Personality Disorder
Disclaimer:
ICD-11 has moved away from diagnosing most personality disorders as separate named entities. Instead, personality disorders are classified primarily according to severity and prominent personality trait domains.
However, at a non-specialist and undergraduate level, it remains important to recognise the traditional named personality disorders and their characteristic clinical patterns. Therefore, this article uses the DSM-5 categorical framework, including the traditional Cluster A, B and C personality disorders, to support clinical and exam pattern recognition.
This approach is also consistent with current NICE guidance, which continues to provide dedicated guidelines for borderline personality disorder and antisocial personality disorder.
Rapid, one-liner description of various personality disorders: [Ref]
| Personality disorder | Key characteristic feature |
|---|---|
| Paranoid | Mistrust and suspicion |
| Schizoid | Disinterest in others |
| Schizotypal | Eccentric ideas and behaviour |
| Antisocial | Social irresponsibility, disregard for others, deceitfulness, and manipulation of others for personal gain |
| Borderline | Inner emptiness, unstable relationships, and emotional dysregulation |
| Histrionic | Attention seeking and excessive emotionality |
| Narcissistic | Self-grandiosity, need for admiration, and lack of empathy |
| Avoidant | Avoidance of interpersonal contact due to rejection sensitivity |
| Dependent | Submissiveness and a need to be taken care of |
| Obsessive-compulsive | Perfectionism, rigidity, and obstinacy |
Learning aid and disclaimer:
- The traditional Cluster A, B and C classification can be helpful for grouping and learning personality disorders, but it is less important to memorise exactly which disorder belongs to each cluster
- In exams, one is more likely to be asked to recognise the characteristic features of a personality disorder themselves than to identify its cluster
Key points about management:
- The main treatment for personality disorders is psychological therapy
- Do not use medications solely to treat personality disorders itself, they may be used to target specific symptoms or treat co-existing mental health disorders, e.g. depression or anxiety
Cluster A – Odd / Eccentric
Paranoid Personality Disorder
Key features:
- Pervasive distrust and suspicion of other people
- Frequently assumes that other people have harmful, deceptive or hostile intentions
- May question the loyalty or trustworthiness of friends, colleagues or partners
- Reluctant to confide in others because information may be used against them
- May interpret neutral remarks or events as threatening, insulting or personally directed
- Highly sensitive to perceived criticism or disrespect
- May hold grudges for prolonged periods
- Recurrent unjustified suspicions regarding a partner’s fidelity may occur
High-yield recognition: Persistent mistrust and suspiciousness without psychosis
Example vignette: A man repeatedly accuses colleagues of deliberately undermining him, refuses to share personal information because he believes it will be used against him and remains angry about minor comments made several years ago
Schizoid Personality Disorder
Key features:
- Pervasive detachment from social relationships
- Prefers solitary activities and spending time alone
- Little desire for close friendships or intimate relationships
- Has few close friends or confidants
- May appear emotionally cold, detached or indifferent
- Limited outward expression of emotions
- Relatively indifferent to praise or criticism
- May derive pleasure from relatively few activities
- May have little interest in sexual relationships
High-yield recognition: Not interested in others, resulting in social isolation + no or few friends + not interested in relationships
- Due to a preference for being alone, but NOT due to the fear of rejection or criticism (which is the feature of avoidant personality disorder)
Example vignette: A man lives alone, prefers hobbies that can be carried out alone, has no close friends and never had a sexual / romantic relationship, showing little concern for criticism.
Schizotypal Personality Disorder
Key features:
- Unusual thoughts and perceptions
- Magical thinking or unusual beliefs, e.g. believing they can predict events or communicate telepathically
- Ideas of reference, where unrelated events are interpreted as having a special personal meaning
- Unusual perceptual experiences may occur
- Behavioural and communication
- Eccentric appearance or behaviour
- Unusual or vague patterns of speech
- May appear markedly unconventional or peculiar
- Interpersonal features
- Few close relationships
- Significant social discomfort or anxiety
- Suspicious or paranoid thinking may occur
High-yield recognition: Eccentric idea / behaviour + magical thinking / ideas of reference + interpersonal difficulties
- There is no persistent frank psychosis, such as fixed delusions, persistent hallucinations or marked disorganised speech / behaviour
Example vignette: A university student has few friends, dresses unusually, speaks in an odd way and believes television presenters occasionally send messages specifically intended for him, while also describing himself as able to sense events before they happen
Cluster B – Dramatic / Emotional / Erratic
Antisocial Personality Disorder
Note: Antisocial personality disorder does not mean “antisocial” in the everyday sense of disliking socialising or preferring to be alone
Key features:
- Disregard for others
- Persistent disregard for the rights, safety or wellbeing of other people
- Repeated violation of social norms or laws
- May exploit or manipulate others for personal benefit
- Behaviour
- Deceitfulness and repeated lying
- Impulsivity and poor forward planning
- Irritability or aggression
- Reckless behaviour with little regard for personal or others’ safety
- Persistent irresponsibility (e.g. repeatedly failing to meet occupational or financial responsibilities)
- Emotional features
- Little or no remorse after harming others
- May rationalise their behaviour or blame others for its consequences
Important diagnostic points:
- Antisocial personality disorder can only be diagnosed in adults (i.e. ≥18 y/o)
- There should be evidence of conduct disorder before 15 y/o
- While conduct disorder is a required precursor for antisocial personality disorder, most children with conduct disorder do not go on to develop antisocial personality disorder as adults
High-yield recognition: Disregard for others’ feelings and rights + deceitfulness or aggression + irresponsibility + manipulate others for personal gain
Example vignette: A man with a childhood history of repeated fighting, theft, animal cruelty and school exclusion continues to lie for financial gain, repeatedly breaks the law and expresses no remorse / regret after harming others.
Borderline Personality Disorder (Emotionally Unstable Personality Disorder)
Key features:
- Emotional instability
- Marked and rapidly changing emotions
- Difficulty regulating emotional responses
- Episodes of intense anger or difficulty controlling anger
- Chronic feelings of emptiness
- Relationship problems
- Intense fear of abandonment or rejection
- May make significant efforts to prevent real or perceived abandonment
- Unstable and intense interpersonal relationships
- Relationships may alternate between strongly idealising and strongly disliking the same person
- Self-image
- Unstable self-image or sense of identity
- May experience marked changes in personal goals, values or view of themselves
- Impulsivity and self-harm
- Impulsive behaviours with potentially harmful consequences (e.g. risky sexual behaviour, substance misuse, binge eating, reckless driving or excessive spending)
- Recurrent self-harm
- Suicidal behaviour or recurrent suicidal threats may occur
Key management principles (NICE):
- Assess current risk to self and others
- Refer to community mental health services if there is repeated self-harm, persistent risk-taking, or marked emotional instability
- Psychotherapy of choice (specifically to reduce recurrent self-harm): dialectical behaviour therapy (not CBT!)
High-yield recognition: Emotional instability + unstable relationships + fear of abandonment + impulsivity or self-harm + unstable self-image
Example vignette: A young woman has repeated intense relationships followed by sudden break-ups, becomes extremely distressed when she believes her partner may leave her, repeatedly self-harms after interpersonal conflict and rapidly shifts between describing her partner as perfect and believing that he hates her
Histrionic Personality Disorder
Key features:
- Attention seeking
- Strong need to be noticed or receive attention from others
- May feel uncomfortable when they are not the centre of attention
- May use appearance or behaviour to attract attention
- Emotional expression
- Dramatic or theatrical behaviour
- Emotions may appear exaggerated
- Emotions may change rapidly and appear relatively shallow
- Interpersonal behaviour
- May behave in an excessively flirtatious or seductive manner
- Speech may be dramatic but lacking in detail
- May be highly suggestible or easily influenced by others
- May perceive relationships as closer or more intimate than they actually are
High-yield recognition: Dramatic + highly emotional + persistent need to be the centre of attention + excessively flirtatious behaviour
Example vignette: A woman becomes visibly uncomfortable when attention is directed towards someone else, tells dramatic stories with exaggerated emotional expression, describes casual acquaintances as very close friends and is described as flirting with / seducing colleagues.
Narcissistic Personality Disorder
Key features:
- Grandiosity
- Exaggerated sense of self-importance
- May overestimate their abilities or achievements
- May have fantasies involving exceptional success, power, intelligence, attractiveness or status
- May believe that they are special or should associate only with similarly high-status individuals
- Interpersonal behaviour
- Strong need for admiration
- Sense of entitlement and expectation of special treatment
- May exploit others to achieve personal goals
- Reduced ability or willingness to recognise the feelings and needs of others
- Self-esteem
- May appear arrogant or dismissive
- May be envious of others or believe others are envious of them
- Underlying self-esteem may be fragile, with marked sensitivity to criticism or failure
High-yield recognition: Exaggerated sense of self-importance + entitlement + need for admiration + lack of empathy
Example vignette: A senior employee repeatedly shows off and exaggerates his achievements, expects preferential treatment, believes he is irreplaceable within the company, becomes angry when colleagues fail to praise him and dismisses junior staff as unimportant
Cluster C – Anxious / Fearful
Avoidant Personality Disorder
Key features:
- Fear of rejection
- Marked sensitivity to criticism, rejection or disapproval
- May avoid social or occupational situations because of fear of embarrassment or rejection
- Reluctant to become involved with others unless reasonably certain that they will be accepted
- Poor self-perception
- Persistent feelings of inadequacy or inferiority
- May view themselves as socially awkward, unattractive or inferior to other people
- Relationships
- Often wants friendships and relationships but avoids pursuing them because of fear of rejection
- May be very restrained in new relationships because of fear of being ridiculed or disliked
- Reluctant to take interpersonal risks or try new activities where embarrassment is possible
High-yield recognition: Wants relationships but avoids them because of fear of criticism and rejection
Example vignette: A woman who frequently feels lonely but avoids social events because she believes others will find her boring and fears being criticised or embarrassed
Dependent Personality Disorder
Key features:
- Reliance on others
- Excessive need to be cared for
- Difficulty making everyday decisions without considerable reassurance or advice
- May rely on another person to take responsibility for major areas of their life
- Difficulty initiating projects or functioning independently because of limited confidence
- Submissiveness
- May struggle to disagree with others because of fear of losing their support
- May go to excessive lengths to obtain care, reassurance or approval
- May tolerate unpleasant situations or relationships to avoid losing support
- Fear of separation
- Feels uncomfortable or helpless when alone
- Excessive fear of being left to care for themselves
- May urgently seek another supportive relationship when an important relationship ends
High-yield recognition: Submissive and reliant on others because of a strong perceived need to be cared for
Example vignette: A woman relies on her partner to make most everyday decisions, agrees with him even when she privately disagrees and becomes extremely distressed at the possibility of separation because she believes she cannot manage independently
Obsessive-Compulsive Personality Disorder (OCPD)
Key features:
- Perfectionism and order
- Strong preoccupation with organisation, rules, schedules, lists or details
- Perfectionism may become so excessive that it delays or prevents completion of tasks
- May prioritise productivity and work over leisure activities or relationships
- Rigidity and control
- Strong need for control
- May be reluctant to delegate because others may not perform tasks according to their preferred method
- Rigid or stubborn approach to situations
- May apply inflexible standards to themselves and others
- May demonstrate excessive rigidity regarding morality, ethics or values
- May have difficulty discarding objects even when they have little practical or sentimental value
- May be excessively cautious regarding spending or resources
High-yield recognition: Perfectionism + orderliness + rigidity + need for control
Example vignette: A doctor who sees only 2 patients a day because he spends excessive amounts of time making every detail of his work perfect, refuses to work with colleagues as they don’t complete tasks exactly his way and becomes frustrated when plans are changed
OCPD is not the same as OCD:
- OCPD (obsessive compulsive personality disorder): enduring personality style characterised by perfectionism, rigidity and control, with the individual often viewing these behaviours as appropriate or desirable
- OCD (obsessive compulsive disorder): a mental health condition characterised by intrusive obsessions and/or compulsions that are typically unwanted or distressing, which cause clinically significant disturbances and functional impairment