What is a Personality Disorder (PD)?

Many mental health problems, like recurrent major depressive disorder, affect a specific domain (in this case, mood) and tend to be episodic (periods of depression alternating with periods of recovery). Others, like personality disorders, are chronic and pervasive; they tend to be stable over time and affect multiple domains of a person's psychological functioning.

While the term "personality disorder" is ominous and often attracts significant stigma, its meaning is fairly specific. According to the DSM-5, a personality disorder involves significant impairments in personality functioning. Personality functioning is defined as:

• Self-regulation and functioning

  • Identity, sense of self, self-esteem

  • Self-directedness (the ability to set and pursue realistic goals)

• Interpersonal functioning

  • Empathy

  • Intimacy (the ability to form and keep relationships with depth, intimacy, and give-and-take)

Secondly, a PD involves the presence of distressing or impairing personality traits, grouped into five domains:

• A proneness to negative emotion [vs. emotional stability]

  • Emotional lability (instability)

  • Anxiousness

  • Difficulty tolerating separation/being alone

  • Submissiveness

  • Hostility

  • Perseveration

• Detachment [vs. extroversion]

  • Social withdrawal

  • Avoidance of intimacy

  • Inability to feel pleasure

  • Proneness to depression

  • Restricted expression of emotions

  • Suspiciousness

• Antagonism (behaviors that put the individual at odds with others) [vs. agreeableness]

  • Manipulativeness

  • Deceitfulness

  • Grandiosity

  • Attention-seeking

  • Callousness

• Disinhibition [vs. conscientiousness]

  • Irresponsibility

  • Impulsivity

  • Distractibility

  • Risk-taking

  • Rigid perfectionism (a lack of healthy disinhibition)

• Psychoticism [vs. lucidity]

  • Unusual beliefs and experiences

  • Eccentricity

  • Cognitive and perceptual difficulties

    • Depersonalization

    • Derealization

    • Dissociation

    • Mixed sleep-wake experiences

    • Thought-control experiences

In narcissistic personality disorder, the following impairments in personality functioning are common:

• Identity:

  • Needs the validation of others for self-esteem

  • An inflated or deflated view of self, or alternating, with emotion regulation mirroring fluctuations in self-esteem

• Self-direction:

  • Goals are based on getting others' approval

  • Personal standards are unrealistically high, view of self is inflated, or unrealistically low, if entitlement is present

  • May not be aware of own motivations for pursuing various goals

• Empathy:

  • Impaired ability to recognize or respect the feelings and needs of others

  • Or, excessively attuned to the needs of others, but only when doing so meets narcissistic and self-referential needs

  • Over- or under-estimates effect on others

• Intimacy:

  • Superficial relationships largely meant to serve self-esteem regulation

  • Mutuality and reciprocity in relationships constrained by lack of genuine interest in others and need for personal gain

Narcissism also typically involves the problematic personality trait of antagonism in the sense of grandiosity and attention-seeking.

Borderline personality disorder, on the other hand, tends to involve the following. Notice that empathy is affected in a much different manner than in NPD:

• Identity:

  • Impoverished, poorly developed, or unstable/fluctuating

  • View of self and others often organized around victim vs. perpetrator themes

  • Excessive self-criticism

  • Chronic feelings of emptiness

  • Dissociation or paranoia when under stress

• Self-Direction:

  • Instability in goals, values, or career plans

• Empathy:

  • Hypersensitivity compromises ability to recognize needs and feelings of others

  • Perception of others as having negative feelings or motives toward the self

• Intimacy:

  • Intense, unstable, and conflicted close relationships

  • Mistrust, neediness, and anxious preoccupation with abandonment

  • Idealization and devaluation (of self and) others

  • Alternations of over-involvement and withdrawal

And, generally, BPD is associated with the following traits:

• Negative affectivity

  • Emotional lability

  • Anxiousness

  • Separation insecurity

  • Depressivity

• Disinhibition

  • Impulsivity

  • Risk-taking

• Antagonism

  • Hostility

No one gets to pick his or her personality. A personality disorder does not mean that a person is "bad" or hurtful to others. Rather, it implies that the person struggles, to some degree, with their identity and self-esteem, their ability to set and pursue realistic goals, their empathy (especially when distressed), and their ability to form and keep healthy relationships. A PD also implies the presence of personality traits that get in the person's way.

The most researched personality disorder, or at least that with the most available treatments is borderline personality disorder. Therapies (with moderate to strong research support), grouped by family, currently include:

• Cognitive-Behavioral:

  • Dialectical-Behavior Therapy

• Psychodynamic:

  • Mentalization-Based Treatment

  • Transference-Focused Psychotherapy

  • Dynamic Deconstructive Psychotherapy

• Hybrid:

  • Schema-Focused Psychotherapy

No psychiatric medications are currently approved by the FDA for the treatment of personality disorders. In my professional experience, some psychiatrists tend to prescribe medications to target the specific symptoms of a personality disorder. For example, a psychiatrist may prescribe an antidepressant for the depressive aspects of borderline personality disorder, a mood stabilizer for its mood instability, and antipsychotic to target dissociative or paranoid symptoms, and an opiate antagonist to address impulsivity or self-harm.

Other psychiatrists have seemed to view medication as less effective in personality disorders and emphasize psychotherapy.