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The concept of personality disorder itself is much more recent, and tentatively dates back to the French psychiatrist Philippe Pinel’s 1801 description of manie sans délire, a condition which he characterized as outbursts of rage and violence (‘manie’) in the absence of any signs of psychotic illness such as delusions and hallucinations (‘délires’). About 60 years later, in 1896, the German psychiatrist Emil Kraepelin (1856–1926) described seven forms of antisocial behaviour under the umbrella of ‘psychopathic personality’. This term was later broadened by Kraepelin’s younger colleague Kurt Schneider (1887–1967) to include those who ‘suffer from their abnormality’. Schneider’s seminal volume, Psychopathic Personalities (1923), still forms the basis of current classifications of personality disorders such as that Today DSM-IV defines a personality disorder as an enduring pattern of inner experience and behavior that deviates markedly from cultural expectations, is inflexible and pervasive, has its onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment. DSM-IV lists ten personality disorders, and allocates each one to one of three groups or ‘clusters’: A, B, or C.
Cluster A (Odd, bizarre, eccentric)
Paranoid PD, Schizoid PD, Schizotypal PD
Cluster B (Dramatic, erratic)
Antisocial PD, Borderline PD, Histrionic PD, Narcissistic PD
Cluster C (Anxious, fearful)
Avoidant PD, Dependent PD, Obsessive-compulsive PD
Before going on to characterize these ten personality disorders, it is important to remember that they are more the product of historical observation than of scientific study, and thus that they are rather vague and imprecise concepts. For this reason, they rarely present in their pure ‘textbook’ form, and have a marked tendency to blur into one another. Their division into three clusters (A, B, and C) in DSM-IV is intended to reflect this tendency, with a given personality disorder most likely to blur with other personality disorders within its own cluster.
The majority of people with a personality disorder never come into contact with mental health services, and those who do usually do so in the context of another psychiatric disorder or at a time of personal crisis, for example, after harming themselves or committing a criminal offence. Nevertheless, personality disorders are important to psychiatrists and physicians in general because they predispose to mental disorders and affect the presentation and treatment of mental disorders that are already present. They also (by definition) result in considerable distress and impairment, and may therefore need to be addressed ‘in their own right’.
1. Paranoid personality disorder
Cluster A comprises paranoid, schizoid, and schizotypal personality disorder. Paranoid personality disorder is characterised by a pervasive distrust of others, including even friends and partner. The person is guarded and suspicious, and constantly on the lookout for clues or suggestions to confirm his or her fears. He or she has a strong sense of self-importance and personal rights, is overly sensitive to setbacks and rebuffs, easily feels shame and humiliation, and persistently bears grudges. As a result he or she may have a tendency to withdraw from other people, and find it particularly difficult to engage in close relationships.
2. Schizoid personality disorder
Coined by Bleuler in 1908, the term ‘schizoid’ designates a natural tendency to direct attention toward one’s inner life and away from the external world. In schizoid personality disorder, the person is detached and aloof and prone to introspection and fantasy. He or she has no desire for social or sexual relationships, is indifferent to others and to social norms and conventions, and lacks emotional response; in extreme cases, he or she may appear cold and callous. Treatment is often not provided because people with schizoid personality disorder are generally able to function well despite their reluctance to form close relationships, and are not unduly concerned by the fact that they may be seen to have a mental disorder. Another view about people with schizoid personality disorder is that they are highly sensitive and have a rich inner life; while they experience a deep longing for intimacy, they find initiating and maintaining interpersonal relationships too difficult or too distressing and so retreat into their inner worlds.
3. Schizotypal disorder
Schizotypal disorder is characterized by oddities of appearance, behaviour, and speech, and anomalies of thinking similar to those seen in schizophrenia. Anomalies of thinking may include odd beliefs, magical thinking (for example, thinking that words affect the world—‘speak of the devil and he’ll appear’), suspiciousness, obsessional ruminations, and unusual perceptual experiences. A person with schizotypal disorder often fears social interaction and sees other people as ill-intentioned and potentially harmful. This may lead him or her to develop so-called ‘ideas of reference’, which are fleeting impressions that objects, people, or situations have a special significance for him or her. For example, he or she may have the impression that strangers on the bus are talking about him or her, or that the traffic warden’s signaling is an elaborate means of revealing his or her destiny. Compared to the average person, people who suffer from schizotypal disorder have a relatively high probability of ‘converting’ to schizophrenia at some time in the future; for this reason, schizotypal disorder has historically been referred to as ‘latent schizophrenia’.
4. Antisocial personality disorder
Cluster B comprises antisocial, borderline, histrionic, and narcissistic personality disorder. Until Schneider broadened the concept of personality disorder to include those who ‘suffer from their abnormality’, personality disorder was more or less synonymous with antisocial personality disorder. Antisocial personality disorder is far more common in men than in women, and is characterized by a callous unconcern for the feelings of others. The person disregards social rules and obligations, is irritable and aggressive, acts impulsively, lacks guilt, and fails to learn from experience. In many cases he has no difficulty finding relationships, and can even appear superficially charming (the so-called ‘charming psychopath’). However, his relationships are usually fiery, turbulent, and short-lived. People with antisocial personality disorder often have a criminal record or even a history of being in and out of prison.
5. Borderline personality disorder
In borderline personality disorder, the person essentially lacks a sense of self, and as a result experiences feelings of emptiness and fears of abandonment. There is a pattern of intense but unstable relationships, emotional instability, outbursts of anger and violence (especially in response to criticism), and impulsive behaviour. Suicidal threats and acts of self-harm are common, for which reason people with borderline personality disorder frequently come into contact with healthcare services. Borderline personality disorder was so-called because it was thought to lie on the ‘borderline’ between neurotic (anxiety) disorders and psychotic disorders such as schizophrenia and bipolar affective disorder. It has been suggested that borderline personality disorder often results from childhood sexual abuse, and that the reason why it is more common in women is because women are more likely to be victims of childhood sexual abuse. However, feminists have argued that borderline personality disorder merely appears to be more common in women, since women presenting with angry and promiscuous behaviour tend to be diagnosed with borderline personality disorder, whereas men presenting with identical behaviour tend to be diagnosed with antisocial personality disorder.
6. Histrionic personality disorder
People with histrionic personality disorder lack a sense of self-worth, for which reason they depend on the attention and approval of others. They often seem to be dramatizing or ‘playing a part’ (‘histrionic’ derives from the Latin ‘histrionicus’, ‘pertaining to the actor’) in a bid to attract and manipulate attention. They may take great care of their physical appearance and behave in a manner that is overly charming or inappropriately seductive. As they crave excitement and act on impulse or suggestion, they may put themselves at great risk of having an accident or being exploited. Their dealings with other people often seem insincere or superficial, which can impact on their social and romantic relationships. This is especially distressing for them, because they are especially sensitive to criticism and rejection and react badly to loss or failure.
7. Narcissistic personality disorder
Narcissistic personality disorder takes its name from the myth of Narcissus, a beautiful youth who fell in love with his own reflection. In narcissistic personality disorder the person has a grandiose sense of self-importance, a sense of entitlement, and a need to be admired. He or she is envious of others and expects them to be the same of him or her. He or she lacks empathy and readily exploits others to achieve his or her goals. To others he or she may seem self-absorbed, controlling, intolerant, selfish, and insensitive. If he or she feels slighted or ridiculed, he or she may be provoked into a fit of destructive anger and revenge-seeking. Such ‘narcissistic rage’ can have disastrous consequences for all those involved.
8. Avoidant personality disorder
Cluster C comprises avoidant, dependent, and anankastic personality disorder. In avoidant personality disorder, the person is persistently tense because he or she believes that he or she is socially inept, unappealing, or inferior, and as a result fears being embarrassed, criticised, or rejected. He or she avoids meeting people unless he or she is certain of being liked, is restrained even in his or her intimate relationships, and avoids taking risks. Avoidant personality disorder is strongly associated with anxiety disorders, and may also be associated with actual or perceived rejection by parents or peers during childhood.
9. Dependent personality disorder
Dependent personality disorder is characterized by a lack of self-confidence and an excessive need to be taken care of. The person needs a lot of help to make everyday decisions and needs important life decisions to be taken for him or her. He or she greatly fears abandonment and may go to considerable lengths to secure and maintain relationships. A person with dependent personality disorder sees him- or her-self as inadequate and helpless, and so abdicates personal responsibility and puts his or her fate in the hands of one or more protective others; he or she imagines being at one with these protective others whom he or she idealises as being competent and powerful, and towards whom he or she behaves in a manner that is ingratiating and self-effacing. People with dependent personality disorder often assort with people with a cluster B personality disorder, who feed from the unconditional high regard in which they are held.
10. Obsessive-compulsive (anankastic) personality disorder
Obsessive-compulsive or anankastic personality disorder (not to be confused with obsessive-compulsive disorder or OCD) is characterized by excessive preoccupation with details, rules, lists, order, organisation, or schedules; perfectionism so extreme that it prevents a task from being completed; and devotion to work and productivity at the expense of leisure and relationships. A person with anankastic personality disorder is typically doubting and cautious, rigid and controlling, humorless, and miserly. His or her underlying high level of anxiety arises from a perceived lack of control over a universe that escapes his or her understanding. As a natural consequence, he or she has little tolerance for grey areas and tends to simplify the universe by seeing actions and beliefs as either absolutely right or absolutely wrong. His or her relationships with friends, colleagues, and family tend to be strained by the unreasonable and inflexible demands that he or she makes upon them.
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