Personality Disorders
Personality disorders are a class of conditions characterized by enduring patterns of inner experience and behaviour that deviate markedly from cultural expectations, are pervasive and inflexible, begin by adolescence or early adulthood, are stable over time, and lead to distress or impairment.
Overview
Personality disorders are a class of mental disorders defined in the DSM-5-TR by enduring patterns of inner experience and behaviour that deviate markedly from the expectations of the individual’s culture. The patterns are pervasive across personal and social situations, inflexible, begin by adolescence or early adulthood, are stable over time, and lead to clinically significant distress or impairment in social, occupational, or other important areas of functioning.
The DSM-5-TR includes ten specific personality disorders organized into three clusters based on descriptive similarities:
- Cluster A — odd, eccentric: Paranoid (301.0), Schizoid (301.20), Schizotypal (301.22).
- Cluster B — dramatic, emotional, erratic: Antisocial (301.7), Borderline (301.83), Histrionic (301.50), Narcissistic (301.81).
- Cluster C — anxious, fearful: Avoidant (301.82), Dependent (301.6), Obsessive-Compulsive Personality Disorder (301.4).
The DSM-5-TR also includes Personality Change Due to Another Medical Condition, Other Specified Personality Disorder, and Unspecified Personality Disorder. The DSM-5-TR Section III contains an Alternative Model for Personality Disorders that conceptualizes personality pathology dimensionally along self-functioning and interpersonal-functioning impairments plus pathological personality traits — an approach that has growing research support and is being adopted in clinical practice.
Lifetime prevalence of any personality disorder is approximately 9-15% in U.S. and Canadian adult samples. Personality disorders aggregate substantially with other psychiatric conditions; comorbidity with mood disorders, anxiety disorders, and substance use disorders is the rule rather than the exception. Suicide risk is elevated across the personality disorders.
Treatment is increasingly recognized as effective. Long-standing pessimism about personality disorder treatability has been substantially revised over the past three decades by accumulating evidence that specific, manualized treatments — particularly Dialectical behaviour Therapy, Mentalization-Based Treatment, Transference-Focused Psychotherapy, and Schema-Focused Therapy — produce meaningful symptom and functional improvement in many patients. Long-term studies show substantial rates of sustained symptom remission, particularly for borderline personality disorder where the evidence base is strongest.
Signs and symptoms
- Pervasive pattern across contexts — Characteristic interpersonal, emotional, and behavioural patterns appear across multiple contexts (work, relationships, family, social) rather than being situation-specific.
- Inflexibility — Patterns are rigid, resistant to change despite negative consequences, and do not adapt to varying interpersonal demands.
- Identity disturbance — Persistent uncertainty about who one is, what one wants, or what one believes; identity may be unstable, fragmented, or rigidly over-defined depending on the disorder.
- Interpersonal difficulties — Relationships are characterized by recurrent patterns — instability, exploitation, suspicion, withdrawal, dependence, etc. — that produce distress and dysfunction.
- Affect dysregulation — Difficulty modulating emotional intensity; mood instability, restricted affect, or chronic negative affect depending on the specific disorder.
- Impulse control problems — Difficulty regulating impulses around spending, substance use, sex, eating, self-harm, or aggression — particularly characteristic of Cluster B disorders.
- Cognitive distortions — Characteristic patterns of misperceiving self, others, or events — paranoid attribution, splitting, idealization-devaluation, mistrust, or perfectionism, depending on the disorder.
- Functional impairment — Significant difficulty in occupational, academic, social, or self-care domains.
- High comorbidity — Co-occurring mood disorders, anxiety disorders, substance use disorders, eating disorders, and other conditions are common.
- Onset by early adulthood — Patterns are stable from adolescence or early adulthood; if features emerged later in life, alternative diagnoses (medical, neurological, traumatic) should be considered.
Diagnostic context
The DSM-5-TR general criteria for a Personality Disorder require:
- A. An enduring pattern of inner experience and behaviour that deviates markedly from the expectations of the individual’s culture, manifested in two (or more) of: cognition (perception of self, others, events); affectivity (range, intensity, lability, appropriateness); interpersonal functioning; impulse control.
- B. The enduring pattern is inflexible and pervasive across a broad range of personal and social situations.
- C. Leads to clinically significant distress or impairment in social, occupational, or other important areas of functioning.
- D. Stable and of long duration; onset traceable to at least adolescence or early adulthood.
- E. Not better explained as a manifestation or consequence of another mental disorder.
- F. Not attributable to physiological effects of a substance or another medical condition.
The 10 specific personality disorders each have their own diagnostic criteria. Differential diagnosis is complex and requires distinguishing personality disorder from: episodic mood and anxiety disorders that resemble personality features during episodes; substance-induced behaviour; medical and neurological conditions affecting personality; cultural and developmental variation; and adolescent presentations that may not yet meet duration criteria.
The DSM-5-TR Alternative Model in Section III conceptualizes personality pathology dimensionally:
- Criterion A: moderate or greater impairment in personality functioning (self and interpersonal).
- Criterion B: presence of one or more pathological personality traits (negative affectivity, detachment, antagonism, disinhibition, psychoticism).
Validated assessment instruments include the Structured Clinical Interview for DSM-5 Personality Disorders (SCID-5-PD), Personality Inventory for DSM-5 (PID-5; for the Alternative Model), and disorder-specific instruments (Personality Assessment Inventory, Millon Clinical Multiaxial Inventory).
Causes and risk factors
Personality disorders develop through complex interactions of genetic, neurobiological, developmental, and environmental factors:
Genetic factors: heritability of personality disorders ranges from approximately 0.30 to 0.65 across disorders. Personality traits underlying the disorders (negative affectivity, detachment, antagonism, disinhibition) have substantial genetic contribution. Family aggregation is well-documented.
Neurobiological factors: alterations in serotonergic, dopaminergic, and noradrenergic systems; differences in prefrontal-limbic regulation; HPA-axis dysfunction; and structural and functional brain differences are documented across the personality disorders, with specific patterns by disorder.
Developmental and environmental factors:
- Childhood adversity — abuse (physical, sexual, emotional), neglect, exposure to family violence, chronic instability — is strongly associated with most personality disorders, particularly borderline, antisocial, and Cluster A disorders.
- Attachment disruption — disorganized and insecure attachment patterns in early childhood are predictive across the personality disorders.
- Family environment — high criticism, low warmth, inconsistent discipline, parental mental illness, and parental substance use all elevate risk.
- Temperamental factors — early temperamental features (high reactivity, low effortful control, behavioural inhibition) interact with environmental risk to shape personality development.
Cultural factors: some personality features are culturally normative in some contexts and pathological in others; the criterion that the pattern “deviates markedly from the expectations of the individual’s culture” is intentional. Assessment must distinguish cultural variation from pathology.
Comorbidity: across the personality disorders, comorbidity with mood disorders, anxiety disorders, substance use disorders, eating disorders, and other personality disorders is the rule rather than the exception. Individual cases typically involve multiple co-occurring conditions.
Typical treatments
Treatment varies by specific disorder; the strongest evidence base is for borderline personality disorder, with emerging evidence for other disorders:
Dialectical behaviour Therapy (DBT; Linehan): the most extensively studied personality disorder treatment, originally developed for borderline personality disorder. Includes individual therapy, skills group, phone coaching, and consultation team. Strong evidence base; adaptations for adolescent BPD, eating disorders, substance use disorders, and antisocial features.
Mentalization-Based Treatment (MBT; Bateman & Fonagy): develops the capacity to reflect on mental states (one’s own and others’) as a core treatment task. Strong evidence base for BPD, growing evidence for narcissistic and antisocial features.
Transference-Focused Psychotherapy (TFP; Kernberg, Yeomans, Clarkin): twice-weekly psychodynamic approach addressing identity diffusion and primitive defenses through exploration of the transference. Strong evidence base for BPD; increasingly applied to narcissistic and other Cluster B disorders.
Schema-Focused Therapy (Young): integrates cognitive, behavioural, and experiential techniques to address early maladaptive schemas. Substantial evidence base for personality disorders, particularly BPD.
Cognitive behavioural Therapy for Personality Disorders (Beck, Davis, Freeman; Davidson) — structured, skills-based approach with evidence for several personality disorders.
General Psychiatric Management (GPM; Gunderson): structured but less-intensive approach with comparable outcomes to specialized treatments in some studies. Often more accessible.
Interpersonal Therapy adapted for personality disorders — emerging evidence base.
Pharmacotherapy: no medication is approved specifically for any personality disorder. Adjunctive pharmacotherapy targets specific symptom clusters: SSRIs for affective dysregulation and depression; atypical antipsychotics for severe affective instability, transient paranoid features, or aggression; mood stabilizers for impulsivity. Polypharmacy is common but should be carefully reviewed.
Treatment of comorbidity — concurrent depression, anxiety, substance use, eating disorders, and PTSD typically need integrated treatment. Outcomes for personality disorders without addressing comorbid conditions are typically poor.
Long-term course: longitudinal studies (McLean Adult Development Study, Collaborative Longitudinal Personality Disorders Study) demonstrate that 50-85% of individuals with BPD achieve sustained symptom remission over 10-16 years, with rates higher among those who engage in evidence-based treatment. Other personality disorders show variable long-term courses; treatment substantially improves outcomes across the cluster.
When to seek help
Professional evaluation is indicated when:
- You recognize persistent patterns of interpersonal difficulty, emotional dysregulation, identity disturbance, or impulsivity that have affected multiple areas of your life since adolescence or early adulthood.
- Multiple important relationships have ended in similar ways with similar reports from former partners, friends, or colleagues.
- You experience persistent emptiness, identity confusion, or sense of being fundamentally different from others.
- You have been treated for depression or anxiety without lasting improvement.
- You experience self-harm, suicidality, or substance use as recurrent coping strategies.
- A family member, partner, or close friend has been diagnosed with a personality disorder and you are seeking support for the impact.
For partners and family members of someone with a personality disorder: separate, parallel therapy is often essential. The relational impact is itself stress-producing, and recovery work for the affected person is independent of whether the person with the personality disorder ever engages in their own treatment.
If suicidal thoughts or self-harm urges are present, free 24-hour support is available across Canada at 9-8-8 (Suicide Crisis Helpline, call or text), 1-833-456-4566 (Talk Suicide Canada), or 811 (Health Link).
Frequently asked questions
Are personality disorders treatable?
Are personality disorders the same as personality traits?
Can someone have more than one personality disorder?
Are personality disorders caused by trauma?
Can personality disorders be diagnosed in adolescents?
How long does treatment take?
References
- American Psychiatric Association. (2022). Diagnostic and Statistical Manual of Mental Disorders (5th ed., text rev.). APA.
- Linehan, M. M. (2014). DBT Skills Training Manual (2nd ed.). Guilford Press.
- Bateman, A., & Fonagy, P. (2016). Mentalization-Based Treatment for Personality Disorders: A Practical Guide. Oxford University Press.
- Yeomans, F. E., Clarkin, J. F., & Kernberg, O. F. (2015). Transference-Focused Psychotherapy for Borderline Personality Disorder: A Clinical Guide. American Psychiatric Publishing.
- Skodol, A. E. (2018). Long-term course and outcome of personality disorders. Psychiatric Clinics of North America, 41(4), 551–567.
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ShiftGrit Psychology & Counselling is professionally regulated, certified, and recognized by leading psychology and mental-health organizations across Alberta and Canada. These associations reflect our commitment to ethical practice, clinical standards, and evidence-informed therapy through Identity-Level Therapy and Reconditioning.
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