6 General adult psychiatry6.1 Psychiatric disorders in adulthood
6.1.9 Personality disorders
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Written by Resident Doctor Committee · Published
Definition and classification
Personality disorder is a persistent difficulty in self or interpersonal functioning, shown across contexts and causing distress or impairment.
The named personality types in older research and treatment guidance describe clinical patterns. Current diagnoses use ICD-11 severity and trait qualifiers; these patterns do not map one-to-one onto trait domains.
ICD-11 severity and trait domains
The International Classification of Diseases, 11th revision (ICD-11), drops the categories. It grades severity first, as mild, moderate or severe by functional impairment and harm, then describes the disorder with trait domain qualifiers.
ICD-11 domain | What it describes |
|---|---|
Negative affectivity | Anxiety, anger, tearfulness or self-loathing out of proportion to small stressors, with low self-esteem and mistrust |
Detachment | Social and emotional distance, with little pleasure or emotional response |
Dissociality | Disregard for others and self-centredness |
Disinhibition | Impulsive action |
Anankastia | Narrow focus on one's own standard of perfection, with rigid control, inflexibility and emotional and behavioural constraint |
Personality difficulty is a subthreshold grade and is not a mental disorder.
The borderline pattern specifier is a separate, optional qualifier.
ICD-11 places schizotypal disorder in the schizophrenia spectrum, outside the personality disorders.
Detachment is told from autism spectrum disorder by preserved reciprocal conversation and the absence of restricted or repetitive behaviour.
Epidemiology
These estimates use older categorical diagnoses and cluster groupings; they are not prevalence estimates for the ICD-11 severity grades.
Setting | Any personality disorder |
|---|---|
British households (2006 survey) | 4.4%; cluster C 2.6%, A 1.6%, B 1.2%; single categories under 1%, such as borderline 0.7% and antisocial 0.6% |
General psychiatric outpatients | About one third; cluster C 22%, B 13%, A 6% |
Male prisoners (Fazel and Danesh) | About 65%; antisocial about 47% |
Female prisoners | About 42%; antisocial about 21% |
The commonest single type depends on setting: obsessive-compulsive in the community, avoidant in outpatients, borderline in inpatient units and antisocial in prisons.
Obsessive-compulsive personality disorder affects a few per cent of adults but rarely presents to services, unlike borderline and antisocial disorders.
Childhood abuse
Among adult outcomes of childhood sexual abuse, personality disorder shows the largest relative increase in risk, more than depressive disorder.
About half of people with borderline personality disorder (40 to 70% across studies) report sexual abuse, mostly in childhood.
Childhood adversity is neither necessary nor sufficient for personality disorder.
Assessment
Acute depression, intoxication, trauma or crisis can resemble personality dysfunction, so defer an uncertain label.
Personality disorder instruments (categorical interviews, screens and dimensional trait inventories) differ from scales that rate the severity of current symptoms.
Instrument | Format | Result |
|---|---|---|
International Personality Disorder Examination (IPDE) | A self-administered screening questionnaire (IPDE-SQ), then a semi-structured clinical interview of each criterion | A positive screen leads on to the interview, not to a diagnosis |
Personality Diagnostic Questionnaire | Self-completed true or false screen based on older categorical criteria | Sensitive but over-inclusive; not an ICD-11 diagnostic assessment |
Distrust, detachment and eccentricity
Paranoid pattern
A paranoid pattern is pervasive, unwarranted distrust of others with hypersensitivity to slights, rebuffs and criticism.
The person bears grudges, reacts with lasting hostility, is reluctant to confide and gets into repeated conflict.
There are no psychotic features, and thinking is otherwise clear.
Prominent mistrust and sensitivity to slights suggest a paranoid pattern; persistent cognitive and perceptual distortions prompt assessment for schizotypal disorder.
Schizoid pattern
A schizoid pattern is detachment from relationships, with emotional coldness and restricted expression.
The person is indifferent to praise and criticism and has no wish for closeness.
Schizotypal disorder
Schizotypal disorder belongs to the primary psychotic disorders in ICD-11 and is a long-standing interpersonal deficit with cognitive and perceptual distortion and eccentric speech or dress.
The distortions (odd beliefs, magical thinking, ideas of reference, perceptual oddities) are held with doubt, short of fixed delusion.
These cognitive and perceptual distortions distinguish schizotypal disorder from personality trait patterns.
Borderline pattern
Features
The ICD-11 borderline pattern qualifier requires a pervasive pattern of instability in relationships, self-image and affect with marked impulsivity, indicated by at least five of nine features. It accompanies a personality disorder diagnosis graded by severity.
Frantic efforts to avoid real or imagined abandonment form one criterion.
Relationships swing from idealisation to devaluation.
Identity is unstable, and the person feels chronically empty.
The person self-harms impulsively.
Affective dysregulation is marked mood reactivity: intense dysphoria, irritability or anxiety lasting hours, rarely days.
Brief stress-related dissociation (depersonalisation, derealisation, memory gaps) is a recognised feature; persistent symptoms need assessment for another disorder.
Kernberg's borderline personality organisation relies on primitive defences with splitting at their core, rather than the higher-level defences of neurotic organisation.
Differential diagnosis
Confused with | What separates them |
|---|---|
Bipolar disorder | Identity disturbance and chronic emptiness belong to borderline disorder, not bipolar disorder |
ICD-11 complex post-traumatic stress disorder (PTSD) | Both can show reckless or self-destructive behaviour from the affect dysregulation cluster. Identity instability and abandonment concerns can support a borderline pattern but neither is individually required; complex PTSD needs the core PTSD features, with a fixed negative self-concept and relationships avoided rather than stormy |
Course
Most people stop meeting criteria within a decade, so remission is the usual outcome.
In the McLean study about 90% of an inpatient cohort remitted by ten years, but only about half regained good social and vocational function.
Psychological treatment
Dialectical behaviour therapy (DBT) combines individual work, skills groups and coaching, and has the largest evidence base: only DBT had enough trials to pool in the 2012 Cochrane review.
The National Institute for Health and Care Excellence (NICE) names a comprehensive DBT programme for women in whom reducing recurrent self-harm is the priority.
Mentalisation-based therapy is an evidence-based, structured, long-term treatment that builds understanding of one's own and others' mental states.
NICE advises against psychological interventions lasting under three months when offered specifically for borderline disorder or its individual symptoms.
Dissocial pattern
ICD-11 records the dissocial pattern through personality disorder severity and the dissociality domain, adding other domains when appropriate.
Its core is callous disregard for others: lack of empathy, remorselessness, deceit, exploitation, entitlement and instrumental aggression.
Impulsivity belongs to the separate disinhibition domain, not to dissociality.
ICD-11 permits personality disorder diagnosis in adolescents when enduring dysfunction is established, typically over two years or more; ordinary developmental change must be excluded.
NICE recommends considering group-based cognitive and behavioural interventions, and offering treatment for comorbid alcohol or drug misuse.
NICE does not support drugs for the disorder itself or its aggression, anger and impulsivity. Psychological and psychosocial approaches come first, and drugs are kept for comorbid conditions.
Histrionic and narcissistic patterns
A histrionic pattern is theatrical, attention-seeking and seductive behaviour, with shallow emotion that switches off.
Speech is vivid but vague, and the person is over-familiar and suggestible.
It is told from borderline disorder by the absence of self-destructiveness, chronic emptiness and identity disturbance.
A narcissistic pattern is grandiosity, entitlement, exploitation of others, poor empathy and a need for excessive admiration that confirms a sense of superiority.
Beneath the grandiosity, self-esteem is fragile, not secure, and criticism wounds it.
Anxious, dependent and anankastic patterns
Avoidant (anxious) pattern
An avoidant pattern is wanting relationships but avoiding them from fear of criticism, shame, ridicule and rejection.
The person sees themselves as inferior and is sensitive to social evaluation.
Avoidant withdrawal comes from fear of rejection; schizoid withdrawal and the detachment domain come from indifference.
Dependent pattern
A dependent pattern is an excessive need to be cared for, with fear of losing support.
The person hands decisions to others, needs excessive advice and reassurance, and agrees with others against their own view.
They quickly find a new carer and feel helpless when alone.
Anankastic pattern
An anankastic pattern is ego-syntonic rigidity, with a need for control and devotion to work.
Perfectionism stops tasks being finished, and the person refuses to delegate unless things are done their way.
They cannot discard worn-out, worthless objects and are confident in their own methods.
It lacks the intrusive thoughts of obsessive-compulsive disorder.
Drug treatment
No drug is licensed for borderline personality disorder or its symptom domains, and NICE advises against routine drug treatment.
Drugs gathered over past crises should be reviewed, reduced and stopped when there is no comorbid illness.
Benzodiazepines worsen impulsivity and behavioural dyscontrol in borderline disorder, increasing impulsive self-harm, aggression and risk-taking.
In a borderline crisis NICE allows cautious sedation for no longer than a week, using a drug with few side effects, low addictive potential and relative safety in overdose, such as the sedative antihistamine promethazine.
Where drugs are used in personality disorder, the choice follows the symptom domain.
Symptom domain | Drug |
|---|---|
Impulsive aggression | A selective serotonin reuptake inhibitor (SSRI) first, as impulsive aggression is linked to low central serotonin turnover; trials used fluoxetine |
Affective dysregulation | A mood stabiliser (lithium, valproate or topiramate) once an SSRI has failed |
Cognitive-perceptual features | A low-dose antipsychotic such as risperidone |