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According to the Diagnostic and Statistical Manual V, Revised Edition (American Psychological Association, 2013), Personality disorders are associated with ways of thinking and feeling about oneself and others that significantly and adversely affect how an individual functions in many aspects of life.
The term “Personality Disorder” implies there is something not-quite-right about someone’s personality. However, the term “personality disorder” simply refers to a diagnostic category of psychiatric disorders characterized by a chronic, inflexible, and maladaptive pattern of relating to the world. This maladaptive pattern is evident in the way a person thinks, feels, and behaves. The most noticeable and significant feature of these disorders is their negative effect on interpersonal relationships. A person with an untreated personality disorder is rarely able to enjoy sustained, meaningful, and rewarding relationships with others, and any relationships they do form are often fraught with problems and difficulties.
To be diagnosed with a “personality disorder” does not mean that someone’s personality is fatally flawed or that they represent some freak of nature. In fact, these disorders are not that uncommon and are deeply troubling and painful to those who are diagnosed with these disorders. Studies on the prevalence of personality disorders performed in different countries and amongst different populations suggest that roughly 10% of adults can be diagnosed with a personality disorder (Torgersen, 2005).
Many types of disorders are evidenced by a complete and total deviation from normal and healthy functioning (e.g., epilepsy). However, personality disorders cannot be understood independently from healthy personalities. Since everyone has a personality (but not everyone has epileptic seizures), personality disorders reflect a variant form of normal, healthy personality. Thus, a personality disorder exists as a special case of a normal, healthy personality in much the same way as a square is a special case of the more general construct of a rectangle. Therefore, it is useful for us to begin our discussion of personality disorders by first discussing the broader, more general construct of personality.
What is Personality?
In psychological parlance, “personality” refers to a person’s unique and enduring pattern of thinking, feeling, and behaving. When viewed in this manner it becomes evident that “personality” encompasses nearly every aspect of human experience. Subsequently, our personalities have the potential to greatly impact our well-being. In particular, the quality of our relationships is significantly affected by our personalities. Moreover, because human beings are social creatures, this means our personalities greatly influence our overall success and satisfaction with life. These are pretty bold assertions, so let’s examine why this is so:
Let’s begin by examining the relationship between our personalities and our thoughts, feelings, and behavior.
In each and every moment, we receive enormous amounts of information from everything going on around us in the world. Psychologists use the term “environment” to refer to these external events going on around us. As we receive this information from our environment, it undergoes a subjective, internal process of evaluation and interpretation. We begin with a subjective evaluation of the information detected by our senses (what we see, hear, etc.) Then, an interpretive thought forms about what we think is going on. In addition, the information is assigned some kind of meaning and importance. As this occurs, we will experience an array of feelings, in a varying degrees of intensity, about what we think is going on around us. The intensity of the feelings that arise in us is usually determined by the importance we assign to a particular thought. We tend to have very strong feelings about things that are highly important to us, and less intense feelings about things that are less important. This process of interpretation (our thoughts) and assigning meaning and importance (our feelings about those thoughts) will then determine our behavioral response to these external events in our environment. In other words, what I think and feel determines how I will behave.
Not only does the environment impact our behavior but our behavior will subsequently impact the environment. Therefore, there is a dynamic, interactive exchange between the environment and our personalities (what we think and feel, and how we behave). This interactive exchange creates a circular feedback loop that leads to the development and maintenance of habitual patterns of exchange between a person and their environment. These habitual patterns form the foundation of “personality.” Therefore, the environment influences the development of our personalities, and our personalities’ influence how we respond to the environment.
Before we continue, let’s use an example to illustrate how this circular pattern forms between our personalities (how we think, feel, and behave) and the environment:
Suppose a woman has smiled at me with sincere and genuine kindness, and I have observed this event (the smiling woman being an event occurring in my external environment). However, as I subjectively evaluate what I observed, I incorrectly interpret her smile as a menacing smirk. My interpretation of her smile as a menacing smirk then causes me to become somewhat suspicious about her motivations and I begin to feel worried. I don’t like people smirking at me like that. Maybe she plans to hurt me! Because I suspect malicious intent from this smirking woman, I’m likely to behave in a negative manner. Maybe I’ll make some unkind comment to this “smirking” woman- I’ll show her! Now, because I’ve said something unkind to her, this formerly happy, smiling woman becomes upset with me. She returns the favor and shouts at me, “You’re a jerk!” You see? I was right! I knew she meant to cause me harm.
The above example demonstrates how a circular pattern is formed between the environment and our personalities. It also illustrates that once formed, these patterns are reinforced and maintained over time to create an enduring pattern. Notice that my unique, subjective, internal interpretation of the environment and subsequent thoughts about the environment (the woman is smirking, not smiling), led to my suspicious, wary feelings. These suspicious feelings then led to by my unkind behavior, causing the environment (the smiling woman) to change accordingly (the formerly smiling woman is now upset, and calls me a “jerk”). Since she called me a “jerk” her comment verified my initial (incorrect) interpretation this event (that she was smirking, not smiling), and the feedback loop is thus completed.
Over time, this circular pattern of interactions between people and their environments will cause enduring patterns of internal experience and behavior to develop. In other words, people eventually develop habits of interpreting and responding to the environment that influence the way they experience and interpret their world. These enduring patterns of internal experience and behavior are called “personality traits” and the specific combinations of those traits comprise our personalities. Because of the circular nature of the feedback loop, once these patterns have formed, they are maintained and become fairly stable. So generally, personality traits will not radically change across time or situations. For instance, if someone is typically generous, we don’t expect them to suddenly become miserly.
Flexibility: The Key to a Healthy Personality
Now that we have a better understanding of what is meant by “personality,” let’s return to the original question. What is a personality disorder?
Many psychologists and mental health professionals have struggled with how to define a “disordered” personality, as distinguished from a healthy one. For our purposes, it may be most helpful to think about someone with a healthy personality as a person who accurately interprets their environment. Thus, their subsequent thoughts, feelings, and behaviors reasonably correspond to the reality of their environment. As a result, they can accurately appraise their own strengths, weaknesses, and motivations. Likewise, they can accurately identify the strengths, weaknesses, and motivations of others. Therefore, a person with a healthy personality is someone who can navigate the world effectively, with a minimum of unproductive detours, and who usually manages to steer clear of major storms.
If we were sailors navigating the world on the open seas, we would need to have a set of precisely tuned, highly sophisticated instruments in order to navigate effectively. Our navigational tools would need to be capable of swiftly adjusting to changing conditions (weather conditions, cargo weight, etc.). The same is true of our personalities. In other words, we must be able to adjust our reactions to the specific circumstances of each situation. This means our perceptions and interpretations of the world must not only be accurate, but also nuanced. This requires of our personalities a high degree of flexibility in order to take into account the special needs and circumstances of every unique situation we encounter. Each situation may need to be interpreted differently. Our reactions must be finely tuned and properly adjusted to precisely correspond with the unique demands of each individual situation. Unfortunately, people with personality disorders lack this essential flexibility, and respond to situations and events with a characteristically rigid constellation of thoughts, feelings, and behaviors. This inflexibility, and difficulty forming nuanced responses, represents the primary difference between healthy and disordered personalities.
The question remains, how do we account for this fundamental difference between healthy and unhealthy personalities? The answer seems to lie in the “navigational instruments.” It appears that people with personality disorders are missing an important tool. Research by Fonagy and his colleagues (1996) found that people with personality disorders seem to lack a highly necessary skill called “mentalization.” Mentalization refers to the ability to reflect upon the behaviors, internal states, and motivations of both ourselves and other people. The ability to mentalize may enable people with healthy personalities to adjust their behaviors to the differing demands of each unique situation. In other words, what permits this flexibility may be the capacity to reflect upon one’s own behaviors and motivations, and to reflect upon the behaviors and motivations of others. Thus, the ability to mentalize permits an accurate assessment of each unique situation that renders an appropriate response for that situation.
This concept of flexibility further suggests that what may be a healthy and adaptive response in one circumstance or situation, might be maladaptive in another. Typically, healthy personalities are flexible enough to account for these differences and respond accordingly. Let’s use an example to illustrate this concept. Suppose I work as a receptionist within a prison. It is healthy and advantageous for me to adopt a vigilant approach in this kind of workplace. Thus, it is adaptive for me to be cautious and somewhat suspicious of others because these thoughts, feelings, and behaviors properly match that particular situation and circumstance. Now, imagine what might happen if I attempted to use this same approach in a different workplace setting; say for example, a clothing store. If I am constantly vigilant and distrustful of others, and suspect my co-workers or customers might try to harm me at any moment, I will likely behave in a manner that is overly-guarded, hostile, suspicious, or withholding. This approach would certainly interfere with my performance at the clothing store, and would negatively affect my interactions with co-workers, supervisors, and customers.
This example illustrates what can happen when people attempt to navigate the world with a rigid, inflexible approach. People with healthy personalities would account for the differing demands of each workplace, and would select behaviors appropriate to each one. This flexible approach increases the likelihood they will experience workplace satisfaction and success. In contrast, people with personality disorders, who cannot so easily adjust their approach, will eventually experience dissatisfaction and a lack of success.
While we may intuitively recognize that it is not sensible to use the same approach for every situation, it doesn’t answer, why is this considered adaptive and healthy? The flexibility that is characteristic of people with healthy personalities is considered “adaptive” because their patterns of thoughts, feelings, and behaviors do not usually lead to any significant distress, and ensure a reasonable degree of success and satisfaction. Or, to continue with our metaphor, they navigate their world with few unproductive detours and typically steer clear of major storms. Conversely, the inflexibility that is characteristic of “disordered” personalities is considered maladaptive because it leads to distress, dissatisfaction, and failure. These unfortunate folks frequently experience stormy relationships and repeatedly find themselves in situations that lead to their unhappiness and lack of success. When personality traits consistently cause distress and impair interpersonal relationships, or impair one’s ability to function successfully at work, we then begin to consider the possibility of a personality disorder.
Of course, we all have our issues, conflicts, and hardships that certainly can cause us distress. We don’t behave well all the time. Sometimes we annoy other people. In other words, some storms are inevitable and some detours are difficult to resist. As we mentioned earlier, a personality disorder is a variant form of a normal, healthy personality. Therefore, it is quite reasonable to expect that healthy personalities will experience some difficulty some of the time. In order for a personality disorder to be diagnosed, an enduring pattern needs to be present. This pattern consists of problematic behaviors and traits, starting early in life, observed across many different situations, over a long period of time, that cause significant distress.
Why Don’t People Know They Have a Personality Disorder?
The above-mentioned symptom of “significant distress” is an important diagnostic indicator for all mental disorders. Ordinarily, when someone has a mental disorder they are able to recognize their difficulties and can identify their symptoms of discomfort. Their symptoms cause them a significant amount distress and dissatisfaction, and they are deeply troubled by their difficulties.
This is usually true of people with personality disorders. However, an interesting peculiarity of personality disorders is that some people with personality disorders will routinely experience difficulties in their relationships, and difficulties at work or school, but they do not believe that there is anything wrong. In fact, they may not appear to be bothered much at all. In other words, their personality traits do not appear to be causing them any distress; meanwhile, they are causing distress to everyone around them. When that is the case, it is often the other people in their lives who notice the person is frequently hard to get along with, and difficult to relate to. Such people often seem blissfully unaware of any problem. Meanwhile, it is readily apparent to others that they have great difficulty adapting to life’s ordinary challenges, and often seem to steer directly into storms.
There are several reasons for this lack of awareness.
First, a person may simply not know any differently. They may not know there is a better, alternative way of thinking, feeling, or behaving so they have nothing to compare to their way of being in the world. Consider that if you lived in complete darkness you would have no knowledge of this unless you also had light.
Let’s use a more clinical example: Suppose you’ve only experienced relationships in which you were abused and treated with hostility. You lack experience with the alternative experience of being treated with kindness and respect. In this case, you simply wouldn’t know it is preferable to be treated kindly and therefore you blithely accept mistreatment from others with little concern. If someone expressed to you their shock or alarm about the way you “allow” other people to mistreat you, you simply wouldn’t understand what they were talking about. You could not utilize their feedback because you have no alternative experience with which to compare. Thus, to other people you will appear to be unbothered or unaware of any problem.
Similarly, someone may have grown up with poor role models and may not know how to behave any differently. For example, if a young girl only ever heard her parents yell and scream to get what they wanted, she would not know that people can just as easily ask politely and respectfully for what they want. As a result, she would grow up lacking these critical skills and may not know how to behave differently. Thus, any feedback she might receive later in life about her unpleasant method of getting what she wants would be met with a puzzled gaze. She simply has no idea how she could get what she wants without throwing a temper tantrum.
Another reason for this apparent lack of distress is that for some people, it may simply be too painful, overwhelming, or embarrassing to admit to themselves, and to others, that they are at least partially responsible for some of the problems they experience. So instead, they retreat to a position of thinking the problems they experience are everyone else’s fault. This is perhaps a more comfortable, less painful position to adopt, but not a particularly helpful one.
Let’s further illustrate these concepts with some characteristic patterns that are commonly observed in certain personality disorders. Take the example of someone who does not have any friends. They do not desire any friends, and do not get any pleasure or enjoyment from being with other people. Thus, they see nothing wrong with this and so they are completely unconcerned about their lack of friendship, because having no friends doesn’t cause them any emotional distress. However, to other people they seem aloof, odd, and strange. This would make it difficult for their co-workers or family members, to form a positive relationship with them. This person may never have experienced positive, pleasant interactions with others. Therefore, they simply do not know that friendships can be rewarding and enjoyable. They may not have had role models who enjoyed close relationships, so they are unaware of what they’re missing. Because of this, they will also be missing important social skills that are needed to form comfortable and enjoyable relationships with others. Their lack of social skills makes them seem odder still. This lack of social skills makes any attempt to form friendships awkward and uncomfortable. The result is a personality pattern of social awkwardness and isolation.
Another example is someone who has developed a pattern of behavioral extremes. For instance, any time they feel the least bit ignored by a friend, they wind up cutting that friend out of their life entirely, deciding never to speak to them again. This complete severance of the relationship is less distressing to them than the alternative (such as openly discussing their hurt feelings) so they may see no problem with their response.
There are several reasons for this inability to choose a more comfortable and gentle response. A person may lack the interpersonal skills needed to address conflict in a constructive manner. Lacking these skills, it may be difficult to express themselves in a confident and effective manner. Furthermore, they may be too upset to think clearly about what has happened. They may not be able to “mentalize.” This means they cannot empathize with their friend. Furthermore, it is difficult for them to consider the various reasons their friend ignored them, some of which may have nothing to do with them. It may also be too shameful for them to think about their own contribution to the problem they are having with their friend.
The Definition of a Personality Disorder
The Diagnostic and Statistical Manual of the American Psychiatric Association,(abbreviated, DSM-5), captures these differences between healthy and unhealthy personalities that we have been discussing. According to the definition of personality disorders in DMS-5 (APA 2013), the key elements of a personality disorder are:
1. A personality disorder is enduring pattern of inner experience and behavior. This pattern manifests in two or more of the following areas:
a. Thinking
b. Feeling
c. Interpersonal relationships
d. Impulse control
2. This pattern deviates markedly from cultural norms and expectations.
3. This pattern is pervasive and inflexible.
4. It is stable over time.
5. It leads to distress or impairment
The Four Core Features of Personality Disorders1
The DSM-5 (APA, 2013) identifies and describes ten specific personality disorders. These ten diagnoses represent ten specific enduring patterns of thoughts, feelings, and behavior. However, each of these ten patterns can be distilled down to four core features of personality disorders:
1. Rigid, extreme and distorted thinking patterns (thoughts)
2. Problematic emotional response patterns (feelings)
3. Impulse control problems (behavior)
4. Significant interpersonal problems (behavior)
In fact, in order to diagnose a personality disorder a person must exhibit at least two of these four core features.
In this section we will review each of these four core features that are common to all personality disorders. Then in the next section, we will discuss the ten specific personality disorders diagnoses as described in DSM-IV-TR (APA, 2000). As you are reading about these disorders, you may find yourself wondering if they are accurate enough; if they have been defined with enough precision so as to easily distinguish between people who have personality disorders from those who do not. As mentioned, personality disorders are a variant form of normal, healthy personality so such distinctions are often difficult. If such thoughts occur to you, you are not alone. Quite a few clinicians and researchers have raised concerns about this lack of specificity and precision. Later, we will discuss alternatives to the current DSM diagnostic systems for the personality disorders that attempt to resolve this problem of imprecision.
Since the current diagnostic system for personality disorders is difficult to use for the reasons cited above, we want to caution you to refrain from trying to diagnose yourself, or someone else. The diagnostic process for personality disorders is difficult enough, even for seasoned professionals; therefore, self-diagnosis is not recommended. If you suspect a problem or interpersonal difficulty may be related to a personality disorder, we urge you to raise these concerns with a qualified mental health professional. A professional experienced with the diagnosis and treatment of personality disorders is best able to make a correct diagnosis (having done it many times before).An experienced mental health professional will also be in the best position to recommend an effective treatment plan.. In the later part of this article, we will review effective, state-of-the-art treatments for personality disorders.
Defining Features of Personality Disorders: Distorted Thinking Patterns
People with personality disorders tend to exhibit distortions in the way they interpret and think about the world, and in the way they think about themselves. Not surprisingly, people with personality disorders think about things quite differently than people with healthy personalities. They may have thinking patterns that are very extreme and somewhat distorted. These dysfunctional patterns are most evident when someone attempts to understand their interactions with others. Examples of these problematic interpretations of the self-in-the-world include:
1) extreme black-or-white thinking patterns;
2) patterns of idealizing then devaluing other people or themselves;
3) patterns of distrustful, suspicious thoughts;
4) patterns that frequently include unusual or odd beliefs that are contrary to cultural standards; or,
5) patterns of thoughts that include perceptual distortions and bodily illusions.
Let’s look at these five thought patterns a little more closely:
Black-or-white thinking
Black-or-white thinking can also be referred to as all-or-nothing thinking. Thoughts become polarized as either-or; “always this” or “never that.” Some examples of this type of thinking might be: “I never get anything right!” or, “If I am not brilliant, then I must stupid” or, “A woman can’t have a career and be a stay-home mom” or, “If he does not love me, then he must hate me” or, “If I can’t do this perfectly, then I won’t do it at all!” You can see these kinds of thoughts leave no room for shades of gray and do not allow for compromise, or a consideration of multiple alternatives or possibilities. For instance, the conclusion, “If I am right, then you must be wrong” does not include the possibility that we could both be right, or both be wrong.
Vacillation between idealization and devaluation
A specific type of black-or-white thinking is the tendency to vacillate between over-idealizing, then completely devaluing, other people or oneself. This thinking pattern can be summarized by the statement, “If you are not entirely good, then you must be entirely bad. Most healthy people recognize that we each have some good, and some bad qualities; i.e., we behave well sometimes, but certainly not all the time. However, with a vacillating pattern of extreme thinking, people are seen as either all good, or all bad, but not both.
This distorted thinking pattern can be played out when a client begins to work with a new therapist. Initially, the client sees the therapist is seen as the perfect human being. The therapist is viewed as someone who has all the answers to all their problems, who knows everything, never makes any mistakes, and who will never disappoint or frustrate them. However,the moment there is the slightest indication that the therapist has ordinary human limitations, this idealization quickly becomes disgust or even rage. Sometimes therapists get sick and must miss therapy appointments. Sometimes there is no immediate solution to the client’s problems. Therapists often must say or do things that frustrate clients. When these things occur, the all-good therapist suddenly becomes a completely horrible, incompetent, and ignorant person in their client’s eyes.
This pattern can also be played out in friendships, romantic relationships, or family relationships. In particular, this pattern is quite common during the initial stages of romantic relationships. It is quite common to idealize a new romantic partner. However, healthy adults gradually adopt of more realistic and balanced view of their partner. They come to accept their partner has both strengths and weaknesses. They realize their partner behaves well most of the time, but not always. However, if a person personality disorder has this thinking pattern, they do not easily see these shades of grey. Instead, the moment their partner does something that frustrates, disappoints, or annoys them, their partner suddenly becomes someone who is “all bad” rather than someone who has momentarily engaged in a “bad” behavior. This type of thinking creates a great deal of grief and conflict for everyone. Understandably, partners of such folks are often baffled by this type of thinking. They have difficulty understanding why a single “bad” action suddenly defines the entirety of who they are,
Suspiciousness and distrust
A third pattern of distorted thinking is a heightened level of suspiciousness. This includes being distrustful of others, and believing that most other people are dishonest and potentially harmful. With this pattern of thinking, other people’s actions and motivations are nearly always questioned and considered suspect. A person with this pattern of thinking will interpret even the kindest gestures in a negative way. For example, a simple gift might be interpreted as a disguised attempt to manipulate them. It is very easy to imagine that suspiciousness and distrust can cause tremendous distress, and certainly interferes with the formation healthy and enjoyable relationships with others.
Odd or unusual beliefs
Some people with personality disorders have some very odd beliefs including superstitions, unusual religious beliefs, and worldviews that are extremely out of tune with a person’s culture, religion, and environment. This is not to say that everyone who has religious beliefs or superstitions has a personality disorder. It is very important to emphasize that the beliefs have to be extreme and markedly different from the person’s cultural norms and expectations. By way of example, let’s consider a Christian man who grew up in the United States. Assume he is still living in the USA and he thinks that carrying around a slice of cheddar cheese in his pocket all day will help him get to heaven after death. Many people in the Judeo-Christian culture of the USA believe in heaven and some sort of afterlife. However, the belief that cheese has something to do with heaven and an after-life is certainly uncommon. People from this culture would consider the notion that cheese gets you into heaven, an unusual and odd belief.
Perceptual distortions
Another type of distorted thinking is perceptual distortion. Perceptual distortions are particularly common in people with Schizotypal Personality Disorder. Examples of perceptual distortions are things such as seeing another person’s face morph right before your eyes, but then as you look closer, you realize the face is actually still the same. Another example would be feeling as though someone is calling your name, but when you turn around, no one is there. These perceptual distortions are typically fleeting and the person who experiences them is usually able to distinguish these experiences from reality. In other words, they realize these distortions do not represent a factual event. This is quite different from visual or auditory hallucinations that are indistinguishable from reality by the person who experiences them.
Examples of Personality Disorders With Distorted Thinking Patterns
Let’s look at some examples of specific personality disorders to help illustrate these dysfunctional thinking patterns and the types of interpersonal problems that are created as a result.
For instance, persons with Paranoid Personality Disorders exhibit suspicious thinking and therefore have difficulty trusting other people. They may misinterpret what other people say or do as intentional attempts to attack them, hurt them, or take advantage of them. In turn, they end up holding grudges and may act in ways that are overly defensive, hostile, or even aggressive. You can imagine this thought pattern will cause a lot of anxiety for the person who is paranoid, and that this type guardedness, defensiveness, and hostility is very unpleasant for the other people around them. Obviously, this type of distrust makes close relationships nearly impossible.
People with an Avoidant Personality Disorder tend to think they are completely flawed and inferior to others. Persons with an Avoidant Personality Disorder are unable to recognize both their good and bad qualities. Their extremely negative self-image convinces them that other people see them in the same way (as flawed and inferior). Thus, they are certain no one will like them, and expect others will ridicule them. This leads them to avoid social situations because they anticipate these encounters will be painful and unpleasant experiences. Because of these thoughts, it is unlikely they will have any fun at parties or other social events and so they miss opportunities to have a fulfilling social life. Professionally, they might avoid social situations or avoid public speaking and hence miss out on professional and networking opportunities that usually benefit career development and advancement.
People with Schizotypal Personality Disorders exhibit odd beliefs. They might be extremely superstitious and have unusual beliefs in magic or the supernatural. Other people often find such a person odd and eccentric, and may feel uncomfortable being around someone who holds such strange and unusual ideas. People with Schizotypal Personality Disorder sense they are quite different from others and are often aware that other people seem uncomfortable around them. As a result, they have chronic feelings of just not “fitting in.”
People with Narcissistic Personality Disorder exhibit distorted thinking when they go back and forth between over-idealizing themselves, and then completely devaluing themselves. In addition, they have a tendency to over-estimate the importance or significance of their abilities and talents. Persons with a Narcissistic Personality Disorder frequently have fantasies of having unlimited power, success, or special talents. These over-idealized beliefs about themselves can cause them to behave in ways that are arrogant, ruthless, and entitled. Such behavior frequently causes a lot of conflict with others. For example, a person with a Narcissistic Personality Disorder may ignore the social custom of waiting in a queue to purchase a ticket. Instead, they will march to the front of the queue, believing they are more important than the other people in line and are therefore entitled to special treatment. Of course, the people waiting politely in the queue do not respond well and conflict erupts. Eventually, the person with Narcissistic Personality Disorder is likely to run into a situation in which they realize they have some normal, human limitations. When this occurs, they are likely to find it extraordinarily difficult to cope with this realization. Any inkling of failure is hard for them to tolerate. The sudden realization of ordinary human limitations typically leads them to completely debase themselves, shifting from the over-idealized fantasy of unlimited success and special powers, to a devastating and paralyzing sense of complete worthlessness, shame, and defeat.
The pattern of black-or-white thinking is quite common in those with Borderline Personality Disorder. Things tend to be “all or nothing”, “black or white”, “all good, or all bad.” This way of viewing the world can create a lot of emotional suffering and is particularly devastating in relationships. Other people are seen as either “all good” meaning they are perfectly loving and available to meet their needs at all times, or they are “all bad” meaning they are malicious and hateful, with no shades of grey in between. Sometimes, their view of another person can shift in just a few seconds from “that person is completely wonderful” to “that person is horrible.” Take the example of a woman thinking that her partner is the most caring and loving person in the world. Of course, no one can achieve such a perfect ideal all the time so when her partner does one unloving or thoughtless act, such as forgetting their anniversary, the immediate conclusion becomes “He doesn’t love me. He is so mean and horrible.” Sometimes, it doesn’t stop there, because “If he doesn’t love me, he must hate me.” It is easy to understand that this pattern of interpreting relationships creates great distress and will provoke an intense emotional reaction in people who think like this. Subsequently, their partners may be quite baffled and distressed by these extreme ways of thinking. In such cases, conflict is likely to be frequent.
It is important to note that even healthy, well-adjusted people without a personality disorder can also occasionally fall prey to some of the distorted thinking that we just described as characteristic of personality disorders. In fact, distorted thinking is quite common when people are feeling very distressed, depressed, or anxious. Again, recall that personality disorders are a variant form of normal, healthy personality so the difference is in the frequency, degree, and persistence of the distortion. For people with personality disorders the degree of their distortion is more extreme and occurs with greater frequency than for those people without a personality disorder. Additionally, people with personality disorders find it much more difficult to become aware of, and to challenge their distorted thinking.
As we have seen from these examples, distorted thinking patterns can impact both how a person feels, and how they behave. Recall, a person must exhibit at least two of the four core features that are characteristic of personality disorders before they will qualify for a diagnosis. This means someone who exhibits distorted thinking patterns would also have to exhibit at least one more characteristic before it is appropriate for them to receive a personality disorder diagnosis. This leads us to the second core feature of personality disorders: problematic affective (emotional) response patterns.
Defining Features of Personality Disorders: Problematic Emotional
Response Patterns
People with personality disorders exhibit characteristic, emotional response patterns that can become problematic. Generally, each of the personality disorders has an emotional response pattern that is associated with that particular disorder. This inflexible pattern of emotional response often creates difficulty. Some personality disorders are characterized by emotional sensitivity and a tendency to experience feelings with great intensity. Other personality disorders are characterized by little or no emotional response, regardless of the circumstance or situation. Yet another set of disorders are characterized by bouncing back and forth between these two extremes: from being overwhelmed with intense emotions one moment, to feeling numb and disconnected in the next.
Some theorists understand this aspect of personality disorders as a problem of emotional regulation; some disorders are characterized by a tendency to under-regulate emotions, whereas others tend to over-regulate emotions. This differs from a healthy personality where we expect a full range of emotional intensity from controlled to fully expressive. This range is dictated by the situation and circumstance. Of course, people with healthy personalities will occasionally get overwhelmed with emotions, or can feel emotionally detached at times. Similar to the distorted thinking patterns we discussed earlier, the problem for people with personality disorders is the extreme degree and persistence of their dys-regulated affect.
In addition, people with healthy personalities tend to understand when it is beneficial to express a particular emotion, and when it is best to restrict its expression. In other words, people with healthy personalities have learned that there are times when it is wise and appropriate to fully express a particular emotion. At other times it is best to regulate or restrict its expression, or to dampen down its intensity. Having decided just how much emotion is appropriate to display, they then display only the appropriate amount, knowing just how to do that. As we have emphasized previously, a key feature of healthy personalities is flexibility. Healthy personalities have a flexible range of affective responses that properly consider the time, place, and circumstance.
Unfortunately, persons with personality disorders are not nearly as flexible. Depending upon the type of personality disorder, affective (emotional) features can range from being very constricted, indifferent, cold, and experiencing little pleasure in life; to rapidly changing and wildly fluctuating emotions, often expressed with great intensity and dramatic flair. In some personality disorders this lack of flexibility surrounding emotional expression leads to problems with chronic anger and irritability, problems with extreme anxiety, or a complete lack of empathy.
Examples of personality disorders with problematic emotional response patterns
Just as we did before when we considered disordered thinking patterns, let’s look at some examples of specific personality disorders to illustrate these problematic emotional response patterns, and the types of interpersonal problems that are created a result.
People with Schizoid Personality Disorder are at the over-regulated end of the affective spectrum and appear emotionally constricted and indifferent. They tend to experience little or no pleasure in things, seem indifferent to praise or criticism, and come across as detached, cold, and unexpressive. To other people, they seem unfeeling, unresponsive, and insensitive and are thus unlikely candidates for friendships of any sort. On the other side of the affective spectrum is the Histrionic Personality Disorder, which represents emotional under-regulation. This disorder is characterized by an extremely reactive emotional pattern that shifts very rapidly. These people tend to be rather dramatic in their emotional expression to such an extent they seem to be disingenuous, shallow, and insincere. Other people will often react to their intense emotional expression with discomfort, and regard the rapidly shifting emotions with a sense of disbelief or distrust.
For persons with Avoidant Personality Disorders, the anxiety they experience in social situations and their fear of being inadequate, rejected, and ridiculed, dominates their emotional life and interferes with their ability to function. Their high level of anxiety causes them to avoid social situations such as parties and other social gatherings. Typically, people with Avoidant Personality Disorder have only a small number of close friends. Similarly, for people with Dependent Personality Disorder, anxiety dominates their affective experience. However, in contrast to those with Avoidant Personality Disorder who prefer to avoid relationships, people with a Dependent Personality Disorder are preoccupied with fears of being alone, fears of separation and abandonment, and fears of not being taken care of by others. Their anxiety over the possibility of losing important caregivers and their fear of being unable to take care of themselves can make it very difficult for them to stand up for themselves. Consequently, they may tolerate mistreatment, and avoid conflict at the expense of their dignity and self-respect.
The Borderline Personality Disorder provides an example of the affective pattern of experiencing both emotional extremes; from highly intense and dys-regulated emotions, to the extreme opposite– feelings of numbness and detachment. Persons with Borderline Personality Disorder tend to be highly sensitive and react with great emotional intensity. They have powerful feelings in the context of interpersonal relationships particularly when difficulties and conflict cause them to feel intensely anxious, angry, or down. During interpersonal conflicts they become easily overwhelmed with the intensity of their emotions, and may have a hard time calming down once they are upset. At other times, people with Borderline Personality Disorder can rapidly shift to the polar opposite and suddenly feel completely disconnected, numb, empty, and detached. Many people with Borderline Personality Disorder end up injuring or harming themselves in reaction to this emptiness and the accompanying feelings of numbness. Other people tend to react with fear or anger to their rapidly shifting emotional states and their self-injurious behavior. This only serves to escalate interpersonal conflict. Therefore, interpersonal relationship difficulties and conflicts are a common consequence of the intense, rapidly fluctuating emotions associated with this disorder.
For most of us, an emotion is connected to an urge to “do something”. For instance, when we get angry, we may have an urge to verbally or even physically attack the other person with whom we feel angry. When we feel anxious, we may have an impulse to run away or avoid the situation that is frightening us. Healthy people do not typically act upon these impulses if the action associated with the impulse is not situationally appropriate. However, for people with Borderline Personality Disorder, emotions may become so intense that it becomes difficult for them to avoid acting on these impulsive urges; regardless of the whether it is wise or healthy to do so. For example, a diagnostic criterion for Borderline Personality Disorder is outbursts of intense anger that often result in yelling, throwing things, or even hitting other people. It is not simply the intensity of the emotion that causes these dangerous outbursts. Most of us at one time or another have experienced some form of intense anger, or even rage. Rather, problems occur when intense emotion is coupled with a lack of impulse control. As we will see in the next section, this issue of self-control is another defining feature of personality disorders.
Defining Features of Personality Disorders: Impulse Control Problems
People with personality disorders tend to exhibit problems with impulse control. These problems can manifest as either over-controlled or under-controlled impulses. (Under-controlled impulse control is commonly called a “lack of impulse control”. In the same manner that people with personality disorders may have problems with over- or under-controlled affective (emotional) regulation, they also tend to have problems regulating their impulses. Here, too, we can think of impulse regulation along a continuum ranging from over-control to under-control, with healthy personalities falling somewhere in the middle between these two extreme poles.
Consider the issue of self-control and the need for a healthy balance between overcontrol and under-control. On the one hand, we need to control our impulses and to consider the consequences of acting upon an impulse. Having considered the consequences, we then decide how to act accordingly. We determine whether to allow ourselves to indulge the impulse, or whether to inhibit it. The inhibition of certain impulses enables us to behave in ways that are both responsible and socially acceptable. Therefore, in some circumstances the inhibition of our impulses serves to promote our success in both relationships and in the workplace. Two areas of particular concern are aggressive and sexual impulses. If we were to act on our every aggressive or sexual impulse, we would easily get ourselves into a great deal of trouble. On the other hand, the over-control of impulses leads to its own set of problems. A certain amount of carefully considered risk-taking is necessary to reap the benefits of creative expression, rewarding relationships, and successful problem-solving. Some amount of risk-taking is part of the excitement, fun, and spontaneity associated with an enjoyable life. With too much impulse control, we end up feeling restricted, bored, and dull; with too little we can get ourselves into a great deal of trouble. Clearly, a balance between these two extreme poles of over- and under-control would represent a healthy personality.
The challenge to strike the right balance of impulse control affects everyone from time-to-time, including people with healthy personalities. We all have had occasions where we behaved irresponsibly, or unwisely chose to act upon an impulse. At other times, we may have been too controlled, failing to take a risk that would have ultimately benefitted us. Once again, flexibility enables healthy personalities to achieve the proper balance of impulse control most of the time. People with personality disorders are distinguished by the rigidity of their pattern of over- or under-control, and the severity and persistence of their impulse control problems. Rigid and persistent over-control of impulse can manifest itself as inhibition, reluctance to do anything that involves any type of uncertainty or risk, reluctance to start new things or try new activities, and over-conscientiousness or scrupulousness. Rigid and persistent under-control can manifest itself as recklessness and a disregard for rights and needs of other people. This pattern can lead to troublesome or dangerous problems such as drug use, dangerous or risky sexual liaisons, over-spending, assault, or self-injury.
Examples of personality disorders with impulse control problems
Now let’s look at some examples of specific personality disorders to illustrate these problems of over- or under-control of impulses.
On the over-controlled side of the continuum is the Avoidant Personality Disorder. People with this disorder are afraid to try new things for fear of embarrassment, and fear of ridicule. They hold back when they are with other people and can come across as stiff and constricted. They lack spontaneity as every action must be considered for its potential to result in embarrassment or ridicule. Subsequently, people with this disorder end up missing out on some of life’s unplanned but enriching adventures. Similarly, people with Obsessive-Compulsive Personality Disorder also tend to over-control their impulses. Overly worried about rules and regulations, they can be very scrupulous, and tend to be excessively focused on conscientiousness, morals, and ethics. Preoccupied with lists, and a rigid sense of right and wrong, they rivet their attention toward the smallest details and become unable to complete a task; i.e., they become so distracted by so many small details that they can’t see the forest for the trees.
On the other side of the continuum are problems with under-control, or more commonly stated, a lack of impulse control. This lack of impulse control can manifest itself as failure to plan ahead or to think about the long-term consequences. Lack of impulse control is evidenced by such things as impulsive spending; risky sexual behavior; combative and assaultive behaviors; substance abuse; recklessness and excessive risk-taking; gambling; and binge eating. The Antisocial Personality Disorder provides a prime example of these problems with impulse control. Persons with this disorder don’t really plan ahead and this type of reckless disregard can cause them to engage in risky behavior merely because it feels good in that one moment. They do not consider the consequences of their behavior, nor its effect on other people or themselves. This is how they end up breaking the law, getting themselves into trouble, and hurting others.
People with Borderline Personality Disorder can have similar problems. As mentioned previously, for someone with Borderline Personality Disorder, the inability to regulate their intense emotions when coupled with poor impulse control can lead to dire consequences. An emotion can become so intense that it becomes very difficult to avoid acting upon the immediate impulse or the urge to do something. Powerful negative emotions such as anger, coupled with a lack of impulse control, will often have disastrous results such as assault or self-injury. Some impulsive behaviors such as alcohol or other drug use, risky sex, and binge eating can also function as coping mechanisms for people with Borderline Personality Disorder. These behaviors may represent ineffective attempts to cope with intense and difficult emotions. These behaviors are dysfunctional because while the behavior may enable the person feel relieved and better in the moment, it ultimately has harmful long-term consequences.
As we have emphasized throughout, these first three core features of personality disorders 1) problems with disordered thinking, 2) problems with affective regulation (feeling), and 3) problems with impulse control (behavior) all have a profound and negative impact upon interpersonal relationships. As a result, the fourth core feature of personality disorders, which we are about to discuss, is considered the most significant and defining feature of all personality disorders.
The Most Significant, Defining Featured of Personality Disorders: Interpersonal Difficulties
Problems with interpersonal relationships are common to all personality disorders. Experts consider these interpersonal difficulties to be the most significant and defining feature that all personality disorders share.
Quite logically, the three defining features described above (i.e., problems with thinking, emotional regulation, and impulse regulation) cause significant interpersonal difficulties. These problematic thoughts, feelings, and behaviors converge to create a very negative impact on people’s ability to fulfill social roles, and their ability to form and maintain healthy and rewarding relationships.
Previously, we suggested two core features of personality disorder, affective (emotional) regulation and impulse regulation, could be understood along a single continuum of regulation. At one pole of this regulation continuum is extreme over-regulation (of emotion and/or impulsivity).At the other pole is extreme under-regulation (of emotion and/or impulsivity). In other words, there is a single dimension of regulation ranging from very high to very low, with personality disorders falling at each end of the continuum, and healthy personalities falling somewhere in the middle of these two extremes.
However, the interpersonal problems associated with personality disorders are a bit different. Instead of a single dimension, some experts believe that two dimensions are necessary to properly describe these interpersonal problems. These two dimensions are called the need for power and the need for relationship and are understood to be at right angles to one another (orthogonal), just like the X and Y axes on a graph. On the vertical Y axis is the need-for-power dimension ranging from high need-for-power (dominance) to low need-for-power (submission). On the X axis is the need-for-relationship dimension ranging from high need for relationship (affiliation) to low need for relationship (detachment).
Most of the personality disorders can be placed into one of the four quadrants that are created by the intersecting lines of these X and Y axes. Some personality disorders, such as the Borderline Disorder, are considered to bounce back and forth between two quadrants (see diagram A). In contrast, healthy personalities exhibit a full range of interpersonal approaches and will generally adjust their manner of relating to others based on the person, the type of relationship, the situation, and the circumstances. Thus, they can comfortably interact in each of the four quadrants and modify their interpersonal style as needed. For instance, it’s probably best to interact on the slightly deferential, submissive side of things when we interact with our boss, but probably best to operate on the more dominant side when parenting our children. Once again we see that healthy personalities are distinguished by flexibility; in this case, interpersonal flexibility.
Interpersonal Difficulties Continued
Here are some examples of different personality disorders in terms of their tendency to seek relationships, versus avoiding them; and in terms of their tendency to dominate, versus submit to others:
In the dominant-affiliation quadrant is the Antisocial Personality Disorder. People with disorder are often described as quite charming and charismatic but their need for relationship belies a deeper need to dominate others for personal gain, via deception and exploitation. However, some people with Antisocial Personality use intimidation instead of charm and charisma to obtain their advantage. Their reckless disregard of others and lack of remorse and empathy often leads them to hurt other people.
Still on the dominant side, but with less need for relationship, are people with Narcissistic Personality Disorder. People with Narcissistic Personality Disorder are very preoccupied with themselves and their energies are often devoted to shoring up their own fragile sense of self-esteem. They have a strong desire to feel special and to be admired by others. Therefore, they often use others as a sort of prop to bolster their ego – other people are frequently seen as an audience who exist to satisfy their needs. When possible, people with this disorder will associate themselves with people who are famous, wealthy, or powerful. Their wish in assembling such a prestigious audience is that some prestige and glory will reflect back upon them; less important people who cannot reflect glory are not really worth their while.
In contrast, in the submissive-affiliation quadrant are people with Dependent Personality Disorder. They strongly desire to be in relationship with others because they feel they need to be taken care of, and have a hard time making decisions on their own. Since they are extremely afraid of being alone and worry about being left alone to care for themselves, they tend to avoid conflict. They don’t dare to disagree with others or stand up for themselves. They fear that by doing so, they might lose the love and support they so desperately need. This tendency to avoid conflict at all cost places them on the submissive side of the power continuum.
In the submissive-detached quadrant are people with Avoidant Personality Disorder. Persons with this disorder are characterized by intense feelings of inadequacy and a fear of being shamed or ridiculed in social situations. Thus, they have a tendency to avoid social situations. Unlike persons with a Dependent Personality Disorder who have a strong need for relationship, these folks have neither a need for power, nor relationship.
Summary of What is a Personality Disorder
In summary, the defining features of a personality disorder are: a) distorted thinking, b) problems with emotional regulation, and c) problems with impulse regulation) that all work together to contribute to the fourth and most important core feature of personality disorders, d) interpersonal difficulties.
When people have distorted ways of thinking about themselves and others, have difficulty regulating their emotions, and have trouble regulating their impulses, it only makes sense that these problems will go on to affect the way they enter into, and behave in relationships. Likewise, these problematic patterns of thoughts, feelings, and behaviors affect the way they handle conflict with others; and the way other people will react to them.
For more information, contact Dr. Savannah (415) 877-4004 or sav@savannahellis.net
References and Resources
Simone Hoermann, Ph.D., Corinne E. Zupanick, Psy.D. & Mark Dombeck, Ph.D.
American Psychiatric Association. (2000). Diagnostic and Statistical Manual of Mental Disorders (4th ed., Text Revision). Washington, DC: Author.
American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders, (5th ed.). Arlington, VA: American Psychiatric Publishing.
American Psychiatric Association. (2001). Practice Guidelines for the Treatment of Psychiatric Disorders: Compendium. Arlington, VA: Author.
