that are related to personality development, including what are considered normal and abnormal personality states in a given setting. For example, children reared in collectivist societies may develop attachment styles and traits that are viewed as dependent or avoidant related to the norms of more individualistic cultures. In turn, traits of self-involvement that are accepted or positively valued in individualistic cultures may be considered narcissistic in collectivist cultures.
• Diagnosis of Personality Disorder must take into account the person’s cultural background. Collateral information may be needed to assess whether certain disruptive self-states and behaviours are considered culturally uncharacteristic and therefore consistent with Personality Disorder in a given culture. In general, a diagnosis of Personality Disorder should be assigned only when the symptoms exceed thresholds that are normative for the socio-cultural context.
• Among ethnic minority, immigrant, and refugee communities, responses to discrimination, social exclusion, and acculturative stress may be confused with Personality Disorder. For example, suspiciousness or mistrust may be common in situations of endemic racism and discrimination.
• Socio-cultural contexts of exclusion affecting marginal social groups can evoke repeated attempts at self-affirmation or acceptance by others that are based on ambiguous or troubled relationships with authority figures and limited adaptability. These reactions may be confounded with manifestations of Borderline pattern, such as impulsivity, instability, affective lability, explosive/aggressive behaviour or dissociative symptoms. However, a diagnosis should be assigned only when the symptoms exceed thresholds that are normative for the socio-cultural context.

Sex- and/or Gender-Related Features:

• Available evidence indicates that gender distribution of Personality Disorder is approximately equal. However, there are significant gender differences in the behavioural expression of Personality Disorder and in the associated trait domains. Specifically, elevations on Dissociality and Disinhibition are more common among men, and elevations on Negative Affectivity are more common among women.

Boundaries with Other Disorders and Conditions (Differential Diagnosis):

• Boundary with Personality Difficulty: Individuals with pronounced personality characteristics that do not rise to the level of severity to merit a diagnosis of Personality Disorder may be considered to have Personality Difficulty if they affect treatment or health services. In contrast to Personality Disorder, Personality Difficulty is manifested only intermittently (e.g., during times of stress) or at low intensity. The difficulties are associated with some problems in functioning but these are insufficiently severe to cause notable disruption in social, occupational, and interpersonal relationships and may be limited to specific relationships or situations.
• Boundary with persistent mental disorders: A number of persistent and enduring mental disorders (e.g., Autism Spectrum Disorder, Schizotypal Disorder, Dysthymic Disorder, Cyclothymic Disorder, Separation Anxiety Disorder, Obsessive-Compulsive Disorder, Complex Post-Traumatic Stress Disorder, Dissociative Identity Disorder) are characterized by enduring disturbances in cognition, emotional experience, and behaviour that are maladaptive, manifest across a range of personal and social situations, and that are associated with significant problems in functioning of aspects of the self (e.g., self-esteem, self-direction), and/or interpersonal dysfunction (e.g., ability to develop and maintain close and mutually satisfying relationships, ability to understand others’ perspectives and to manage conflict in relationships). Accordingly, individuals with these disorders may also meet the diagnostic requirements for Personality Disorder. Generally, individuals with such disorders should not be given an additional diagnosis of Personality Disorder unless additional personality features are present that contribute to significant problems in functioning of aspects of the self or interpersonal functioning. However, even in the absence of these additional features, there may be specific situations in which an additional diagnosis of Personality Disorder is warranted (e.g., entry into clinically indicated forms of treatment that are connected to a Personality Disorder diagnosis).
• Boundary with Conduct-Dissocial Disorder with limited prosocial emotions: Conduct-Dissocial Disorder is characterized by a recurrent pattern of behaviour in which the basic rights of others or major age-appropriate social or cultural norms, rules, or laws are violated that may range in duration from a discrete period lasting a number of months to a pattern that persists across the lifespan. Conduct-Dissocial Disorder with limited prosocial emotions is further characterized by limited or absent empathy or sensitivity to others’ feelings and limited or absent remorse, shame, or guilt. Conduct-Dissocial Disorder with limited prosocial emotions has features in common with Personality Disorder with Dissociality, which is characterized by disregard for the rights and feelings of other, self-centeredness, and lack of empathy. Conduct-Dissocial Disorder may be diagnosed among pre-adolescent children and based on shorter duration of symptoms than Personality Disorder. Among individuals with Conduct-Dissocial Disorder, an additional diagnosis of Personality Disorder is warranted only if there are personality features in addition to Dissociality that contribute to significant impairments in functioning of aspects of the self or problems in interpersonal functioning.
• Boundary with Secondary Personality Change: Secondary Personality Change is a persistent personality disturbance that represents a change from the individual’s previous characteristic personality pattern that is judged to be a direct pathophysiological consequence of a medical condition not classified under Mental, Behavioural or Neurodevelopmental Disorders, based on evidence from the history, physical examination, or laboratory findings. Personality Disorder is not diagnosed if the symptoms are due to another medical condition.
• Boundary with Disorders Due to Substance Use: Disorders Due to Substance Use often have pervasive effects on functioning of the self and interpersonal functioning. For example, they may exhibit problems with self-direction, self-esteem, difficulties and conflicts in relationship, dissocial behaviour related to obtaining or using drugs, and a wide range of other features that are commonly seen in individuals with Personality Disorder. If the personality disturbance is entirely accounted for by a Disorder Due to Substance Use, a diagnosis of Personality Disorder should not be given. However, if the personality disturbance is not entirely accounted for by the Disorder Due to Substance Use (e.g., if the personality disturbance preceded the onset of substance use) or if there are features of a Personality Disorder that are not accounted for by substance use (e.g., perfectionism), an additional diagnosis of Personality Disorder may be assigned.