What is one of the reasons that the category of personality disorders is controversial

Personality disorders are characterized by patterns of thinking, feeling, behaving, and interacting that deviate from cultural expectations and cause significant distress and problems functioning. Personality refers to the way a person behaves, thinks, and feels, and is influenced by genetic and environmental factors. People can develop a personality disorder in adolescence or early adulthood.

There are 10 personality disorders, according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). They are grouped within one of three clusters, and the disorders within each cluster share similar characteristics.

Cluster A Personality Disorders

Cluster A personality disorders are characterized by odd and eccentric behavior, and include paranoid personality disorder, schizoid personality disorder, and schizotypal personality disorder. The personality disorders that fall under this category share not only similar symptoms, but similar genetic and environmental risk factors as well. The prevalence of this cluster of personality disorders by some estimates is around 5.7%.

Paranoid Personality Disorder

The characteristics of paranoid personality disorder (PPD) include paranoia, relentless mistrust, and suspicion of others without adequate reason to be suspicious. PPD affects between 2.3% and 4.4% of the general population.

Its cause is thought to be a combination of biological and psychological factors. PPD is more common in people who have close relatives with schizophrenia and delusional disorder, suggesting a genetic link between PPD and these conditions. Childhood trauma—physical and emotional—is also believed to be a contributing factor to PPD.

A person is diagnosed with PPD if they have more than four of the following:

• Unjustified suspicion that others are exploiting, injuring, or deceiving them
• Preoccupation with unjustified doubts about the reliability of others
• Reluctance to confide in others for fear that the information will be used against them
• Misinterpretation of benign remarks or events as having hidden belittling, hostile, or threatening meaning
• Holding grudges against others for insults, injuries, or slights
• Often thinking that their character or reputation has been attacked, and quick to react angrily or to counterattack
• Recurrent, unjustified suspicions of spousal infidelity

Schizoid Personality Disorder

People with schizoid personality disorder (ScPD) have a lifelong pattern of indifference toward others and social isolation. Those with ScPD do not have paranoia or hallucinations (cognitive or perceptual disturbances) like people with schizophrenia do. The prevalence of schizoid personality disorder ranges from 3.1% to 4.9% in the general population.

Not much is known about the cause or risk factors for this personality disorder, but many believe that heritability significantly contributes to ScPD. Twin studies using self-report questionnaires have estimated heritability rates for schizoid personality disorder to be about 30%.

A diagnosis of ScPD is made if more than four of the following are present:

• No desire for or enjoyment of close relationships
• Strong preference for solitary activities
• Little, if any, interest in sexual activity with others
• Enjoyment of few, if any, activities
• Lack of close relationships, except possibly first-degree relatives
• Apparent indifference to praise or criticism
• Emotional coldness, detachment, or flattened affect

Schizotypal Personality Disorder

People with schizotypal personality disorder prefer to keep their distance from others and are uncomfortable being in relationships. They sometimes have odd speech or behavior, and they have an odd or limited range of emotions. It typically begins early in adulthood. It is estimated that about 3% of the U.S. population have this personality disorder.

Schizotypal personality disorder is in the middle of a spectrum of related disorders, with schizoid personality disorder on the milder end and schizophrenia on the more severe end. It is believed that people with these disorders share similar genetic vulnerabilities, but it is unclear why some develop more severe forms of the disorder.

A diagnosis of schizotypal personality disorder is made if a person has more than five of the following:

• Ideas of reference (notions that everyday occurrences have special meaning or significance personally intended for or directed to themselves)
• Odd beliefs or magical thinking (e.g., believing in clairvoyance, telepathy, or a sixth sense)
• Unusual perceptual experiences (e.g., hearing a voice whispering their name)
• Odd thoughts and speech (e.g., speech that is vague, metaphorical, excessively elaborate, or stereotyped)
• Suspicions or paranoid thoughts
• Incongruous or limited affect
• Odd, eccentric, or peculiar behavior and appearance
• Lack of close friends or confidants, except for first-degree relatives
• Excessive social anxiety that does not improve with familiarity and is associated with paranoid fears rather than negative judgments about self

Classification of personality disorders (PDs) is controversial for several reasons. PD trait distributions have been found to be quite unlike what are presented in the DSM-5, and many people with personality disorders often fit into more than one diagnosis. Personality structure may be more accurately described as a constellation of maladaptive personality traits.

Cluster B Personality Disorders

Cluster B personality disorders are characterized by issues with impulse control and emotional regulation. People with personality disorders in this cluster are usually described as dramatic, emotional, and erratic, and are often involved in interpersonal conflicts. Prevalence of these personality disorders has been estimated to vary between 1% and 6%. It is the least prevalent of all three clusters.

Antisocial Personality Disorder

People with antisocial personality disorder (ASPD) have a long-term pattern of manipulating, exploiting, or violating the rights of others without any remorse. This behavior may cause problems in relationships or at work. It affects 1% of the general population.

Behaviors characteristic of ASPD must have been evidenced as conduct disorder or a phase before the age of 15, but are recognized as part of ASPD if they continue until the age of 18.

A person’s genes and other factors, such as child abuse, may contribute to ASPD. People with an antisocial or alcoholic parent are at increased risk. Far more men than women are affected, and the condition is common among people who are in prison. Setting fires and animal cruelty during childhood are often warning signs of antisocial personality.

A person is diagnosed with ASPD if they have three or more of the following:

• Failure to conform to social norms with respect to lawful behaviors, which is indicated by repeatedly performing acts that are grounds for arrest
• Being deceitful (lying repeatedly, using aliases, or conning others for personal gain or pleasure)
• Acting impulsively or failing to plan ahead
• Irritability and aggressiveness, as indicated by repeated physical fights or assaults
• Reckless disregard for the safety of self or others
• Consistently acting irresponsibly (e.g., quitting jobs with no plans or not paying bills)
• Lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another person

Borderline Personality Disorder

Borderline personality disorder (BPD) is characterized by an ongoing pattern of instability in self-image, varying moods, impulsive behaviors, and problems with relationships. The prevalence of BPD is estimated to be 1.6% in the general population, but may be much higher in certain settings.

Traumatic life events during early childhood, such as abuse, abandonment, or adversity, is a risk factor for BPD. People who have close family members with BPD are more likely to develop the disorder. Studies have shown that people with BPD can have structural and functional changes in the brain, especially in the areas that control impulses and emotional regulation. However, it is unclear whether these changes are risk factors for the disorder or are caused by the disorder.

A diagnosis of BPD is made if five or more of the following are present:

• Desperate efforts to avoid abandonment (real or imagined)
• A pattern of unstable and intense relationships that alternate between idealizing and devaluing the other person
• Markedly unstable self-image or sense of self
• Impulsivity in at least two areas that are potentially self-damaging (e.g., unsafe sex, binge eating, reckless driving)
• Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior
• Rapid changes in mood, lasting usually only a few hours and rarely more than a few days
• Persistent feelings of emptiness
• Inappropriate, intense anger or problems controlling anger
• Temporary paranoid thoughts or severe dissociative symptoms triggered by stress

Histrionic Personality Disorder

People with histrionic personality disorder (HPD) act in a very emotional and dramatic way that draws attention to themselves. People with this disorder may be high functioning and successful at work and in relationships. The prevalence of HPD ranges from less than 1% to 3%.

Causes of histrionic personality disorder are unknown, but genes and early childhood events may be responsible. It is diagnosed more often in women than in men. However, doctors believe that more men may have the disorder than are diagnosed. Histrionic personality disorder usually begins by late teens or early 20s.

A diagnosis of HPD is made if five or more of the following are present:

• Feels uncomfortable in situations where they are not the center of attention
• Interaction with others is often characterized by inappropriate sexually seductive or provocative behavior
• Has rapidly shifting and shallow expression of emotions
• Consistently uses physical appearance to draw attention to self
• Has a style of speech that is excessively impressionistic and lacking in detail
• Self-dramatization, theatricality, and exaggerated expressions
• Is suggestible (easily influenced by others)
• Considers relationships as more intimate than they really are

Narcissistic Personality Disorder

People with narcissistic personality disorder (NPD) have an excessive sense of self-importance, an extreme preoccupation with themselves, and a lack of empathy for others. They also have significant physical and mental health comorbidities, including substance abuse, mood, and anxiety disorders. It affects 1% of the general population.

The exact cause of NPD is unknown, but early life experiences, such as insensitive parenting, are thought to play a role in developing this disorder.

A diagnosis of NPD is made if five or more of the following are present:

• Has a grandiose sense of self-importance (e.g., exaggerates achievements and talents, expects to be recognized as superior without commensurate achievements)
• Preoccupied with fantasies of unlimited success, influence, power, intelligence, beauty, or ideal love
• Believes they are uniquely special and should only associate with, or can only be understood by, other special or high-status people
• Requires excessive admiration
• Has a sense of entitlement (i.e., unreasonable expectations of especially favorable treatment or automatic compliance with their expectations)
• Exploits others to achieve their own goals
• Lacks empathy and is unwilling to recognize or identify with the feelings and needs of others
• Envies others and believes that others envy them
• Exhibits an arrogant and haughty attitude

Cluster C Personality Disorders

Cluster C personality disorders are characterized by intense anxiety and fear to the point where they affect a person’s ability to function in everyday life. These personality disorders are the most common of the three clusters, with a prevalence of 6%.

Avoidant Personality Disorder

People with avoidant personality disorder (AVPD) experience extreme social inhibitions fueled by fear of rejection and feelings of inadequacy. It is suggested to occur at a prevalence of about 2.4% of the general population. Avoidant personality disorder symptoms may be noticed in childhood, and often begin to create discomfort in adolescence or early adulthood. It is usually not diagnosed in people younger than 18 years old.

It is believed that genetics and environment play a role in the development of AVPD. This disorder may be passed down through genes, but this has not yet been proven. Shyness, often normal in young children, lasts into adolescence and adulthood in those with avoidant personality disorder. Those with AVPD often experience parental or peer rejection, which contributes to low self-esteem.

A person is diagnosed with AVPD if they have four or more of the following:

• Avoids job-related activities that involve interpersonal contact because of fear of criticism or rejection
• Is unwilling to get involved with people unless they are sure of being liked
• Shows restraint in close relationships because they fear ridicule or humiliation
• Is preoccupied with being criticized or rejected in social situations
• Is inhibited in new social situations because they feel inadequate
• Views self as socially inept, unappealing, or inferior to others
• Is reluctant to take risks or participate in new activities because they fear embarrassment

Dependent Personality Disorder

People with dependent personality disorder (DPD) often feel helpless, submissive, and incapable of taking care of themselves. They may have trouble making simple decisions, and often depend on others too much for their physical and emotional needs. It affects 0.6% of the general population.

Causes of dependent personality disorder are unknown. The disorder usually begins in childhood. Experts have found DPD is more likely in people with particular life experiences, including abusive relationships, childhood trauma, family history, and certain religious or family behaviors such as cultural or religious practices that emphasize reliance on authority.

A diagnosis of DPD is made if five or more of the following are present:

• Difficulty making daily decisions without consulting others
• Needs others to be responsible for most important aspects of their life
• Difficulty expressing disagreement (due to fearing loss of support or approval)
• Difficulty self-starting projects because they are not confident in their judgment and abilities
• Willingness to go to great lengths to obtain support from others
• Feels uncomfortable or helpless when they are alone (fearing they cannot take care of themselves)
• Urgent need to establish a new relationship to gain care and support when a close relationship ends
• Unrealistic preoccupation with fears of being left to take care of themselves

Obsessive-Compulsive Personality Disorder

Obsessive-compulsive personality disorder (OCPD) is characterized by preoccupation with orderliness, rules, control, and perfectionism. People with this disorder are unwilling to compromise and unable to change their views, which could jeopardize their relationships or careers as a result. Black-or-white thinking is common in people with OCPD: There is no acceptance of gray areas and anything left to chance. The prevalence of this disorder is estimated to be over 2% in the general population.

OCPD tends to occur in families, so genes may be involved. A person’s childhood and environment may also play a role in this disorder, such as a background of harsh discipline and being the oldest child.

A person is diagnosed with OCPD if they have four or more of the following:

• Preoccupation with details, rules, schedules, organization, and lists
• Striving to do something perfectly that interferes with the completion of the task
• Excessive devotion to work and productivity (not due to financial necessity), resulting in neglect of leisure activities and friends
• Excessive conscientiousness, fastidiousness, and inflexibility regarding ethical and moral issues and values
• Unwillingness to throw out worn-out or worthless objects, even those with no sentimental value
• Reluctance to delegate or work with other people unless those people agree to do things exactly as the patients want
• A miserly approach to spending for themselves and others because they see money as something to be saved for future disasters
• Rigidity and stubbornness

Other DSM-5 Personality Disorders

Three personality patterns don’t meet the DSM-5 diagnostic criteria for the 10 recognized personality disorders:

• Personality change due to another medical condition: This change from a previous personality pattern can cause clinically significant distress or impairment in functioning, but is attributed to a direct physiological consequence of a general medical condition and cannot be better explained by another mental disorder (such as dementia).
• Other specified personality disorder: This disorder can be considered a mixed personality disorder or a “catch-all” for people with symptoms that span across and don’t neatly fit one specific personality disorder. People in this category may go undiagnosed or undertreated.
• Unspecified personality disorder (a.k.a., personality disorder not otherwise specified, or NOS): This is another personality disorder diagnosis whereby the patient doesn’t meet the criteria of any one personality disorder or there is insufficient information to make a more specific diagnosis, but they exhibit impaired functioning and pathological personality traits. 

A Word From Verywell

If you have the traits of any one or more of the above personality disorders, or are experiencing notable changes to your usual sense of self and behavior patterns, it is worth reaching out to an experienced mental health professional for assessment. While patterns are present early in life, they can often go undiagnosed and lead to significant social, career, and personal problems. With the right treatment, you can manage symptoms and cope with your personality disorder.

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