The American Psychiatric Association (APA) had reported that when the Diagnostic and Statistical Manual of Mental Disorders – Fifth Edition (DSM-5) would be released in 2013, the diagnostic category of personality disorders would be revamped; however, there was very little change in the description of personality disorders and their diagnostic criteria from the previous version, the DSM-IV.
Types of Personality Disorders
The DSM-5 continues to list 10 different major personality disorders that are divided into three general clusters.
- Cluster A personality disorders consist of disorders with odd, bizarre, or eccentric behaviors. These include:
- Paranoid personality disorder, where there is a pattern of suspiciousness and distrust of others and their motives
- Schizoid personality disorder, where there is a pattern of detachment, difficulties forming relationships, and a restricted range of one’s ability to express emotions
- Schizotypal personality disorder, where there is a pattern of discomfort in close relationships, eccentric behavior, and either perceptual or cognitive disturbances
- Cluster B personality disorders consist of disorders where there is a prevalence of dramatic and erratic types of behaviors. These include:
- Antisocial personality disorder, where there is a pattern of disregard for the rights of others and the violation of the rights of others.
- Borderline personality disorder, where there is a pattern of instability in relationships, with one’s own self-image and emotions, and significant impulsivity
- Histrionic personality disorder, where there is a pattern of attention-seeking and excessive expression of emotions
- Narcissistic personality disorder, where there is a pattern of an excessive need for admiration, feelings of grandiosity, and a lack of empathy
- Cluster C personality disorders consist of disorders that involve anxious and fearful behaviors. These include:
- Avoidant personality disorder, where there are feelings of inadequacy, social inhibition, and significant hypersensitivity to perceived negative evaluations of the person from others
- Dependent personality disorder, where there is a pattern of submissive behavior and cleaning, such that the individual displays an excessive need to be taken care of
- Obsessive-compulsive personality disorder, where there is a pattern of perfectionism, need for control, and preoccupation with being orderly
- The DSM-5 also specifies categories for:
- Personality disorder due to another medical condition, where a medical condition is believed to alter an individual’s personality (e.g., a brain injury)
- Other specified personality disorder and unspecified personality disorder, where suspected personality disorders do not quite meet the diagnostic criteria for the above 10 major personality disorders, but there is enough information to suggest that the person may have a personality disorder of some type
Each personality disorder has specialized diagnostic criteria that must be met in order for an individual to receive a diagnosis. Only a licensed and trained mental health clinician can formally diagnose a personality disorder in anyone. Personality disorders, by their very nature, represent behaviors, attitudes, and patterns of relationships that appear very early in the development of the individual (often in childhood or adolescence), are very rigid and not adaptable, and lead to significant distress or dysfunction in the person.
In terms of the description and diagnosis of personality disorders, there are several serious issues with the way personality disorders are presented in the DSM-5. These issues result in significant criticism regarding this category of disorders, and whether they actually exist according to the manner in which they are presented, defined, and diagnosed by APA.
For instance, individuals diagnosed with the same personality disorder may display symptoms that are significantly different from one another. For example, there are a total of nine symptoms that can be used to diagnose borderline personality disorder. An individual must display five or more of the symptoms in order to receive a diagnosis. Of the total nine potential symptoms of borderline personality disorder, there are 126 different combinations of five; however, there are also individuals who are diagnosed with borderline disorder who display six of nine symptoms, seven of nine symptoms, etc., making the total number of different combinations of symptoms that can lead to a diagnosis of borderline personality disorder even greater. Thus, it is entirely possible that different individuals who are diagnosed with borderline personality disorder have markedly different overall presentations and actually share few symptoms used to diagnose the same disorder. This is a major problem for some critics of the DSM series.
Adding to the above complication is the observation that many of the symptoms of different personality disorders share significant overlap (e.g., narcissistic personality disorder and antisocial personality disorder), making the issue even more complicated and confusing. Someone diagnosed with narcissistic personality disorder by one clinician might receive a diagnosis of antisocial personality disorder by another. In some cases, an individual may be diagnosed with two personality disorders, a seemingly impossible occurrence. Numerous other issues regarding overlap in the diagnostic criteria for these disorders also exist.
These types of issues can complicate the diagnosis and treatment of these disorders, particularly when an individual diagnosed with a personality disorder is diagnosed with a comorbid (co-occurring) disorder. One of the most common co-occurring disorders with personality disorders is a diagnosis of a substance use disorder.
Personality Disorders and Substance Abuse
APA recognizes that there is significant comorbidity for substance use disorders in individuals who are diagnosed with any of the personality disorders; comorbidity refers to a situation where a person has more than one disorder at the same time. The most commonly studied substance of abuse is alcohol, and research studies suggest that the prevalence of personality disorders in individuals who are diagnosed with alcohol use disorders ranges from 22% to as high as 78%. The type of personality disorder, particular sample of participants in the study, and other factors contribute to this large variance.
Most research studies concentrate on one cluster personality disorders or one particular type of personality disorder. The Cluster B group is the most frequently studied, particularly antisocial, borderline, or narcissistic personality disorder, where it is believed there is extremely high prevalence rates of comorbid alcohol use disorders. However, research has also indicated that alcohol abuse is relatively common in other personality disorders and in other clusters.
Common lay explanations for the relationship between substance abuse and personality disorders tend to concentrate on the notion of self-medication. In this explanation, it is suggested that individuals with significant psychological distress use drugs or alcohol in an attempt to medicate their symptoms. However, research studies do not always support the notion that alcohol abuse follows the presentation of the symptoms associated with a personality disorder, and a significant number of individuals with severe personality disorders may not abuse drugs or alcohol.
Instead, when one considers the observation that nearly any individual given a diagnosis of any psychiatric disorder according to the DSM-5 criteria is at an increased risk for the development of numerous substance abuse issues, it becomes clear that the factors that interact to produce a substance use disorder in any type of mental health disorder must be interrelated. These factors can consist of genetic background, upbringing, learning, and other experiences, such as stress, abuse, or even major life disappointments. Numerous factors most likely interact to produce both personality disorders and other types of mental health disorders, including substance use disorders. Simply being at risk to develop any particular mental health disorder also increases the risk to develop many other mental health disorders.
Individuals with comorbid personality disorders and alcohol use disorders experience significant more distress in their functioning and personal relationships than individuals who have either of these disorders alone. Research has indicated that having a comorbid personality disorder and alcohol use disorder can result in a greater potential to experience:
- Relationship issues, such as divorce or estrangement from family
- Issues with occupation, including higher rates of unemployment
- Numerous medical issues, including but not limited to cardiovascular issues, gastrointestinal issues, and potential cancer
- Vulnerability to develop even more severe issues with emotional functioning, such clinically significant depression, anxiety, or stress-related disorders
- Higher rates of mortality from the effects of alcohol abuse, disease, being the victim of an accident or crime, or suicide
Complications with Treating Personality Disorders
By their very definition, personality disorders represent longstanding behaviors, tendencies, and beliefs in individuals who are diagnosed with them. The symptoms of personality disorders often begin in late childhood or early adolescence, and have no discernible origin; family members and long-term friends may remark that the individual with a personality disorder “has always been that way.”
Individuals who are diagnosed with personality disorders can present with interesting treatment challenges. First, these individuals do not often feel like they have a problem, but most often approach the world as if other people have a problem, and are responsible for the stress and issues they experience. Such an individual can be very hard to get into treatment in the first place.
Individuals with personality disorders often enter treatment due to feelings of disappointment, depression, relationship issues, at the bequest of employers or family members, as a result of entanglements with the legal system, or even for substance abuse issues. In these instances, during the assessment phase, the clinician may suspect that there are more chronic issues that inhibit the individual’s behavior. As might be expected, individuals with personality disorders are often not initially interested in changing themselves, but in changing others to fit their own agenda.
Treatment for Co-Occurring Disorders
Not surprisingly, individuals with substance use disorders often share many of the above challenges in assessment and treatment of their issues. Individuals with alcohol use disorders often attempt to find ways to manipulate other people, the system, and even treatment providers to meet their own agenda. They rationalize their alcohol use as being “normal for them” and even perhaps beneficial for them, whereas other individuals demonstrating similar problems associated with substance abuse are considered by them to be dysfunctional. It should be no surprise then that an individual with a personality disorder and comorbid alcohol use disorder would be exceptionally challenging during treatment.
When a person is diagnosed with any type of mental health disorder and a comorbid substance use disorder, they are said to have co-occurring disorders. Treatment for individuals with co-occurring disorders is comprehensive, intense, and overseen by teams of treatment providers that come from different backgrounds (multidisciplinary teams). These team members meet to discuss the overall treatment plan and their contribution the treatment, and then individually address the treatment of the individual according to their own area of specialty.
This form of treatment is often referred to as integrated treatment. Multidisciplinary teams most often consist of one or more physicians (e.g., psychiatrists, addiction medicine physicians, etc.), psychologists, social workers, and other treatment specialists. The goal is to provide a comprehensive treatment program that addresses both the individual’s personality disorder and alcohol use disorder at the same time. Research has indicated that attempts to address one disorder and ignore or hold the other disorder in check inevitably results in overall failure.
The treatment protocol consists of various components.
- Treatment interventions are often applied according to the stipulations of the Motivational Interviewing paradigm. Motivational Interviewing attempts to address an individual’s alcohol use disorder and other issues (e.g., a personality disorder) according to their own understanding of their need for treatment. Using Motivational Interviewing techniques, the therapist can find out where the person stands on understanding the need for an intervention and help them to realize their need for intervention for their personality disorder or alcohol use disorder.
- For individuals with severe withdrawal issues as a result of their alcohol use disorder, treatment in an inpatient withdrawal management program is mandatory. Inpatient treatment will allow for 24-hour monitoring of any complications and more control over preventing relapse in the individual. Because withdrawal from alcohol can be fatal, a physician-assisted withdrawal management program is required for individuals who experience moderate to severe withdrawal symptoms.
- The use of medications or other medically assisted treatments should be implemented when deemed necessary.
- Following the completion of the withdrawal management program, the person should agree to random alcohol and drug screening in order to provide objective evidence that they are maintaining abstinence within their treatment program. According to the National Institute on Drug Abuse, random monitoring of abstinence through the use of objective methods (e.g., drug and alcohol screenings) is one of the major components of an effective program to treat a substance use disorder.
- Psychotherapy for both the individual’s substance use disorder and personality disorder would be the foundation of the treatment program for the person. Most often, the most recommended type of therapy for these issues comes from the cognitive-behavioral paradigm (approach), but other approaches can also be used, such as dynamic therapy.
- Treatment for personality disorders and alcohol use disorders is typically long-term and ongoing. Individual therapy sessions, group therapy sessions, family therapy sessions, and combinations of individual and group therapy sessions are used.
- Specific types of Cognitive Behavioral Therapy designed for specific personality disorders, such as Dialectical Behavior Therapy for borderline personality disorder, could be used depending on the issues involved.
- Participation in Alcoholics Anonymous and other social support groups can enhance the effectiveness of treatment.
- Other interventions, as identified in the initial assessment, should also be implemented by trained specialists.
Individuals with co-occurring personality disorders and alcohol use disorders should maintain involvement in a long-term aftercare program that addresses all of their issues. This would most likely entail some form of group therapy and social support group participation in addition to any other treatments, such as medications, that need to be ongoing.
It is important to understand that the treatment and psychotherapy used to address individuals with substance use disorders and personality disorders never “cures” the person in the same way that someone could be cured from the measles or some other disease. Instead, treatment protocols help individuals to adjust, change their inclinations, and recognize the signs and symptoms associated with dysfunctional behaviors. Many of these individuals need to remain involved in some type of treatment-related activity for decades. Participation in social support groups (e.g., Alcoholics Anonymous or other local groups for individuals with specific types of personality disorders or substance abuse), where people with the same issues get together and discuss their issues, is often the most effective way for these individuals to avoid returning to their old habits.