Personality Disorders: Information & Specialists

Personality disorders are present when individuals exhibit behaviors that deviate from typical social expectations. They result in significant distress either for the affected individual and/or for those around them.

For a personality disorder to be diagnosed, the deviant patterns of experience and behavior must be clearly evident in at least two of the following areas:

• Cognition (thought processes)
• Affect (emotional world)
• Need satisfaction and impulse control
• Interpersonal relationships and how they are managed

Personality disorders begin in childhood and adolescence and persist into adulthood. They remain present over a long period of time. Those affected often do not perceive them as a “disorder,” unlike, for example, the symptoms of depression.

A personality disorder is not present if the behavior is the result of another mental or organic illness. For example, a brain dysfunction can cause behavioral abnormalities. However, these are not classified as personality disorders.

The causes of personality disorders are not fully understood. What is certain, however, is that they arise from an interplay of

• environmental factors (upbringing, surroundings) and
• genetic factors (genes, genetic makeup)

.

Personality disorders are widespread. It is estimated that 10 percent of the general population meets the diagnostic criteria for a personality disorder.

Various theories attempt to explain the causes of personality disorders. In particular, stressful life circumstances lead to lasting disruptions in personality development. Personality disorders are also frequently associated with psychosomatic disorders.

Several specific personality disorders are distinguished. We present them below.

Paranoid Personality Disorder

Patients with paranoid personality disorder

• exhibit an unjustified distrust of others that dominates their personality
• tend to attribute malicious motives to others
• tend to distort their experiences by misinterpreting neutral or friendly actions of others as hostile or contemptuous
• particularly frequently exhibit an unjustified distrust of their spouse’s or sexual partner’s fidelity
• are usually hypersensitive to criticism
• tend, due to their excessive need for autonomy, to adopt an oppositional stance and react aggressively

People with paranoid personality disorder feel that others wish them harm © Vyacheslav Dumchev | AdobeStock

Schizoid Personality Disorder

Patients with schizoid personality disorder

• tend toward social isolation and a solitary lifestyle
• have few or no close relationships outside their immediate family
• are cold and emotionally distant in interpersonal relationships and come across as unapproachable. They have little ability to show warm and affectionate feelings—or even anger—toward others
• are often indifferent to social norms, as well as to praise and criticism from others
• often show little interest in sexual experiences with another person

Antisocial Personality Disorder

Patients with antisocial personality disorder

• exhibit a marked and persistent lack of responsibility and disregard for social norms, rules, and obligations
• usually have a low tolerance for frustration – are egocentric and incapable of genuine love and attachment
• exhibit a low threshold for aggressive, even violent, behavior
• are often superficially charming, but insincere and disingenuous
• feel neither remorse nor shame
• lack the ability to see themselves through the eyes of others
• are unable to put themselves in other people’s shoes (lack of empathy)

Borderline Personality Disorder

Patients with borderline personality disorder

• exhibit instability in relationships, self-image, and emotions, as well as impulsivity
• often tend toward self-harm and suicidal behavior

Histrionic (hysterical) personality disorder

Patients with histrionic personality disorder

• tend to express their emotions in an exaggerated manner
• have an increased desire for attention and admiration
• tend to be theatrical and dramatic
• tend to engage in inappropriate, sexually seductive, and provocatively manipulative behavior
• are suggestible and easily influenced
• crave excitement and activities in which they are the center of attention
• tend to engage in manipulative behavior to satisfy their own needs

Narcissistic Personality Disorder

Patients with narcissistic personality disorder:

• tend to have a sense of grandiosity
• have a need for admiration and a lack of empathy

Anankastic (Obsessive-Compulsive) Personality Disorder

Patients with anankastic (obsessive-compulsive) personality disorder

• tend to be precise and conscientious to the point of pedantry
• exhibit an excessive love of order and rigidity
• tend toward perfectionism
• tend to experience intense doubt and heightened caution
• have a preference for details, rules, lists, order, organization, or schemas
• are limited in their ability to enjoy themselves
• often suffer from the occurrence of unwanted thoughts and impulses

Anxious-Avoidant/Insecure Personality Disorder

Patients with an anxious-avoidant/insecure personality disorder

• tend to experience persistent and intense feelings of tension and anxiety
• believe they are socially inferior, unattractive, or inferior to others
• exhibit an exaggerated fear of being criticized or rejected by others
• avoid social or occupational activities that require interpersonal contact out of fear of criticism, disapproval, or rejection
• are restricted in their lifestyle by the need for security

Asthenic Personality Disorder

Asthenic (dependent) personality disorder is also known as dependent personality disorder. Patients

• exhibit a dependent pattern of relationships
• tend to be compliant and submissive toward people with whom they have a dependent relationship
• tend to delegate important life decisions to others
• feel helpless and anxious about being unable to take care of themselves
• passively rely on others for both minor and major life decisions
• have a strong fear of separation
• are afraid of being abandoned by a significant other and having to take care of themselves
• struggle to meet the demands of daily life
• appear powerless in both intellectual and emotional spheres
• tend to shift responsibility onto others when faced with difficulties

About 11 percent of all Germans suffer from a personality disorder.

Overall, women and men are affected by personality disorders with equal frequency. However, there are sometimes significant gender differences for individual personality disorders. For example, women are more likely to be affected by borderline personality disorder or avoidant personality disorder. Antisocial and obsessive-compulsive personality disorders, on the other hand, occur more frequently in men.

People with personality disorders have a significantly increased risk of developing another mental disorder. For example,

• depression,
• anxiety disorders, or
• substance use disorders.

In addition, other mental illnesses often take a more severe and complicated course in these individuals than in people without a personality disorder. As a result, approximately 50 percent of all patients with mental illness have an (additional) personality disorder. Borderline personality disorder and avoidant personality disorder are particularly common.

However, it is virtually impossible to reliably diagnose a personality disorder during the acute phase of a mental illness. For example, almost all patients with acute depression describe themselves as insecure. Only after the depression subsides does their self-assured side reemerge.

Standardized questionnaires are now available for diagnosing personality disorders. The doctor completes them together with the patient.

Typically, these disturbed personality patterns become apparent in childhood or adolescence. They remain relatively stable in their specific characteristics.

However, whether the affected individual (and those around them) suffers significantly from these patterns—or to what extent they constitute a genuine “disorder”—depends heavily on

• external life circumstances,
• life demands, and
• the person’s significant others

.

Major life changes such as

• moving,
• a new job, or
• changes in significant others,

require flexibility and problem-solving skills. In such situations, people with personality disorders can run into serious difficulties.

For example, a young woman with avoidant personality disorder may be able to fulfill her social roles relatively well as long as she lives in her parents’ neighborhood, completes her training at a business owned by an old family friend, and primarily socializes with former classmates. However, moving in with a partner who lives 50 km away—combined with a job change and the need to adjust to a new social environment—can lead to

• significant problems,
• anxiety,
• ruminating,
• despondency, and
• despair
• all the way to a full-blown case of depression

.

Most personality disorders are chronic. In approximately 30 percent of those affected, a very unfavorable course with significant impairments is to be expected.

About 50 percent of patients can benefit greatly from therapy.

Treatment for personality disorders includes

• crisis intervention and
• long-term work on relationship difficulties.

The treatment of choice is psychotherapy. Psychotropic medications serve only a supportive role. The following psychotherapeutic methods may be used:

• modified analytical approaches with structure-building psychotherapeutic measures to develop deficient ego structures, such as
  • emotion regulation,
  • impulse control,
  • affect differentiation,
  • improvement of interpersonal skills.
• Behavioral therapy approaches with
  • comprehensive social skills training,
  • systematic desensitization, and
  • exposure therapy.
• Cognitive therapy approaches aim to modify dysfunctional beliefs about oneself and the world.
• Trauma-focused psychotherapies should be used for traumatized patients.

Personality disorders are very often treated with inpatient psychotherapy.

Case Study 1: Borderline Personality Disorder

A 35-year-old nurse presents for admission to a psychotherapy program. She speaks openly about her problems and establishes a good rapport very quickly. She reports that her biggest problems are extreme states of tension and intense self-hatred. These symptoms usually occur simultaneously and are unpredictable to her.

These problems have persisted since she was regularly sexually abused by a relative over a long period of time during her childhood. To manage her anxiety, she cuts herself on both arms and abuses alcohol and medications. She has a small circle of friends, and most of her relationships have been volatile and complicated. There is nothing she desires more than a stable relationship.

The patient feels rejected and unloved very quickly. As a result, various conflicts arise with fellow patients or treatment providers during inpatient treatment. Such situations are analyzed in detail. In addition, the patient receives intensive, symptom-focused individual and group therapy.

After treatment ends, she is able to reduce tension without resorting to self-harm or substance abuse. Relationship problems and self-hatred still occur, but the patient is somewhat better able to distance herself from them.

Case Study 2: Schizoid Personality Disorder

Mr. P., a 31-year-old man, is a patient in an inpatient alcohol detoxification program. He appears very calm and withdrawn. He makes little eye contact with others and barely reacts to jokes or friendly remarks.

Regarding his social situation, he states that the mother of his child recently broke up with him. He says he didn’t quite understand the reason for this. Naturally, he finds this unfortunate. But overall, other people are of little importance to him; he is relatively indifferent to their opinions of him. He gets along best on his own, and he doesn’t place much value on a sexual relationship either.

Since losing his job as a bricklayer two years ago, he has hardly socialized with anyone. However, his alcohol consumption has become very heavy during this time.

Case Study 3: Insecure Personality Disorder

Ms. P., a 26-year-old woman and trained gardener, also has to advise customers in her sales role. She finds this extremely difficult; she’s afraid of making a fool of herself. As a result, she frequently calls in sick and repeatedly gets into trouble with her boss. In her personal life, she is also extremely shy; she feels inferior to her peers and doesn’t dare to speak to people she doesn’t know well. She usually feels clumsy and awkward.

Ms. P. is undergoing a two-year course of behavioral therapy focused on practicing how to deal with the situations she avoids. As a result, she is now able to confidently handle her professional responsibilities and enjoys a more fulfilling social life. However, she still describes herself as shy and plagued by inferiority complexes.