Personality disorders (PD) are a group of psychiatric conditions characterized by experience and behavior patterns that cause serious problems with respect to any two of the following: thinking, mood, personal relations, and the control of impulses.
Most personality disorders are associated with problems in personal development and character which peak during adolescence and are then defined as personality disorders. Children and adolescents with a personality disorder have great difficulty dealing with others. They tend to be inflexible, rigid, with inadequate response to the changes and demands of life. They have a narrow view of the world and find it hard to participate in social activities. There are many formally identified personality disorders, each with its own types of associated behaviors. Most PDs, however, fall into three distinct categories or clusters, namely: cluster A, which includes disorders characterized by odd or eccentric behavior; cluster B, which includes disorders marked by dramatic, emotional or erratic behavior; and cluster C, which includes disorders accompanied by anxious and fearful behavior. The most common disorders in each cluster are given below.
Cluster A disorders
These disorders include the following:
- Schizoid personality disorder. Schizoid personalities are introverted, withdrawn, solitary, emotionally cold, and distant. Often absorbed with their own thoughts and feelings, they fear closeness and intimacy with others. People suffering from schizoid personality tend to be more daydreamers than practical action takers, often living "in a world of their own."
- Paranoid personality disorder. Paranoid personalities interpret the actions of others as deliberately threatening or demeaning. People with paranoid personality disorder are untrusting, unforgiving, and often resort to angry or aggressive outbursts without justification because they see others as unfaithful, disloyal, or dishonest. Paranoid personalities are often jealous, guarded, secretive, and scheming, and may appear to be emotionally "cold" or excessively serious.
- Schizotypal personality disorder. Schizotypal personalities tend to have odd or eccentric manners of speaking or dressing. They often have strange, outlandish, or paranoid beliefs and thoughts. People with schizotypal personality disorder have difficulties bonding with others and experience extreme anxiety in social situations. They tend to react inappropriately or not react at all during a conversation, or they may talk to themselves. They also have delusions characterized by "magical thinking," for example, by saying that they can foretell the future or read other people's minds.
Cluster B disorders
Cluster B disorders include the following:
- Antisocial personality disorder . Antisocial personalities typically ignore the normal rules of social behavior. These individuals are impulsive, irresponsible, and callous. They often have a history of violent and irresponsible behavior, aggressive and even violent relationships. They have no respect for other people and feel no remorse about the effects of their behavior on others. Antisocial personalities are at high risk for substance abuse, since it helps them to relieve tension, irritability, and boredom.
- Borderline personality disorder. Borderline personalities are unstable in interpersonal relationships, behavior, mood, and self-image. They are prone to sudden and extreme mood changes, stormy relationships, unpredictable and often self-destructive behavior. These personalities have great difficulty with their own sense of identity and often experience the world in extremes, viewing experiences and others as either "black" or "white." They often form intense personal attachments only to quickly dissolve them over a perceived offense. Fears of abandonment and rejection often lead to an excessive dependency on others. Self-mutilation or suicidal threats may be used to get attention or manipulate others. Impulsive actions, persistent feelings of boredom or emptiness, and intense anger outbursts are other traits of this disorder.
- Narcissistic personality disorder. Narcissistic personalities tend to have an exaggerated sense of self-importance, and are absorbed by fantasies of unlimited success. They also seek constant attention, and are oversensitive to failure, often complaining about multiple physical disorders. They also tend to be prone to extreme mood swings between self-admiration and insecurity, and tend to exploit interpersonal relationships.
Cluster C disorders
Cluster C disorders include the following:
- Avoidant personality disorder. Avoidant personalities are often fearful of rejection and unwilling to become involved with others. They are characterized by excessive social discomfort, shyness , fear of criticism, and avoidance of social activities that involve interpersonal contact. They are afraid of saying something considered foolish by others and are deeply hurt by any disapproval from others. They tend to have no close relationships outside the family circle and are upset at their inability to form meaningful relationships.
- Dependent personality disorder . As the name implies, dependent personalities exhibit a pattern of dependent and submissive behavior, relying on others to make decisions for them. They fear rejection, need constant reassurance and advice, and are oversensitive to criticism or disapproval. They feel uncomfortable and helpless if they are alone and can be devastated when a close relationship ends. Typically lacking in self-confidence, the dependent personality rarely initiates projects or does things independently.
- Compulsive personality disorder. Compulsive personalities are conscientious, reliable, dependable, orderly, and methodical, but with an inflexibility that often makes them incapable of adapting to changing circumstances. They have such high standards of achievement that they constantly strive for perfection. Never satisfied with their performance or with that of others, they take on more and more responsibilities. They also pay excessive attention to detail, which makes it very hard for them to make decisions and complete tasks. When their feelings are not under strict control, when events are unpredictable, or when they must rely on others, compulsive personalities often feel a sense of isolation and helplessness.
In 2001 to 2002, fully 16.4 million Americans (7.9% of all adults) had obsessive-compulsive personality disorder; 9.2 million (4.4%) had paranoid personality disorder; 7.6 million (3.6%) had antisocial personality disorder; 6.5 million (3.1%) had schizoid personality disorder; 4.9 million (2.4%) had avoidant personality disorder; and 1.0 million (0.5%) had dependent personality disorder. According to the National Institutes of Health, nearly 31 million Americans meet criteria for at least one personality disorder. A 2004 survey showed that nearly 14.8 percent of adult Americans met diagnostic criteria for personality disorders as defined by the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders. The risk of having avoidant, dependent, and paranoid personality disorders is greater for females than males, whereas risk of having antisocial personality disorder is greater for males than females. There are no gender differences in the risk of having compulsive or schizoid personality disorders. In general, other risk factors contributing to the emergence of personality disorders include being Native American or African American; being a young adult; having a low socioeconomic status; and having any other status than married.
Causes and symptoms
The exact cause of personality disorders is unknown. However, evidence points to genetic and environmental factors such as a history of personality disorders in the family. Some experts believe that traumatic events occurring in early childhood exert a crucial influence upon behavior later in life. Others propose that people are genetically predisposed to personality disorders or that they have an underlying biological disturbance (anatomical, electrical, or neurochemical).
Symptoms vary widely depending on the specific type of PD, but according to the American Psychiatric Association, individuals with personality disorders have most of the following symptoms in common:
- self-centeredness that manifests itself through a "me-first," self-preoccupied attitude
- lack of individual accountability that results in a "victim mentality" and blaming others for their problems
- lack of empathy and caring
- manipulative and exploitative behavior
- unhappiness, suffering from depression, and other mood and anxiety disorders
- vulnerability to other mental disorders
- distorted or superficial understanding of self and others' perceptions that results in being unable to see how objectionable, unacceptable, and disagreeable their behavior is
- self-destructive behavior
- socially maladaptive, changing the "rules of the game," or otherwise influencing the external world to conform to their own needs
When to call the doctor
An appointment should be made with a healthcare provider or a mental health professional if a child has persistent symptoms of a personality disorder. Parents are often concerned about their child's emotional health or behavior, but they do not know where to start to get help. The mental health system can also be complicated and difficult for parents to understand. When worried about their child's behavior, parents can start by talking to the child's pediatrician or family physician about their concerns. Personality disorders require treatment and parents should try to find a mental health professional with advanced training and experience with children, adolescents, and families. Parents should always ask about the professional's training and experience. It is also very important to find a good match between child, family, and the mental health professional.
The character of a person is shown through his or her personality, by the way the person thinks, feels, and behaves. When the behavior is inflexible, maladaptive, and antisocial, then that individual is diagnosed with a personality disorder. Personality disorders are diagnosed following a psychological evaluation that records the history and severity of the symptoms. A personality disorder must fulfill several criteria. A deeply ingrained, inflexible pattern of relating, perceiving, and thinking that is serious enough to cause distress or impaired functioning defines a personality disorder. Personality disorders are usually recognizable by adolescence or earlier, continue throughout adulthood, and become less obvious in middle age.
There are many types of help available for the different personality disorders. Treatment may include individual, group, or family psychotherapy. Medications, prescribed by a patient's physician, may also be helpful in relieving some of the symptoms of personality disorders, such as problems with anxiety and delusions. Psychotherapy is a form of treatment designed to help children and families understand and resolve the problems due to PD and modify the inappropriate behavior. In some cases a combination of medication with psychotherapy may be more effective. PD psychotherapy focuses on helping patients see the unconscious conflicts that are causing their disorder. It also helps them become more flexible and is aimed at reducing the behavior patterns that interfere with everyday living. In psychotherapy, patients have the opportunity to learn to recognize the effects of their behavior on others. The different types of psychotherapies available to children and adolescents include the following:.
- Cognitive behavior therapy (CBT). CBT is focused on improving a child's moods and behavior by examining confused or distorted patterns of thinking. With CBT, the child learns that thoughts cause feelings and moods that can influence behavior. For example, if a child has problematic behavior patterns, the therapist seeks to identify the underlying thinking that is causing them. The therapist then helps the child replace this thinking with thoughts that result in more appropriate feelings and behaviors.
- Dialectical behavior therapy (DBT). DBT is used to treat older adolescents with suicidal thoughts or who intentionally engage in self-destructive behavior or who have borderline personality disorder. DBT teaches how to take responsibility for one's problems and how to deal with conflict and negative feelings. DBT often involves a combination of group and individual sessions.
- Family therapy . This therapy approach is designed to help the family unit function in more positive and constructive ways by exploring patterns of communication and providing support and education. Family therapy sessions can include the child or adolescent along with parents and siblings.
- Group therapy (GT). GT uses group dynamics and peer interactions to increase understanding, communication, and improve social skills.
- Play therapy. This type of therapy is directed at helping younger children. It involves the use of toys , blocks, dolls, puppets, drawings , and games to help the child recognize, identify, and verbalize feelings. The psychotherapist observes how the child uses play materials and identifies themes or patterns to understand the child's problems. Through a combination of talk and play the child has an opportunity to better understand conflicts, feelings, and behavior.
Alternative treatments are available for personality disorders and most are complementary to conventional psychotherapy. They include the following:
- Coloring therapy. CT uses the activity of coloring as a self-help medium. While a person colors (with felt tipped markers, colored pens, pencils, etc.) a state of consciousness similar to meditation occurs. The approach is based on how people speak to themselves on the "inside." During a coloring session, people are asked to listen to the thoughts going on in their minds so as to become aware of where their thoughts, feelings, and opinions come from.
- Creative arts therapies. These therapies include art therapy, dance/movement therapy, drama therapy, music therapy, poetry therapy, and psychodrama. They use arts and creative processes to promote health, communication, and expression; they encourage the integration of physical, emotional, cognitive, and social functioning while enhancing self-awareness and facilitating change.
- Neurolinguistic programming. NLP is a method of examining the way a person thinks and acts through language and using this knowledge to effect change.
The notion that foods and nutrients influence brain function and behavior generated in the early 2000s widespread interest in the general public and in the scientific community. However, the evaluation data are still ambiguous when it comes to establishing a direct link between personality disorders and diet, aside from recommending the avoidance of alcoholic and stimulant beverages.
The PD outlook varies. Some personality disorders diminish during middle age without any treatment, while others persist throughout life despite treatment.
The prevention of personality disorders is an area surrounded with pessimism and controversy. Many mental health specialists believe that these disorders are untreatable, that individuals with personality disorder have little capacity for change; therefore not surprisingly, they remain skeptical about prevention prospects. However, even though the innate temperament of a person cannot be modified, understanding the factors that influence the development of personality disorders (such as genetic risks and environmental factors) may help prevention. Accordingly, some mental health professionals advocate primary prevention steps, which should include education of parents and primary healthcare workers, as well as early psychotherapy and protection of traumatized children, which can be carried out by child developing services. Some evidence suggests that traditional doctor-patient relationships are of much less value than programs which enable parents to see their own role as crucial and their own actions as able to bring changes for the better in their child's behavior. High quality parenting plays a critical role in child development and, thus, in the prevention of personality disorders.
Understanding personality disorders can be challenging for parents as well as for children. During the last third of the twentieth century, great advances were made in the areas of diagnosis and treatment of personality disorders. Parents can help children understand that these are real illnesses that can be treated. In order for parents to talk with a child about a personality disorder, they must be knowledgeable of the subject. Parents may have to do some homework to become better informed. They should have a basic understanding and answers to questions such as what are personality disorders, who gets them, what causes them, how are diagnoses made, and what treatments are available. When explaining to a child about how personality disorders affect a person, it may be helpful to explain that feelings of anxiety, worry, and irritability are common for most people. However, when these feelings get very intense, last for a long period of time, and begin to interfere with school and relationships, it may be a sign of a personality disorder that can, however, be treated.
A child's personality disorder often causes disruption to both the parents' and the child's world. Parents may have difficulty being objective. They may blame themselves or worry that others such as teachers or family members will blame them. Recognizing these feelings and seeking the help of professional care providers and support groups is the best way to cope with this issue.
Medication can also be an effective part of the treatment for several personality disorders in childhood and adolescence. A doctor's recommendation to use medication often raises many concerns and questions in both the parents and the child. The physician who recommends medication should be experienced in treating psychiatric illnesses in children and adolescents. He or she should fully explain the reasons for medication use, what benefits the medication should provide, as well as the possible negative side-effects or dangers and other treatment alternatives.
Anxiety —Worry or tension in response to real or imagined stress, danger, or dreaded situations. Physical reactions, such as fast pulse, sweating, trembling, fatigue, and weakness, may accompany anxiety.
Caring —The demonstration of an awareness of and a concern for the good of others.
Character —An individual's set of emotional, cognitive, and behavioral patterns learned and accumulated over time.
Delusion —A belief that is resistant to reason or contrary to actual fact. Common delusions include delusions of persecution, delusions about one's importance (sometimes called delusions of grandeur), or delusions of being controlled by others.
Eccentric —Deviating from the center; conduct and behavior departing from accepted norms and conventions.
Empathy —A quality of the client-centered therapist, characterized by the therapist s conveying appreciation and understanding of the client's point of view.
Erratic —Having no fixed course; behavior that deviates from common and accepted opinions.
Introversion —A personal preference for solitary, non-social activities and settings.
Maladaptive —Unsuitable or counterproductive; for example, maladaptive behavior is behavior that is inappropriate to a given situation.
Personality —The organized pattern of behaviors and attitudes that makes a human being distinctive. Personality is formed by the ongoing interaction of temperament, character, and environment.
Substance abuse —Maladaptive pattern of drug or alcohol use that may lead to social, occupational, psychological, or physical problems.
Temperament —A person's natural disposition or inborn combination of mental and emotional traits.
Moskovitz, Richard, A. Lost in the Mirror: An Inside Look at Borderline Personality Disorder. Lanham, MD: Taylor Trade Publishing, 2001.
Kantor, Martin. Distancing: Avoidant Personality Disorder. Westport, CT: Praeger Publishers, 2003.
Chiesa, M. et al. "Residential versus community treatment of personality disorders: a comparative study of three treatment programs." American Journal of Psychiatry 161, no. 8 (August, 2004): 1463–70.
Gothelf, D., et al. "Life events and personality factors in children and adolescents with obsessive-compulsive disorder and other anxiety disorders." Comprehensive Psychiatry 45, no. 3 (May-June, 2004): 192–98.
Haugaard, J. J. "Recognizing and treating uncommon behavioral and emotional disorders in children and adolescents who have been severely maltreated: borderline personality disorder." Child Maltreatment 9, no. 2 (May, 2004): 139–45.
Krueger, R. F., and S. R. Carlson. "Personality disorders in children and adolescents." Current Psychiatry Reports 3, no. 1 (February, 2001): 46–51.
American Academy of Child & Adolescent Psychiatry (AACAP). 3615 Wisconsin Ave., NW, Washington, DC 20016–3007. Web site: http://www.aacap.org.
American Psychiatric Association. 1000 Wilson Boulevard, Suite 1825, Arlington, Va. 22209–3901. Web site: http://www.psych.org.
Federation of Families for Children's Mental Health. 1101 King Street, Suite 420, Alexandria, VA 22314. Web site: http://www.ffcmh.org.
National Mental Health Association (NMHA). 2001 N. Beauregard Street, 12th Floor, Alexandria, VA 22311. Web site: http://www.nmha.org.
Lebelle, Linda. "Personality Disorders." Focus Adolescent Services. Available online at http://www.focusas.com/PersonalityDisorders.html (accessed October 13, 2004).
Monique Laberge, Ph.D.