Personality Disorders

I can be smooth, charming, and slick. I can leave a very confident impression, and it’s hard to catch me off guard. At times, I find myself fantasizing about unlimited success, power, and beauty. I’ve often used deceit to manipulate or defraud others for my personal gain. To be honest, I don’t have much concern for other people’s feelings or suffering. This doesn’t sound like the Hank you know, does it?

These are all statements from a Self-Assessment for Personality Disorders, which allows patients to describe themselves by ranking how accurate each statement is. However, you can’t always rely on self-reports like this to assess what we’re discussing today. Some people who are overly confident, obsessed with power, or deceitful might admit it, but others might not. Many of the disorders we’ve covered so far are “ego-dystonic,” meaning the person is aware they have a problem and is often distressed by it. For example, someone with Bipolar Disorder or OCD generally recognizes they have a condition and dislikes how it affects them. However, some disorders are trickier.

They are “ego-syntonic,” meaning the person may not recognize they have a problem and, at times, may even believe the problem lies with others. Personality disorders fall into this category. These are psychological disorders marked by inflexible, disruptive, and persistent behavior patterns that impair social and other functioning—whether the individual recognizes it or not. Unlike many other conditions we’ve discussed, personality disorders are often seen as chronic issues that cause significant problems in daily life. And as shown by these self-assessment statements, they can range from mild narcissism to a troubling lack of empathy for others.

Personality disorders can be difficult to diagnose and understand and can even be frightening. The most extreme and severe ones are often associated with terms like psychopathy or sociopathy, and we’re talking about individuals like serial killers, mob bosses, or historical figures like Vlad the Impaler. The concept of personality disorders is relatively new, and our modern classifications are largely based on the work of German psychiatrist Kurt Schneider, who first published a treatise on psychopathy in 1923. Today, the DSM-5 lists ten distinct personality disorders, grouped into three clusters.

Cluster A includes “odd” or “eccentric” personality traits. For example, someone with paranoid personality disorder may feel a constant distrust of others and be overly guarded, while someone with schizoid personality disorder would be aloof, indifferent, and uninterested in relationships. Cluster B encompasses dramatic, emotional, or impulsive personality traits. Someone with narcissistic personality disorder may display a grandiose sense of self-importance, while someone with histrionic personality disorder may seek attention through dramatic behaviors, even risking their own safety. These disorders are often associated with self-destructive actions and frequent hospitalization.

Cluster C involves anxious, fearful, or avoidant behaviors. People with avoidant or dependent personality disorders may avoid new people or experiences, showing a lack of confidence, excessive need for care, and a fear of abandonment. Some of these categories have been controversial, as many researchers argue that some disorders overlap significantly, making it difficult to distinguish them. For instance, narcissistic and histrionic personality disorders share many traits, leading to the diagnosis of Personality Disorder Not Otherwise Specified (PDNOS) in many cases. This suggests that while clinicians can recognize a personality disorder, determining the specifics can be messy and challenging.

One proposed alternative for diagnosing these disorders is the Dimensional Model, which replaces discrete diagnoses with a spectrum of personality traits or symptoms. Rather than categorizing someone into a single disorder, this model assesses each trait and rates the person on various dimensions. The Dimensional Model is still being developed, so the clinical definition of “personality disorder” may evolve in the future.

One of the most studied personality disorders is Borderline Personality Disorder (BPD). Despite the name, people with BPD are not “close” to being healthy. They often use dysfunctional behaviors like outbursts of rage or self-harm to meet their psychological needs for love and validation. BPD was once labeled as “attention-seeking” but is now understood as a complex set of learned behaviors, often stemming from traumatic or neglectful childhood environments. People with BPD may learn that anger or self-harm helped them cope with trauma, but they continue using these coping mechanisms even in non-traumatic situations. Though BPD is challenging for both patients and clinicians, some therapies have been successful, even with severely hospitalized patients.

Arguably the most famous and troubling personality disorder is Antisocial Personality Disorder (ASPD), also known as psychopathy or sociopathy. People with ASPD, usually men, lack conscience or empathy for wrongdoing, even toward friends or family. Their destructive behaviors often begin in childhood or adolescence, with excessive lying, violence, theft, or manipulation. As adults, they may either struggle with criminal behavior or become charming con-artists or ruthless executives in positions of power. Figures like Tony Soprano could be diagnosed with ASPD, though not as extreme as serial killers like Ted Bundy or Vlad the Impaler.

Despite the common traits of remorselessness, lack of empathy, and sometimes criminal behavior, not all antisocial individuals engage in crime. Many who have criminal records do not fit the psychopathic profile, as they feel remorse and care for their loved ones. However, antisocial personalities make up about 1% of the general population, yet are estimated to constitute 16% of the incarcerated population.

The causes of ASPD likely involve a combination of genetic and environmental factors. Twin and adoption studies show that relatives of individuals with psychopathic traits are more likely to engage in similar behaviors. Early signs of ASPD can appear as young as age three or four, often as a lack of fear response to frightening stimuli, such as loud noises. Children who develop ASPD may fail to learn the consequences of their actions, making it harder for them to connect with others’ feelings. Research has also linked ASPD symptoms to deficiencies in certain brain areas, particularly the frontal lobe, which is responsible for impulse control and aggression regulation.

Although most people with ASPD don’t seek treatment due to their ego-syntonic nature, some promising interventions exist for children and adolescents, whose brains are more adaptable. Early identification of Conduct Disorder, a precursor to ASPD, and intervention can help steer children away from destructive behaviors, possibly redirecting their energy toward more positive outlets, like athletics or adventure.

It’s important to remember that Antisocial Personality Disorder is only one type of personality disorder. This group of disorders is diverse, and research into their biological, psychological, and social roots is ongoing. Today, we explored the difference between ego-dystonic and ego-syntonic disorders, the three clusters of personality disorders, and how symptoms often overlap. We also examined Borderline and Antisocial Personality Disorders, their potential origins, and the current understanding of their treatment.