personality disorders

Personality disorders (PD) are a class of mental health conditions characterized by enduring maladaptive patterns of behavior, cognition, and inner experience, exhibited across many contexts and deviating from those accepted by the culture. These patterns develop early, are inflexible, and are associated with significant distress or disability. The definitions vary by source and remain a matter of controversy. Official criteria for diagnosing personality disorders are listed in the sixth chapter of the ''International Classification of Diseases'' (ICD) and in the American Psychiatric Association's ''Diagnostic and Statistical Manual of Mental Disorders'' (DSM).

Personality, defined psychologically, is the set of enduring behavioral and mental traits that distinguish individual humans. Hence, personality disorders are characterized by experiences and behaviors that deviate from social norms and expectations. Those diagnosed with a personality disorder may experience difficulties in cognition, emotiveness, interpersonal functioning, or impulse control. For psychiatric patients, the prevalence of personality disorders is estimated between 40 and 60%. The behavior patterns of personality disorders are typically recognized by adolescence, the beginning of adulthood or sometimes even childhood and often have a pervasive negative impact on the quality of life.

Treatment for personality disorders is primarily psychotherapeutic. Evidence-based psychotherapies for personality disorders include cognitive behavioral therapy and dialectical behavior therapy, especially for borderline personality disorder. A variety of psychoanalytic approaches are also used. Personality disorders are associated with considerable stigma in popular and clinical discourse alike. Despite various methodological schemas designed to categorize personality disorders, many issues occur with classifying a personality disorder because the theory and diagnosis of such disorders occur within prevailing cultural expectations; thus, their validity is contested by some experts on the basis of inevitable subjectivity. They argue that the theory and diagnosis of personality disorders are based strictly on social, or even sociopolitical and economic considerations.

Classification and symptoms

The two latest editions of the major systems of classification are:
* the International Classification of Diseases (11th revision, ICD-11) published by the World Health Organization
* the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition, DSM-5) by the American Psychiatric Association.

The ICD is a collection of alpha-numerical codes which have been assigned to all known clinical states, and provides uniform terminology for medical records, billing, statistics and research. The DSM defines psychiatric diagnoses based on research and expert consensus. Both have deliberately aligned their diagnoses to some extent, but some differences remain. For example, the ICD-10 included ''narcissistic personality disorder'' in the group of ''other specific personality disorders'', while DSM-5 does not include ''enduring personality change after catastrophic experience''. The ICD-10 classified the DSM-5 ''schizotypal personality disorder'' as a form of schizophrenia rather than as a personality disorder. There are accepted diagnostic issues and controversies with regard to distinguishing particular personality disorder categories from each other.

DSM-5

The fifth edition of the ''Diagnostic and Statistical Manual of Mental Disorders'' stresses that a personality disorder is an enduring and inflexible pattern of long duration leading to significant distress or impairment and is not due to use of substances or another medical condition. The DSM-5 lists personality disorders in the same way as other mental disorders, rather than on a separate 'axis', as previously. DSM-5 lists ten specific personality disorders: paranoid, schizoid, schizotypal, antisocial, borderline, histrionic, narcissistic, avoidant, dependent and obsessive–compulsive personality disorder. The DSM-5 chapter on personality disorders also contains three diagnoses for conditions not matching these ten disorders, which nevertheless exhibit characteristics of a personality disorder:
* Personality change due to another medical conditionpersonality disturbance due to the direct effects of a medical condition
* Other specified personality disorderused when recording the presence of personality disorder along with the reasons for the condition not being classified as one of the specific personality disorders.
* Unspecified personality disorderused when a patient presents with personality disorder symptoms that cause distress or impairment, but the clinician either chooses not to indicate the specific reason these criteria are not met for any one disorder, or there isn’t enough information available to make a more precise diagnosis.
The specific personality disorders are grouped into the following three clusters based on descriptive similarities:

Cluster A (odd or eccentric disorders)

People with these disorders can be paranoid and have difficulty being understood by others, as they often have odd or eccentric modes of speaking and an unwillingness and inability to form and maintain close relationships.
* Paranoid personality disorderpattern of irrational suspicion and mistrust of others, interpreting motivations as malevolent
* Schizoid personality disordercold affect and detachment from social relationships, apathy, and restricted emotional expression
* Schizotypal personality disorderpattern of extreme discomfort interacting socially, and distorted cognition and perceptions
Significant evidence suggests a small proportion of people with Cluster A personality disorders, especially schizotypal personality disorder, have the potential to develop schizophrenia and other psychotic disorders. These disorders also have a higher probability of occurring among individuals whose first-degree relatives have either schizophrenia or a Cluster A personality disorder.

Cluster B (dramatic, emotional, or erratic disorders)

Cluster B personality disorders are characterized by dramatic, impulsive, self-destructive, emotional behavior and sometimes incomprehensible interactions with others.

* Antisocial personality disorderpervasive pattern of disregard for and violation of the rights of others, lack of empathy, lack of remorse, callousness, bloated self-image, and manipulative and impulsive behavior
* Borderline personality disorderpervasive pattern of abrupt emotional outbursts, fear of abandonment, unhealthy attachment, altered empathy, and instability in relationships, self-image, identity, behavior and affect, often leading to self-harm and impulsivity
* Histrionic personality disorderpervasive pattern of attention-seeking behavior, including excessive emotions, an impressionistic style of speech, inappropriate seduction, exhibitionism, and egocentrism
* Narcissistic personality disorderpervasive pattern of grandiosity, haughtiness, intense anger towards criticism, overwhelming envy, need for admiration, deceptive and vindictive tendencies, and lack of empathy (and, in more severe expressions, criminal behavior remorse).

Cluster C (anxious or fearful disorders)

Cluster C personality disorders are characterised by a consistent pattern of anxious thinking or behavior.
* Avoidant personality disorderpervasive feelings of social inhibition and inadequacy, and extreme sensitivity to negative evaluation
* Dependent personality disorderpervasive psychological need to be cared for by other people
* Obsessive–compulsive personality disorderrigid conformity to rules, perfectionism, and control to the point of exclusion of leisurely activities and friendships (distinct from obsessive–compulsive disorder)

DSM-5 general criteria

The DSM-5 provides a definition and six criteria for a general personality disorder, which should be met by all personality disorder cases before a more specific diagnosis can be made. The DSM-5 indicates that any of its ten personality disorder diagnoses is subject to the following criteria for ''General Personality Disorder'':
* There is an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual's culture. This pattern is manifested in two (or more) of the following areas:
** Cognition (i.e., ways of perceiving and interpreting self, other people, and events)
** Affectivity (i.e., the range, intensity, lability, and appropriateness of emotional response)
** Interpersonal functioning
** Impulse control
* The enduring pattern is inflexible and pervasive across a broad range of personal and social situations.
* The enduring pattern leads to clinically significant distress, or impairment in functioning, in social, occupational, or other important areas.
* The pattern is stable and of long duration, and its onset can be traced back at least to adolescence or early adulthood.
* The enduring pattern is not better explained as a manifestation or consequence of another mental disorder.
* The enduring pattern is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., head trauma).

DSM-5 Alternative model

The Alternative DSM-5 Model for Personality Disorders (AMPD) presents a dimensional approach to diagnosis, contrasting with traditional categorical systems. It aims to address several limitations of categorical systems, particularly the issues imprecision of excessive comorbidity. This model evaluates personality pathology through two fundamental components: impaired personality functioning and pathological personality traits.

Personality functioning is assessed across self and interpersonal domains. The self domain encompasses identity and self-direction, while the interpersonal domain includes capacity for empathy and intimacy. Clinicians rate the degree of impairment using the Level of Personality Functioning Scale (LPFS), which ranges from 0 (little or no impairment) to 4 (extreme impairment).

The model identifies five broad trait domains that characterize pathological personality expression: Negative Affectivity, Detachment, Antagonism, Disinhibition, and Psychoticism. These domains are further divided into 25 specific trait facets that provide detailed characterization of individual presentations.

For diagnosis, the AMPD requires that these difficulties must be pervasive across situations and stable over time, typically emerging in adolescence or early adulthood. The disturbances cannot be better explained by other mental disorders, substance use, medical conditions, or attributed to developmental stages or sociocultural contexts.

The AMPD includes six specific personality disorders: antisocial, avoidant, borderline, narcissistic, obsessive-compulsive, and schizotypal. It excludes four personality disorder categories (dependent, histrionic, paranoid, and schizoid) that are present in the standard model. For cases that don't meet criteria for specific disorders but still show significant impairment, the model provides the Personality Disorder-Trait Specified (PD-TS) category, which documents the particular pattern of functional impairment and pathological traits.

ICD-11

The ICD-11 classification of personality disorders is an implementation of a dimensional model of personality disorders, meaning that individuals are assessed along continuous trait dimensions, with personality disorders reflecting extreme or maladaptive variants of traits that are continuous with normal personality functioning, and classified according to both severity of dysfunction and prominent trait domain specifiers. The ICD-11 classification of personality disorders differs substantially from the one in the previous edition, ICD-10; all distinct PDs have been merged into one: ''personality disorder'' (), which can be coded as '' mild'', ''moderate'', '' severe'', or '' severity unspecified''.

Severity is determined by the level of distress experienced and degree of impairment in day to day activities as a result of difficulties in aspects of self-functioning, (e.g., identity, self-worth and agency) and interpersonal relationships (e.g., desire and ability for close relationships and ability to handle conflicts), as well as behavioral, cognitive, and emotional dysfunctions. There is also an additional category called '' personality difficulty'' (), which can be used to describe personality traits that are problematic, but do not meet the diagnostic criteria for a PD. A personality disorder or difficulty can be specified by one or more of the following '' prominent personality traits or patterns'' (): Negative affectivity, Detachment, Dissociality, Disinhibition, and Anankastia. In addition to the traits, a ''Borderline pattern'' () ''–'' similar in nature to borderline personality disorder – may be specified.

In the ICD-11, any personality disorder must meet all of the following criteria:

* There is an enduring disturbance characterized by problems in functioning of aspects of the self (e.g., identity, self-worth, accuracy of self-view, self-direction), and/or interpersonal dysfunction (e.g., ability to develop and maintain close and mutually satisfying relationships, ability to understand others' perspectives and to manage conflict in relationships).
* The disturbance has persisted over an extended period of time (e.g., lasting 2 years or more).
* The disturbance is manifest in patterns of cognition, emotional experience, emotional expression, and behaviour that are maladaptive (e.g., inflexible or poorly regulated).
* The disturbance is manifest across a range of personal and social situations (i.e., is not limited to specific relationships or social roles), though it may be consistently evoked by particular types of circumstances and not others.
* The symptoms are not due to the direct effects of a medication or substance, including withdrawal effects, and are not better accounted for by another mental disorder, a disease of the nervous system, or another medical condition.
* The disturbance is associated with substantial distress or significant impairment in personal, family, social, educational, occupational or other important areas of functioning.
* Personality disorder should not be diagnosed if the patterns of behaviour characterizing the personality disturbance are developmentally appropriate (e.g., problems related to establishing an independent self-identity during adolescence) or can be explained primarily by social or cultural factors, including socio-political conflict.

ICD-10

The ICD-10 lists these general guideline criteria:
* Markedly disharmonious attitudes and behavior, generally involving several areas of functioning, e.g. affectivity, arousal, impulse control, ways of perceiving and thinking, and style of relating to others;
* The abnormal behavior pattern is enduring, of long standing, and not limited to episodes of mental illness;
* The abnormal behavior pattern is pervasive and clearly maladaptive to a broad range of personal and social situations;
* The above manifestations always appear during childhood or adolescence and continue into adulthood;
* The disorder leads to considerable personal distress but this may only become apparent late in its course;
* The disorder is usually, but not invariably, associated with significant problems in occupational and social performance.
The ICD adds: "For different cultures it may be necessary to develop specific sets of criteria with regard to social norms, rules and obligations." Chapter V in the ICD-10 contains the mental and behavioral disorders and includes categories of personality disorder and enduring personality changes. They are defined as ingrained patterns indicated by inflexible and disabling responses that significantly differ from how the average person in the culture perceives, thinks, and feels, particularly in relating to others.

The specific personality disorders () are: paranoid, schizoid, dissocial, emotionally unstable (borderline type and impulsive type), histrionic, anankastic, anxious (avoidant) and dependent. This category also includes '' Other specific personality disorders'' (includes PDs characterized as eccentric, '' haltlose'', immature, narcissistic, passive–aggressive, or psychoneurotic), as well as '' Personality disorder, unspecified'' (includes "character neurosis" and " pathological personality"). In addition to specific PDs, there are also the following categories:
* ''Mixed and other personality disorders'' (; defined as conditions that are often troublesome but do not demonstrate the specific pattern of symptoms in the named disorders).
* ''Enduring personality changes, not attributable to brain damage and disease'' (; for conditions that seem to arise in adults without a diagnosis of personality disorder, following catastrophic or prolonged stress or other psychiatric illness).

Other personality types and Millon's description

Some types of personality disorder were in previous versions of the diagnostic manuals but have been deleted. Examples include sadistic personality disorder (pervasive pattern of cruel, demeaning, and aggressive behavior) and self-defeating personality disorder or masochistic personality disorder (characterized by behavior consequently undermining the person's pleasure and goals). They were listed in the DSM-III-R appendix as "Proposed diagnostic categories needing further study" without specific criteria. Psychologist Theodore Millon, a researcher on personality disorders, and other researchers consider some relegated diagnoses to be equally valid disorders, and may also propose other personality disorders or subtypes, including mixtures of aspects of different categories of the officially accepted diagnoses. Theodore Millon (2004).
Personality Disorders in Modern Life
.'' Wiley, 2nd Edition. .
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. Millon proposed the following description of personality disorders:

Additional factors

In addition to classifying by category and cluster, it is possible to classify personality disorders using additional factors such as severity, impact on social functioning, and attribution.Murray, Robin M. et al (2008). ''Psychiatry. Fourth Edition''. Cambridge University Press. .

Presentation

Comorbidity

It is common for patients with a personality disorder to develop symptoms of another kind, co-occurring. Patients who meet the DSM-IV-TR diagnostic criteria for one personality disorder are likely to meet the diagnostic criteria for another. Psychotic, affective, and anxiety disorders are usually the most common among personality disorders. This can lead to not diagnosing personality disorders. While diagnostic categories provide clear, vivid descriptions of discrete personality types, personality structure of actual patients might be more accurately described by a constellation of maladaptive personality traits. Developing more than one personality disorder leads to higher limitations when doing everyday activities and a greater tendency for suicidal behavior. It's been found that out of a sample of patients who had attempted suicide, 84% had comorbidity.

''Sites used DSM-III-R criterion sets. Data obtained for purposes of informing the development of the DSM-IV-TR personality disorder diagnostic criteria.''

Abbreviations used: ''PPD – Paranoid Personality Disorder, SzPD – Schizoid Personality Disorder, StPD – Schizotypal Personality Disorder, ASPD – Antisocial Personality Disorder, BPD – Borderline Personality Disorder, HPD – Histrionic Personality Disorder, NPD – Narcissistic Personality Disorder, AvPD – Avoidant Personality Disorder, DPD – Dependent Personality Disorder, OCPD – Obsessive–Compulsive Personality Disorder, PAPD – Passive–Aggressive Personality Disorder.''

The disorders in each of the three clusters may share with each other underlying common vulnerability factors involving cognition, affect and impulse control, and behavioral maintenance or inhibition, respectively. They may also have a spectrum relationship to certain syndromal mental disorders:
* Paranoid, schizoid or schizotypal personality disorders may be observed to be premorbid antecedents of delusional disorders or schizophrenia.
* Borderline personality disorder is seen in association with mood and anxiety disorders, with impulse-control disorders, eating disorders, ADHD, ASD, or a substance use disorder.
* Avoidant personality disorder is seen with social anxiety disorder.

Impact on functioning

It is generally assumed that all personality disorders are linked to impaired functioning and a reduced quality of life (QoL) because that is a basic diagnostic requirement. But research shows that this may be true only for some types of personality disorder. In several studies, higher levels of disability and lower QoL were predicted by avoidant, dependent, schizoid, paranoid, schizotypal and antisocial personality disorders. This link is particularly strong for avoidant, schizotypal and borderline PD. Not being able to fit in society for borderline personality disorder leads to a high risk of suicide, but with treatment, that risk can be reduced. However, obsessive–compulsive PD was not related to a reduced QoL or increased impairment. A prospective study reported that all PD were associated with significant impairment 15 years later, except for obsessive compulsive and narcissistic personality disorder.

One study investigated some aspects of "life success" (status, wealth and successful intimate relationships). It showed somewhat poor functioning for schizotypal, antisocial, borderline, and dependent PD; schizoid PD had the lowest scores regarding these variables. Paranoid, histrionic and avoidant PD were average. Narcissistic and obsessive–compulsive PD, however, had high functioning and appeared to contribute rather positively to these aspects of life success. There is also a direct relationship between the number of diagnostic criteria and quality of life. For each additional personality disorder criterion that a person meets there is an even reduction in quality of life. Another study indicated that negative affectivity predicts suicidal attempts. Personality disorders – especially dependent, narcissistic, and sadistic personality disorders – also facilitate various forms of counterproductive work behavior, including knowledge hiding and knowledge sabotage.

In the workplace

Personality disorders can impact workplace experiences in various ways, depending on the diagnosis, severity, individual, and job context. Some individuals may experience difficulties with interpersonal relationships, communication, or stress management, which can affect workplace dynamics. In addition to the direct effects of personality-related traits, indirect factors such as comorbid mental health conditions, educational challenges, or external life stressors may also influence job performance.

While challenges may exist, individuals with personality disorders can also be in high level positions in the corporate world. In 2005 and again in 2009, psychologists Belinda Board and Katarina Fritzon at the University of Surrey, UK, interviewed and gave personality tests to high-level British executives and compared their profiles with those of criminal psychiatric patients at Broadmoor Hospital in the UK. They found that three out of eleven personality disorders were actually more common in executives than in the disturbed criminals:

* Histrionic personality disorder: including superficial charm, insincerity, egocentricity and manipulation

* Narcissistic personality disorder: including grandiosity, self-focused lack of empathy for others, exploitativeness and independence.

* Obsessive–compulsive personality disorder: including perfectionism, excessive devotion to work, rigidity, stubbornness and dictatorial tendencies.

According to leadership academic Manfred F.R. Kets de Vries, it seems almost inevitable that some personality disorders will be present in a senior management team.

Social functioning

Social function is affected by many other aspects of mental functioning apart from that of personality. However, whenever there is persistently impaired social functioning in conditions in which it would normally not be expected, the evidence suggests that this is more likely to be created by personality abnormality than by other clinical variables. The Personality Assessment Schedule gives social function priority in creating a hierarchy in which the personality disorder creating the greater social dysfunction is given primacy over others in a subsequent description of personality disorder.

Issues

In children and adolescents

Diagnosing personality disorders in children is approached with caution. During childhood and adolescence, personality traits are still forming as well as ongoing cognitive and emotional development. Additionally, diagnosing a child with a personality disorder is followed with a big stigma that can be difficult for a child to face. Rather than focusing on formal diagnoses, clinicians and researchers often emphasize identifying early signs of maladaptive behavior patterns that may become more stable over time. Early stages and preliminary forms of personality disorders need a multi-dimensional and early treatment approach. Personality development disorder is considered to be a childhood risk factor or early stage of a later personality disorder in adulthood.

In addition, in Robert F. Krueger's review of their research indicates that some children and adolescents do experience clinically significant syndromes that resemble adult personality disorders, and that these syndromes have meaningful correlates and are consequential. Much of this research has been framed by the adult personality disorder constructs from Axis II of the Diagnostic and Statistical Manual. Hence, they are less likely to encounter the first risk they described at the outset of their review: clinicians and researchers are not simply avoiding use of the PD construct in youth. However, they may encounter the second risk they described: under-appreciation of the developmental context in which these syndromes occur. That is, although PD constructs show continuity over time, they are probabilistic predictors; not all youths who exhibit PD symptomatology become adult PD cases.

Challenges and considerations

Categorical vs Dimensional Approach

Personality disorders classification (DSM-5 and ICD-10) follows a ''categorical approach'' that views personality disorders as discrete entities that are distinct from each other and from normal personality. In contrast, the dimensional approach suggests that personality disorders exist on a continuum, with traits varying in degree rather than kind. This dimensional perspective may allow for more nuanced understanding and flexible diagnostic practices.

Thomas Widiger, a psychologist, and his collaborators have contributed to this debate significantly. He discussed the constraints of the ''categorical approach'' and argued for the ''dimensional approach'' to personality disorders. Specifically, he proposed the Five Factor Model of personality as an alternative to the classification of personality disorders. For example, this view specifies that Borderline Personality Disorder can be understood as a combination of emotional lability (i.e., high neuroticism), impulsivity (i.e., low conscientiousness), and hostility (i.e., low agreeableness). Many studies across cultures have explored the relationship between personality disorders and the Five Factor Model. This research has demonstrated that personality disorders largely correlate in expected ways with measures of the Five Factor Model and has set the stage for including the Five Factor Model within DSM-5.

In clinical settings, personality disorders are typically diagnosed through comprehensive interviews conducted by psychiatrists or clinical psychologists. These assessments often include a mental status examination and may be informed by collateral reports from family members or close acquaintances.

One structured approach to diagnosis involves standardized interviews accompanied by scoring systems. Patients respond to a series of questions, and trained clinicians evaluate their answers based on predefined diagnostic criteria. Although effective, this method is often time-consuming and resource-intensive, which may limit its practicality in some clinical settings.

As of 2002, there were over fifty published studies relating the five factor model (FFM) to personality disorders. Since that time, a number of additional studies have expanded on this research base and provided further empirical support for understanding the DSM personality disorders in terms of the FFM domains. In her seminal review of the personality disorder literature published in 2007, Lee Anna Clark asserted that "the five-factor model of personality is widely accepted as representing the higher-order structure of both normal and abnormal personality traits". The five factor model has been shown to significantly predict all 10 personality disorder symptoms and outperform the Minnesota Multiphasic Personality Inventory (MMPI) in the prediction of borderline, avoidant, and dependent personality disorder symptoms.

Research results examining the relationships between the FFM and each of the ten DSM personality disorder diagnostic categories are widely available. For example, in a study published in 2003 titled "The five-factor model and personality disorder empirical literature: A meta-analytic review", the authors analyzed data from 15 other studies to determine how personality disorders are different and similar, respectively, with regard to underlying personality traits. In terms of how personality disorders differ, the results showed that each disorder displays a FFM profile that is meaningful and predictable given its unique diagnostic criteria. With regard to their similarities, the findings revealed that the most prominent and consistent personality dimensions underlying a large number of the personality disorders are positive associations with neuroticism and negative associations with agreeableness.

Openness to experience

At least three aspects of openness to experience are relevant to understanding personality disorders: cognitive distortions, lack of insight (means the ability to recognize one's own mental illness) and impulsivity. Problems related to high openness that can cause problems with social or professional functioning are excessive fantasising, peculiar thinking, diffuse identity, unstable goals and nonconformity with the demands of the society.

High openness is characteristic to schizotypal personality disorder (odd and fragmented thinking), narcissistic personality disorder (excessive self-valuation) and paranoid personality disorder (sensitivity to external hostility). Lack of insight (shows low openness) is characteristic to all personality disorders and could help explain the persistence of maladaptive behavioral patterns.

The problems associated with low openness are difficulties adapting to change, low tolerance for different worldviews or lifestyles, emotional flattening, alexithymia and a narrow range of interests. Rigidity is the most obvious aspect of (low) openness among personality disorders and that shows lack of knowledge of one's emotional experiences. It is most characteristic of obsessive–compulsive personality disorder; the opposite of it known as impulsivity (here: an aspect of openness that shows a tendency to behave unusually or autistically) is characteristic of schizotypal and borderline personality disorders.

Causes

Personality disorders (PDs) are complex conditions influenced by a combination of genetic, environmental, and experiential factors. These disorders emerge from the interaction of multiple determinants, making the precise causes difficult to identify. Environmental factors play a significant role in the development of personality disorders. These include prenatal conditions, childhood trauma, abuse, neglect, and other adverse childhood experiences. Possible genetic and neurobiological causes have also been identified.

Complex causality

The development of personality disorders cannot be attributed to a single cause. Instead, it is the result of a combination of multiple interacting factors. These factors include genetic predispositions, environmental influences, and life experiences. There are three primary types of causes involved in the development of personality disorders:

* Necessary causes: These are factors that must precede another event for it to occur but are not sufficient by themselves to cause the disorder. For example, a genetic mutation might be necessary for the development of schizophrenia, but other factors would still be required for the disorder to manifest.
* Sufficient causes: These factors are capable of causing pathology on their own. A sufficient cause does not require the presence of other factors to result in the development of a disorder. For example, severe trauma or a particular neurological defect may be enough to cause a personality disorder without any additional contributing factors.
* Contributory causes increase the likelihood of developing a disorder but are neither necessary nor sufficient on their own. Socioeconomic factors, childhood trauma, or other adverse life events may contribute to the emergence of a personality disorder but are not definitive causes. Genetic factors, early childhood experiences, and developmental conditions increase susceptibility to future psychological issues and make an individual more vulnerable to developing a personality disorder, but do not directly cause it. Precipitating factors, such as a traumatic event or significant life stressor, can activate underlying vulnerabilities, leading to the expression of personality disorders.
The problem of genetic confounding is explained by psychologist Svenn Torgersen in a 2009 review:

Twin studies allow scientists to assess the influence of genes and environment, in particular, how much of the variation in a trait is attributed to the "shared environment" (influences shared by twins, such as parents and upbringing) or the "unshared environment" (measurement error, noise, differing illnesses between twins, randomness in brain growth, and social or non-social experiences that only one twin experienced).

Childhood and parenting

Early childhood experiences, especially those involving primary caregivers, play a significant role in shaping personality traits. Psychoanalytic theories suggest that childhood trauma and early relationships are critical to personality development. However, there is ongoing debate about which specific childhood experiences are most influential.

Abuse and neglect

Child abuse and neglect consistently show up as risk factors to the development of personality disorders in adulthood. A study looked at retrospective reports of abuse of participants that had demonstrated psychopathology throughout their life and were later found to have past experience with abuse. In a study of 793 mothers and children, researchers asked mothers if they had screamed at their children, and told them that they did not love them or threatened to send them away. Children who had experienced such verbal abuse were three times as likely as other children (who did not experience such verbal abuse) to have borderline, narcissistic, obsessive–compulsive or paranoid personality disorders in adulthood. The sexually abused group demonstrated the most consistently elevated patterns of psychopathology. Officially verified physical abuse showed an extremely strong correlation with the development of antisocial and impulsive behavior. On the other hand, cases of abuse of the neglectful type that created childhood pathology were found to be subject to partial remission in adulthood.

Parenting and attachment

Evidence shows personality disorders may begin with parental personality issues. These cause the child to have their own difficulties in adulthood, such as difficulties reaching higher education, obtaining jobs, and securing dependable relationships. By either genetic or modeling mechanisms, children can pick up these traits. Additionally, poor parenting appears to have symptom elevating effects on personality disorders. More specifically, lack of maternal bonding has also been correlated with personality disorders. In a study comparing 100 healthy individuals to 100 borderline personality disorder patients, analysis showed that BPD patients were significantly more likely not to have been breastfed as a baby (42.4% in BPD vs. 9.2% in healthy controls). These researchers suggested "Breastfeeding may act as an early indicator of the mother-infant relationship that seems to be relevant for bonding and attachment later in life". Additionally, findings suggest personality disorders show a negative correlation with two attachment variables: maternal availability and dependability. When left unfostered, other attachment and interpersonal problems occur later in life ultimately leading to development of personality disorders.

Repeated negative or dysfunctional patterns of parent-child interactions can reinforce the development of maladaptive personality traits. For instance, inconsistent or punitive parenting may contribute to the development of anxious or avoidant behaviors in children, which could later manifest as personality disorders.

Genetic

Currently, genetic research for the understanding of the development of personality disorders is severely lacking. However, there are a few possible risk factors currently in discovery. Researchers are currently looking into genetic mechanisms for traits such as aggression, fear and anxiety, which are associated with diagnosed individuals. More research is being conducted into disorder specific mechanisms.

Research indicates that personality disorders have a substantial genetic component. Heritability estimates range from 40% to 50% for various disorders. Twin studies show that genetic factors play a larger role than shared family environment in the development of personality disorders. Specific genetic polymorphisms have been associated with different personality disorders, with disorders like borderline and obsessive-compulsive personality disorder showing strong genetic influences. Endophenotypes, which are heritable traits that correlate with personality disorders, offer further evidence of a genetic link.

Gene–environment interactions occur when genetic predispositions increase an individual’s susceptibility to environmental stressors, such as trauma or maltreatment, and other adverse life events. Such environmental factors can interact with genetic predispositions, increasing the likelihood of developing a personality disorder. For example, individuals with a genetic predisposition to certain traits may be more vulnerable to harsh treatment from caregivers, which could exacerbate or trigger the onset of a disorder. This complex interplay complicates the causal relationship between environmental factors and the emergence of personality disorders.

Socioeconomic status

Socioeconomic status has also been looked at as a potential cause for personality disorders. There is a strong association with low parental/neighborhood socioeconomic status and personality disorder symptoms. In a 2015 publication from Bonn, Germany, which compared parental socioeconomic status and a child's personality, it was seen that children who were from higher socioeconomic backgrounds were more altruistic, less risk seeking, and had overall higher IQs. These traits correlate with a low risk of developing personality disorders later on in life. In a study looking at female children who were detained for disciplinary actions found that psychological problems were most negatively associated with socioeconomic problems. Furthermore, social disorganization was found to be positively correlated with personality disorder symptoms.

Neurobiological

Research shows that several brain regions are altered in personality disorders, particularly: hippocampus up to 18% smaller, a smaller amygdala, malfunctions in the striatum-nucleus accumbens and the cingulum neural pathways connecting them and taking care of the feedback loops on what to do with all the incoming information from the multiple senses; so what comes out is anti-social – not according to what is the social norm, socially acceptable and appropriate.

Management

The management of personality disorders involves a combination of psychotherapeutic, behavioral, and occasionally pharmacological interventions aimed at reducing symptoms, improving interpersonal functioning, and enhancing quality of life. Given the heterogeneous nature of personality disorders, treatment approaches are often tailored to the individual's specific diagnosis, severity, and co-occurring conditions.

The management of personality disorders such as antisocial, avoidant, borderline, dependent , histrionic, narcissistic, obsessive–compulsive, paranoid, schizoid, and schizotypal personality disorder includes medication and therapy.

There is a limited amount of evidence in regards to the treatment of AvPD, DPD, HPD, NPD, OCPD, PPD, SzPD, and StPD. Proposed treatments include behavioural therapy, cognitive therapy, brief psychodynamic treatments, schema therapy, graded exposure, social skills training, psychodynamic psychotherapy, and supportive–expressive psychotherapy for AvPD; clarification-oriented psychotherapy and cognitive therapy for DPD; lifestyle modifications, medication, and psychotherapy such as CBT or group therapy for HPD; psychodynamic therapy, cognitive therapy, and radically open dialectical behaviour therapy for OCPD; CBT for PPD; medication, socialization groups, and psychodynamic psychotherapy for SzPD; and risperidone, olanzapine, and social skills training for STPD.

Treatment guidelines focused on managing ASPD and BPD emphasize treating comorbid diagnoses. For ASPD, NICE guidelines recommend group therapy focused on cognitive and behavioural techniques to manage symptoms. The NICE review for BPD recommended DBT in the treatment of BPD symptoms. The American Psychiatric Association and Cochrane both found that psychotherapy was effective in treating BPD.

There are different specific theories or schools of therapy within many of these modalities. They may, for example, emphasize psychodynamic techniques, or cognitive or behavioral techniques. In clinical practice, many therapists use an 'eclectic' approach, taking elements of different schools as and when they seem to fit to an individual client. There is also often a focus on common themes that seem to be beneficial regardless of techniques, including attributes of the therapist (e.g. trustworthiness, competence, caring), processes afforded to the client (e.g. ability to express and confide difficulties and emotions), and the match between the two (e.g. aiming for mutual respect, trust and boundaries).

Psychotherapy

Individual psychotherapy has been a mainstay of treatment. There are long-term and short-term ( brief) forms. Within individual therapy, various theories and schools of therapy are used. Psychodynamic therapy aims to uncover unconscious conflicts and explore the influence of early experiences on current behavior, particularly helpful for disorders with deep-rooted interpersonal and identity issues. Cognitive Behavioral Therapy (CBT) is widely applied across personality disorders, focusing on managing negative thought patterns and maladaptive behaviors. It is evidence-based and commonly used for avoidant, obsessive-compulsive, and dependent personality disorders. Dialectical Behavior Therapy (DBT), developed specifically for borderline personality disorder, combines behavioral strategies with mindfulness and emotional regulation techniques, effectively reducing self-harm and improving emotional stability. Mentalization-Based Therapy (MBT), initially developed for borderline personality disorder, helps individuals understand their own and others' mental states, and has shown promise for treating antisocial traits, especially in individuals with moderate psychopathy.

Psychosocial

There are many different forms (modalities) of treatment used for personality disorders:Magnavita, Jeffrey J. (2004
Handbook of personality disorders: theory and practice
John Wiley and Sons, .

* Family therapy, including couples therapy.
* Group therapy for personality dysfunction is probably the second most used.
* Psychological-education may be used as an addition.
* Self-help groups may provide resources for personality disorders.
* Milieu therapy, a kind of group-based residential approach, has a history of use in treating personality disorders, including therapeutic communities.
* The practice of mindfulness that includes developing the ability to be nonjudgmentally aware of unpleasant emotions appears to be a promising clinical tool for managing different types of personality disorders.

Behavioral management in childhood

Early interventions focused on parenting strategies can reduce the risk of maladaptive personality development: Punitive methods often result in anxiety, social withdrawal, or aggression. Replacing punitive discipline with supportive and structured methods fosters healthy emotional development. Contingent reward methods may promote dependency on approval. Balancing reward with encouragement of autonomy and self-worth is recommended. Inconsistent parenting contributes to confusion and anxiety. Consistency and structure in discipline help develop adaptive behavior patterns.

Pharmacological

Psychiatric medications are not a primary treatment for personality disorders, but may be prescribed to address co-occurring symptoms such as anxiety, depression, or impulsivity. Common medications include antidepressants (for mood-related symptoms), anxiolytics (used cautiously for short-term anxiety), and antipsychotics (for severe cognitive distortions or paranoid ideation).

NICE

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