Personality Disorder

  1. Clearly establish and maintain limits in dealing with patients with identified personality disorders. For example, set limits for:
    • appointment length.
    • drug prescribing.
    • accessibility.
  2. In a patient with a personality disorder, look for medical and psychiatric diagnoses when the patient presents for assessment of new or changed symptoms. (Patients with personality disorders develop medical and psychiatric conditions, too.)
  3. Look for and attempt to limit the impact of your personal feelings (e.g., anger, frustration) when dealing with patients with personality disorders (e.g., stay focused, do not ignore the patient’s complaint).
  4. In a patient with a personality disorder, limit the use of benzodiazepines but use them judiciously when necessary.
  5. When seeing a patient whom others have previously identified as having a personality disorder, evaluate the person yourself because the diagnosis may be wrong and the label has significant repercussions.

General Personality Disorder

    1. An enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture. This pattern is manifested in two (or more) of the following areas:
      • Cognition (i.e., ways of perceiving and interpreting self, other people, and events).
      • Affectivity (i.e., the range, intensity, lability, and appropriateness of emotional response).
      • Interpersonal functioning.
      • Impulse control.
    2. The enduring pattern is inflexible and pervasive across a broad range of personal and social situations.
    3. The enduring pattern leads to clinically significant distress or impairment in social, occupational, or other important areas of functioning.
    4. The pattern is stable and of long duration, and its onset can be traced back at least to adolescence or early adulthood.
    5. The enduring pattern is not better explained as a manifestation or consequence of another mental disorder.
    6. The enduring pattern is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., head trauma).

Cluster A ("Mad")

  • Paranoid personality disorder is a pattern of distrust and suspiciousness such that others’ motives are interpreted as malevolent, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following:
    1. Suspects, without sufficient basis, that others are exploiting, harming, or deceiving him or her.
    2. Is preoccupied with unjustified doubts about the loyalty or trustworthiness of friends or associates.
    3. Is reluctant to confide in others because of unwarranted fear that the information will be used maliciously against him or her.
    4. Reads hidden demeaning or threatening meanings into benign remarks or events.
    5. Persistently bears grudges (i.e., is unforgiving of insults, injuries, or slights).
    6. Perceives attacks on his or her character or reputation that are not apparent to others and is quick to react angrily or to counterattack.
    7. Has recurrent suspicions, without justification, regarding fidelity of spouse or sexual partner.
    • Does not occur exclusively during the course of schizophrenia, a bipolar disorder or depressive disorder with psychotic features, or another psychotic disorder and is not attributable to the physiological effects of another medical condition.
  • Schizoid personality disorder is a pattern of detachment from social relationships and a restricted range of emotional expression in interpersonal settings, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following:
    1. Neither desires nor enjoys close relationships, including being part of a family.
    2. Almost always chooses solitary activities.
    3. Has little, if any, interest in having sexual experiences with another person.
    4. Takes pleasure in few, if any, activities.
    5. Lacks close friends or confidants other than first-degree relatives.
    6. Appears indifferent to the praise or criticism of others.
    7. Shows emotional coldness, detachment, or flattened affectivity.
  • Schizotypal personality disorder is a pattern of acute discomfort in close relationships, cognitive or perceptual distortions, and eccentricities of behavior, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:
    1. Ideas of reference (excluding delusions of reference).
    2. Odd beliefs or magical thinking that influences behavior and is inconsistent with subcultural norms (e.g., superstitiousness, belief in clairvoyance, telepathy, or “sixth sense”; in children and adolescents, bizarre fantasies or preoccupations).
    3. Unusual perceptual experiences, including bodily illusions.
    4. Odd thinking and speech (e.g., vague, circumstantial, metaphorical, overelaborate, or stereotyped).
    5. Suspiciousness or paranoid ideation.
    6. Inappropriate or constricted affect.
    7. Behavior or appearance that is odd, eccentric, or peculiar.
    8. Lack of close friends or confidants other than first-degree relatives.
    9. Excessive social anxiety that does not diminish with familiarity and tends to be associated with paranoid fears rather than negative judgments about self.

Cluster B ("Bad")

  • Antisocial personality disorder is a pattern of disregard for, and violation of, the rights of others, occurring since age 15 years, as indicated by three (or more) of the following:
    1. Failure to conform to social norms with respect to lawful behaviors, as indicated by repeatedly performing acts that are grounds for arrest.
    2. Deceitfulness, as indicated by repeated lying, use of aliases, or conning others for personal profit or pleasure.
    3. Impulsivity or failure to plan ahead.
    4. Irritability and aggressiveness, as indicated by repeated physical fights or assaults.
    5. Reckless disregard for safety of self or others.
    6. Consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or honor financial obligations.
    7. Lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another.
    • The individual is at least age 18 years.
  • Borderline personality disorder is a pattern of instability in interpersonal relationships, self-image, and affects, and marked impulsivity, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:
    1. Frantic efforts to avoid real or imagined abandonment. (Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.)
    2. A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation.
    3. Identity disturbance: markedly and persistently unstable self-image or sense of self.
    4. Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating). (Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.)
    5. Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior.
    6. Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days).
    7. Chronic feelings of emptiness.
    8. Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights).
    9. Transient, stress-related paranoid ideation or severe dissociative symptoms.
  • Histrionic personality disorder is a pattern of excessive emotionality and attention seeking, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:
    1. Is uncomfortable in situations in which he or she is not the center of attention.
    2. Interaction with others is often characterized by inappropriate sexually seductive or provocative behavior.
    3. Displays rapidly shifting and shallow expression of emotions.
    4. Consistently uses physical appearance to draw attention to self.
    5. Has a style of speech that is excessively impressionistic and lacking in detail.
    6. Shows self-dramatization, theatricality, and exaggerated expression of emotion.
    7. Is suggestible (i.e., easily influenced by others or circumstances).
    8. Considers relationships to be more intimate than they actually are.
  • Narcissistic personality disorder is a pattern of grandiosity, need for admiration, and lack of empathy, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:
    1. Has a grandiose sense of self-importance (e.g., exaggerates achievements and talents, expects to be recognized as superior without commensurate achievements).
    2. Is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love.
    3. Believes that he or she is “special” and unique and can only be understood by, or should associate with, other special or high-status people (or institutions).
    4. Requires excessive admiration.
    5. Has a sense of entitlement (i.e., unreasonable expectations of especially favorable treatment or automatic compliance with his or her expectations).
    6. Is interpersonally exploitative (i.e., takes advantage of others to achieve his or her own ends).
    7. Lacks empathy: is unwilling to recognize or identify with the feelings and needs of others.
    8. Is often envious of others or believes that others are envious of him or her.
    9. Shows arrogant, haughty behaviors or attitudes.

Cluster C ("Sad")

  • Avoidant personality disorder is a pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following:
    1. Avoids occupational activities that involve significant interpersonal contact because of fears of criticism, disapproval, or rejection.
    2. Is unwilling to get involved with people unless certain of being liked.
    3. Shows restraint within intimate relationships because of the fear of being shamed or ridiculed.
    4. Is preoccupied with being criticized or rejected in social situations.
    5. Is inhibited in new interpersonal situations because of feelings of inadequacy.
    6. Views self as socially inept, personally unappealing, or inferior to others.
    7. Is unusually reluctant to take personal risks or to engage in any new activities because they may prove embarrassing.
  • Dependent personality disorder is a pattern of submissive and clinging behavior related to an excessive need to be taken care of, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:
    1. Has difficulty making everyday decisions without an excessive amount of advice and reassurance from others.
    2. Needs others to assume responsibility for most major areas of his or her life.
    3. Has difficulty expressing disagreement with others because of fear of loss of support or approval. (Note: Do not include realistic fears of retribution.)
    4. Has difficulty initiating projects or doing things on his or her own (because of a lack of self-confidence in judgment or abilities rather than a lack of motivation or energy).
    5. Goes to excessive lengths to obtain nurturance and support from others, to the point of volunteering to do things that are unpleasant.
    6. Feels uncomfortable or helpless when alone because of exaggerated fears of being unable to care for himself or herself.
    7. Urgently seeks another relationship as a source of care and support when a close relationship ends.
    8. Is unrealistically preoccupied with fears of being left to take care of himself or herself.
  • Obsessive-compulsive personality disorder is a pattern of preoccupation with orderliness, perfectionism, and control, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following:
    1. Is preoccupied with details, rules, lists, order, organization, or schedules to the extent that the major point of the activity is lost.
    2. Shows perfectionism that interferes with task completion (e.g., is unable to complete a project because his or her own overly strict standards are not met).
    3. Is excessively devoted to work and productivity to the exclusion of leisure activities and friendships (not accounted for by obvious economic necessity).
    4. Is overconscientious, scrupulous, and inflexible about matters of morality, ethics, or values (not accounted for by cultural or religious identification).
    5. Is unable to discard worn-out or worthless objects even when they have no sentimental value.
    6. Is reluctant to delegate tasks or to work with others unless they submit to exactly his or her way of doing things.
    7. Adopts a miserly spending style toward both self and others; money is viewed as something to be hoarded for future catastrophes.
    8. Shows rigidity and stubbornness.
  • Personality change due to another medical condition is a persistent personality disturbance that is judged to be due to the direct physiological effects of a medical condition (e.g., frontal lobe lesion).
  • Other specified personality disorder and unspecified personality disorder is a category if the individual’s personality pattern meets the general criteria for a personality disorder, except:
    • The traits of several different personality disorders are present, but the criteria for any specific personality disorder are not met; or
    • The individual is considered to have a personality disorder that is not included in the DSM-5 classification (e.g., passive-aggressive personality disorder).


  • Psychotherapy (no medications approved for the treatment of personality disorders)
  • Treat comorbid conditions