Personality and Personality Disorders
A person’s personality is the sum of all their psychological traits and behaviour patterns, giving them a unique identity. It includes emotional life, perception, thinking, and relationships with others. Personality traits distinguish individuals. Extreme traits may indicate a personality disorder.
Personality traits can change throughout a person’s entire life. A person’s basic temperament, such as being extroverted or introverted, emotional or tough, energetic or sluggish, is mainly determined by genetics and remains relatively stable from early childhood.
Influenced by maturation and experience, temperament is seen as fairly stable from early childhood. Perception and interaction with the environment, central to personality development, are shaped by parenting, life events, environmental factors, and social support.
Development of Personality
The many facets of personality develop through young adulthood, but they can still change over a lifetime. Experiences, events, and how life tasks and conflicts are handled shape these traits.
Parental care and affection can protect against personality disorders, while time spent in institutions, experiences of separation, loss, broken families, neglect, violence, physical and sexual abuse, and other factors can negatively impact personality development.
What Is Personality Disorder?
Personality disorders can be viewed as extreme versions of a personality with inflexible, rigid, and dysfunctional traits that reduce a person’s quality of life, cause distress, or lead to frequent conflicts with others.
These abnormal experiences, patterns, and behaviours limit satisfaction and hinder personal goals or cause regular problems with people or society. “Abnormal” here means behaviour or emotions that significantly deviate from social or cultural expectations, causing interpersonal issues.
A personality disorder is present when these problematic traits are stable, long-lasting, and traceable to adolescence or early adulthood. The disorder shouldn’t be a result of another mental illness, substance use (e.g., drugs, medications, toxins), or other diseases, like a head injury.
Causes of Personality Disorders
Positive and negative role models, as well as experiences of violence, neglect, or special care can influence development. Since many factors shape personality, it is clear that there is a wide range of what is considered normal.
Research has shown that difficult experiences, such as childhood neglect or violence, can lead to changes in certain brain structures. This can have a lasting effect on how emotions are experienced and how relationships with others are formed. Positive and negative role models within the family also influence personality development, for instance, shaping self-confidence and assertiveness or leading to anxiety, avoidance, and defining gender roles within the family.
Personality undergoes changes throughout a person’s life. It develops based on genetics, learning, and relationships, especially in childhood and adolescence. Even in middle and older age, it can change. For example, temperament, which affects personality from the start, is considered largely biological (genetic, prenatal).
Prevalence of Personality Disorders
Worldwide, about 9% suffer from a personality disorder. Among psychiatric patients, the rate is significantly higher at 40 to 60%. Personality disorders occur equally in men and women. Only antisocial personality disorder is more common among men, while the distribution between genders is otherwise balanced in the general population.
The subtypes of personality disorders, described in more detail below, vary greatly in frequency.
Personality Disorders: Clinical Pictures
Personality disorders are divided into three main personality groups, clusters A, B and C:
A cluster: includes paranoid and schizoid personality disorders under the labels “odd, eccentric.”
B Cluster: encompasses histrionic, narcissistic, antisocial, and borderline personality disorders under “dramatic, emotional, erratic.”
C cluster: covers personality disorders with anxiety-related traits, such as “avoidant, dependent, obsessive-compulsive.”
Paranoid Personality Disorder
People with paranoid personality disorder are suspicious, wary, and always expect to be attacked or hurt by others. They are hypersensitive to criticism and overreact in conflicts or disputes. When they feel wronged or attacked, they retaliate. At the same time, they can analyze situations well and have sharp minds. Paranoid personality disorder is rare (1% of the population) and must be distinguished from delusional disorders with paranoia.
Schizoid Personality Disorder
Schizoid personality disorder is also rare, affecting about 1% of the population. People with this disorder appear distant, indifferent, unemotional, or disinterested in others. They live isolated lives with few social contacts. Being typical loners they do not suffer from their lack of relationships.
Schizoid individuals have little emotional reaction to their surroundings. This disorder becomes burdensome when their partner relationships suffer from their emotional detachment. Therapy is sought only if the disorder is mild. In more severe cases, there is no desire for close relationships. Distinguishing schizoid personality disorder from autism spectrum disorders is often challenging.
Histrionic Personality Disorder
Histrionic personality disorder occurs in about 2% of the general population. People with this disorder constantly seek attention and approval from others. They are often extroverted, charismatic, and lively, capable of captivating others. Despite having many friends and an eventful life, they may experience periods of loneliness, dissatisfaction, and inner emptiness with deep self-doubt. These individuals typically seek therapy not for their personality traits but for depression, often after a breakup or other difficulties.
Narcissistic Personality Disorder
Narcissistic individuals often come across as demanding, arrogant, or conceited. Outwardly, they appear very confident, but they are actually sensitive and vulnerable. They struggle with criticism due to a fragile, unstable self-esteem, hidden by a grand facade.
Problems often begin early in their career, as they fail to meet their high expectations and suffer from fears of failure, like test anxiety. Later in life, they may experience work difficulties and fail to live up to their potential. These individuals can face existential crises, leading to intense inner despair, sometimes culminating in suicide. Narcissistic personality disorder has the highest suicide rate, at 14%.
Emotionally Unstable Personality Disorder (Borderline Type)
The International Statistical Classification of Diseases, ICD-10, identifies two forms of emotionally unstable personality disorder: an impulsive type, marked by emotional instability and poor impulse control, and a borderline type.
The borderline type includes impulsive traits along with additional features. Therefore, only borderline personality disorder is discussed below, as it encompasses all aspects of emotional instability.
Borderline personality disorder is a severe psychiatric condition, affecting about 3% of the general population. Those affected feel like victims of their intense emotions and tend to engage in self-harming or, at times, outwardly aggressive behaviour. They appear very moody and are highly sensitive to rejection. Sufferers often describe feeling “alien” or disconnected from themselves. For more detailed information, refer to the article on borderline disorder.
Antisocial Personality Disorder
Antisocial personality disorder is characterized by a tendency towards aggressive and violent behaviour. People with this disorder often break the law because they disregard social norms and act irresponsibly. They are easily irritable, impulsive, and have low frustration tolerance, with some showing no empathy.
Long-term consequences or alternatives to their actions seem to go unnoticed by them.
In work or relationships, routine quickly leads to boredom and discomfort. As a result, they seek excitement, adventure, and constant change. In relationships, they can be unreliable, manipulative, and exploit others for personal gain. In the general population, 3-7% of men and 1-2% of women have this disorder.
Avoidant Personality Disorder
Avoidant (or anxious-avoidant) personality disorder is relatively common, affecting 3-5% of the general population. People with this disorder are shy, inhibited, and feel insecure in many social situations. They tend to isolate themselves out of fear of negative evaluation, criticism, or rejection. They avoid the spotlight and struggle with public speaking.
Individuals with this personality disorder often see themselves as inferior, which leads them to avoid contact with others. However, they are often appreciated by others for being sensitive, empathetic, and considerate.
Avoidant personality disorder can be mistakenly diagnosed as a severe form of generalized anxiety disorder that begins in childhood or adolescence.
Avoidant personalities are prone to developing other mental illnesses, especially anxiety disorders, obsessive-compulsive disorder, and depression. Often, it is a secondary condition that prompts them to seek therapy.
Dependent Personality Disorder
People with dependent personality disorder feel incapable of living independently. They always need someone to support them and make important decisions for them. Out of fear of losing this person, they submit to their partner and don’t express their own feelings or needs.
This “clinging behaviour” often leads to relationship problems. Despite this, dependent individuals are valued as loyal, reliable, and helpful friends. In a stable environment, they can often function well for long periods. However, life changes, such as moving, separation, or the death of a partner, can trigger a psychological crisis.
Obsessive-Compulsive (Anankastic) Personality Disorder
People with obsessive-compulsive personality disorder often appear orderly and correct.
They strive to avoid making mistakes. Their precision and reliability are highly valued, especially in professional settings. However, they expect others to meet their own high standards. This can cause interpersonal conflicts, as they lack spontaneity and ease. Their excessive attention to detail and reluctance to delegate work can lead to exhaustion, particularly later in life.
Difference Between Obsessive-Compulsive Personality Disorder and OCD
Obsessive-Compulsive Disorder (OCD) usually develops later in life, causing significant distress. In contrast, obsessive-compulsive personality disorder symptoms are deeper-rooted and often begin in childhood.
People with obsessive-compulsive personality disorder usually don’t view their behaviours as abnormal. In contrast, individuals with obsessive-compulsive disorder (OCD) experience intrusive thoughts and actions as irrational.
Personality Disorders: Course and Prognosis
Personality disorders are not “incurable” conditions but rather extreme, individual patterns of behaviour, feelings, and thinking. On one hand, people with personality disorders may have certain strengths, but they often face challenges in their professional or interpersonal lives.
The severity of these traits isn’t always constant in every situation.
Many individuals with personality disorders can live stable, fulfilling lives for long periods.
However, stressful events or challenges can destabilize them and lead to crises.
Personality can’t be changed quickly, as it’s a deeply engraved pattern of behaviour shaped by long-term experiences combined with genetic predisposition.
Therapy helps individuals avoid being stuck in harmful patterns that undermine self-esteem.
Alternative strategies help them manage their personality more consciously.
Personality Disorders: Diagnosis
Comprehensive information about the current situation and life history aids in diagnosing personality disorders. Even though personality covers a broad range of normal variations, disorders can be reliably diagnosed today.
For psychiatrists and psychotherapists, it is crucial to get thorough information about the current situation and life history, starting from childhood. Structured and standardized interviews, questionnaires, and checklists help in assessing whether a personality disorder is present and, if so, which type. The goal is to pinpoint the subtype as precisely as possible while also identifying any co-occurring personality disorders.
A person’s personality develops from early childhood through adolescence and into young adulthood. Therefore, diagnosing a personality disorder before age 14 is neither practical nor possible. The earliest age for diagnosing a personality disorder is around 15 years. However, personality disorders often “disappear” between 15 and 18, as teenagers focus on identity formation and autonomy, sometimes rebelling against societal norms. This narcissistic behaviour typically fades once identity formation is complete.
Personality Disorders: Therapy
There are tailored treatment plans for personality disorders. Psychotherapeutic methods are essential in treating personality disorders. Each disorder has specific therapy approaches that consider individual circumstances.
For some disorders, customized treatment plans have proven highly effective.
This is especially true for borderline disorder, antisocial personality disorder, and avoidant personality disorder. The patient’s situation at the time of treatment is crucial to determining the course of therapy. If a patient is in an emotional crisis or has suicidal tendencies, therapy will differ from someone relatively stable.
If other mental illnesses (depression, anxiety disorders, PTSD) are present, they are also treated.
Depending on the illness, psychotherapeutic or medication-based treatments may be used.
Paranoid Personality Disorder
Paranoid individuals rarely seek help, as they blame their environment for their problems. They only pursue therapy when faced with an emotional crisis they cannot handle alone. The primary therapy goal is reducing mistrust of others and improving social skills. Core beliefs of the paranoid person are broken down through behavioural analysis and compared to reality.
This helps them realize that others are often friendly and not a threat.
Group therapy can be useful for addressing withdrawal tendencies and lack of interpersonal engagement. Role-playing exercises help them recognize positive abilities, like strong observational skills, which can aid in problem-solving and understanding others.
Schizoid Personality Disorder
Schizoid individuals typically do not see themselves as needing treatment. Since they do not suffer from a lack of social contacts, they usually feel no desire to change. However, the need to work in a team or conditions like depression, anxiety, or psychotic disorders may lead them to seek help.
Therapy can only succeed if a strong relationship with the therapist is built. Therefore, for schizoid individuals, individual therapy is preferred over group therapy to build a stable relationship with the therapist. Since schizoid individuals have difficulty trusting others, establishing this bond is crucial and often takes time. The therapy goal is to activate emotional processes and enhance social interaction with others.
Histrionic Personality Disorder
The primary goal of therapy for histrionic personality disorder is promoting autonomous, authentic interactions and stabilizing self-esteem. Patients learn to recognize, label, analyze, and appropriately communicate their emotions.
Working with emotion logs, therapy journals, or self-monitoring sheets is highly effective.
Throughout therapy, patients understand how their behaviours and presentation relate to personal life experiences.
Since histrionic individuals define themselves through others, part of therapy involves learning to regularly engage in solo activities.
Narcissistic Personality Disorder
For narcissistic individuals, a stable relationship with the therapist is extremely important. Patients often seek therapy only during existential crises or after suicide attempts. Since they are highly sensitive to criticism, the therapist must balance appreciation with constructive feedback. The main therapy goals include reducing the inflated self-image, improving tolerance for criticism, and fostering empathy. Group therapy can help them understand others’ perspectives through roleplaying and develop empathy.
Emotionally Unstable Personality Disorder (Borderline Type)
Specific psychotherapy technics, such as Transference Focused Psychotherapy (TFP) and Dialectic Behavioural Therapy (DBT) are the key components in treating borderline disorder, though medications can be used as well. For more detailed information, refer to the article on borderline disorder.
Antisocial Personality Disorder
Treating antisocial personality disorder requires a combination of psychotherapeutic methods for success. The therapy aims to improve self-control, social skills, problem-solving abilities, and value development. It also encourages taking responsibility for one’s actions, addressing traits linked to deviant and criminal behaviour.
Antisocial individuals often do not seek therapy voluntarily. Instead, court orders, child services, or partner demands lead them to therapy. If additional conditions, such as depression or anxiety, are present, they must also be treated. In some cases, aggression-reducing medications are used.
Avoidant Personality Disorder
Avoidant personality disorder is treated with psychotherapy. For a shy, sensitive person, a trusting relationship with a reassuring therapist is crucial. The focus of treatment is on reducing social anxiety.
At the start of therapy, the patient is educated about their personality and behaviour patterns.
Together, they explore how these patterns developed and how thoughts, feelings, and behaviours are interconnected.
As therapy progresses, current behaviours are linked to the patient’s life history. This helps the patient understand why certain behaviours emerged. The goal is to break the negative thought cycle and “reprogram” it with positive, supportive thoughts.
Since avoidant patients tend to avoid uncomfortable situations, therapy gradually exposes them to similar, previously analyzed situations. Group therapy is particularly effective, as the group setting itself confronts the patient with an uncomfortable situation. Over time, the patient learns they are not inferior and have valuable skills and resources. Additionally, relaxation techniques like progressive muscle relaxation can help manage physical tension and arousal.
Dependent Personality Disorder
Dependent personality disorder is treated with psychotherapy. The primary goal is to strengthen the patient’s independence and autonomy. Patients must learn to recognize their own wishes and advocate for them externally. Because they are highly adaptable, the therapist must ensure real progress leads to internal growth, not just more compliance.
Through detailed discussions and analyses, the impact of current behaviours on personal and professional relationships is explored. Group therapy has proven effective, as patients can safely practice assertive behaviour and new approaches. Positive experiences reinforce the patient’s confidence in their progress.
Obsessive-Compulsive (Anankastic) Personality Disorder
Many people with obsessive-compulsive personality disorder function well in everyday life.
They often seek therapy when environmental changes disrupt their sense of stability, as their inflexibility prevents them from adapting. This can lead to the development of depression or anxiety disorders.
The primary therapy goal is to foster emotional openness, spontaneity, and willingness to take risks. Psychotherapy helps achieve this by highlighting both the positive and negative aspects of extreme conscientiousness.
Together with the therapist, the patient reflects on and reconsiders their life values, exploring new perspectives. The therapist helps the patient realize that interpersonal interactions can solve problems without rigid adherence to rules. It is also crucial to enhance the patient’s ability to experience pleasure, which can be supported through euthymic therapy.