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# Personality Disorders and Related Traits

Personality refers to an individual's characteristic way of behaving, experiencing life, and of perceiving and interpreting themselves, other people, events, and situations. Personality Disorder is a marked disturbance in personality functioning, which is nearly always associated with considerable personal and social disruption. The central manifestations of Personality Disorder are impairments in functioning of aspects of the self (e.g., identity, self-worth, capacity for self-direction) and/or problems in interpersonal functioning (e.g., developing and maintaining close and mutually satisfying relationships, understanding others' perspectives, managing conflict in relationships). Impairments in self-functioning and/or interpersonal functioning are manifested in maladaptive (e.g., inflexible or poorly regulated) patterns of cognition, emotional experience, emotional expression, and behavior.

The following diagnostic requirements for Personality Disorder present a set of Essential Features, all of which must be present to diagnose a Personality Disorder. Once the diagnosis of a Personality Disorder has been established, it should be described in terms of its level of severity:

* Mild Personality Disorder (6D10.0)
* Moderate Personality Disorder (6D10.1)
* Severe Personality Disorder (6D10.2)

A category relevant to this grouping is:

* Personality Difficulty (QE50.7)

Personality Difficulty is not classified as a mental disorder, but rather is listed in the grouping of Problems Associated with Interpersonal Interactions in the chapter on Factors Influencing Health Status or Contact with Health Services. Personality Difficulty refers to pronounced personality characteristics that may affect treatment or health services but do not rise to the level of severity to merit a diagnosis of Personality Disorder.

Personality Disorder and Personality Difficulty can be further described using five trait domain specifiers. These trait domains describe the characteristics of the individual's personality that are most prominent and that contribute to personality disturbance. As many as necessary to describe personality functioning should be applied. Trait domain specifiers that may be recorded include the following:

* Negative Affectivity (6D11.0)
* Detachment (6D11.1)
* Dissociality (6D11.2)
* Disinhibition (6D11.3)
* Anankastia (6D11.4)

More detailed guidance about the personality characteristics reflected in the trait domain specifiers is provided in the respective sections. Clinicians may also wish to add an additional specifier for 'Borderline pattern':

* Borderline pattern (6D11.5)

The Borderline pattern specifier has been included to enhance the clinical utility of the classification of Personality Disorder. Specifically, use of this specifier may facilitate the identification of individuals who may respond to certain psychotherapeutic treatments. A complete description of a particular case of Personality Disorder includes the rating of the severity level and the assignment of the applicable trait domain specifiers (e.g., Mild Personality Disorder with Negative Affectivity and Anankastia; Severe Personality Disorder with Dissociality and Disinhibition.) The Borderline pattern specifier is considered optional but, if used, should ideally be used in combination with the trait domain specifiers (e.g., Moderate Personality Disorder with Negative Affectivity, Dissociality, and Disinhibition, Borderline pattern).

# 6D10 Personality Disorder

Personality disorder is characterized by problems in functioning of aspects of the self (e.g., identity, self-worth, accuracy of self-view, self-direction), and/or interpersonal dysfunction (e.g., ability to develop and maintain close and mutually satisfying relationships, ability to understand others’ perspectives and to manage conflict in relationships) that have persisted over an extended period of time (e.g., 2 years or more). The disturbance is manifest in patterns of cognition, emotional experience, emotional expression, and behavior that are maladaptive (e.g., inflexible or poorly regulated) and is manifest across a range of personal and social situations (i.e., is not limited to specific relationships or social roles). The patterns of behavior characterizing the disturbance are not developmentally appropriate and cannot be explained primarily by social or cultural factors, including socio-political conflict. The disturbance is associated with substantial distress or significant impairment in personal, family, social, educational, occupational or other important areas of functioning.

## Diagnostic Requirements

### General Diagnostic Requirements for Personality Disorder

Essential (Required) Features:

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

### Severity of Personality Disorder

**Degree and Pervasiveness of Disturbances in Functioning of Aspects of the Self:**

Stability and Coherence of One's Sense of Identity:

1. Extent to which identity or sense of self is variable and inconsistent.
2. Overly rigid and fixed sense of self.

Ability to Maintain an Overall Positive and Stable Sense of Self-Worth:

1. Accuracy of one’s view of one’s characteristics, strengths, limitations.
2. Capacity for self-direction (ability to plan, choose, and implement appropriate goals).

Interpersonal Dysfunction Across Various Contexts and Relationships:

1. Interest in engaging in relationships with others.
2. Ability to understand and appreciate others’ perspectives.
3. Ability to develop and maintain close and mutually satisfying relationships.
4. Ability to manage conflict in relationships.

**Pervasiveness, Severity, and Chronicity of Emotional, Cognitive, and Behavioural Manifestations of the Personality Dysfunction:**

Emotional Manifestations:

1. Range and appropriateness of emotional experience and expression.
2. Tendency to be emotionally over- or underreactive.
3. Ability to recognize and acknowledge emotions that are difficult or unwanted by the individual (e.g., anger, sadness).

Cognitive Manifestations:

1. Accuracy of situational and interpersonal appraisals, especially under stress.
2. Ability to make appropriate decisions in situations of uncertainty.
3. Appropriate stability and flexibility of belief systems.

Behavioural Manifestations:

1. Flexibility in controlling impulses and modulating behaviour based on the situation and consideration of the consequences.
2. Appropriateness of behavioural responses to intense emotions and stressful circumstances (e.g., propensity to self-harm or violence).
3. The Extent to Which Dysfunctions Are Associated with Distress or Impairment in Personal, Family, Social, Educational, Occupational, or Other Important Areas of Functioning.

# 6D10.1 Moderate Personality Disorder

All general diagnostic requirements for Personality Disorder are met. Disturbances affect multiple areas of personality functioning (e.g., identity or sense of self, ability to form intimate relationships, ability to control impulses and modulate behavior). However, some areas of personality functioning may be relatively less affected. There are marked problems in most interpersonal relationships and the performance of most expected social and occupational roles is compromised to some degree. Relationships are likely to be characterized by conflict, avoidance, withdrawal, or extreme dependency (e.g., few friendships maintained, persistent conflict in work relationships and consequent occupational problems, romantic relationships characterized by serious disruption or inappropriate submissiveness). Specific manifestations of personality disturbance are generally of moderate severity. Moderate Personality Disorder is sometimes associated with harm to self or others, and is associated with marked impairment in personal, family, social, educational, occupational or other important areas of functioning, although functioning in circumscribed areas may be maintained.

## Diagnostic Requirements

### Essential (Required) Features:

- All general diagnostic requirements for Personality Disorder are met.
- Disturbances affect multiple areas of functioning of the self (e.g., stability and coherence of identity, self-worth, self-direction; see Table 6.18 and are of moderate severity.
- There are marked problems in most interpersonal relationships and the performance of most expected social and occupational roles is compromised to some degree.
- Relationships are likely to be characterized by conflict, avoidance, withdrawal, or extreme dependency (e.g., few friendships maintained, persistent conflict in work relationships and consequent occupational problems, romantic relationships characterized by serious disruption or inappropriate submissiveness).
- Specific manifestations of personality disturbance are generally of moderate severity (see below for examples).
- Moderate Personality Disorder is sometimes associated with harm to self or others.
- Moderate Personality Disorder is associated with marked impairment in personal, family, social, educational, occupational or other important areas of functioning, although functioning in circumscribed areas may be maintained.

## Examples of specific personality disturbances in Moderate Personality Disorder

Note: This list of examples is not exhaustive and not intended to suggest that all items will be present in any single individual.

- The individual's sense of self may become incoherent in times of crisis.
- The individual has considerable difficulty maintaining positive self-esteem or, alternatively, has an unrealistically positive self-view that is not modified by evidence to the contrary.
- The individual exhibits poor emotion regulation in the face of setbacks, often becoming highly upset and giving up easily. Alternatively, the individual may persist unreasonably in pursuit of goals that have no chance of success.
- The individual may exhibit little genuine interest in or efforts toward sustained employment.
- Major limitations in the ability to understand and appreciate others' perspectives hinder developing close and mutually satisfying relationships.
- There are persistent problems in those relationships that do exist. They may be characterized by frequent, serious, and volatile conflict, or be significantly unbalanced (e.g., the individual is highly dominant or highly submissive).
- Under stress there are marked distortions in the individual's situational and interpersonal appraisals. There may be mild dissociative states or psychotic-like beliefs or perceptions (e.g., paranoid ideas).

# 6D10.2 Severe Personality Disorder

All general diagnostic requirements for Personality Disorder are met. There are severe disturbances in functioning of the self (e.g., sense of self may be so unstable that individuals report not having a sense of who they are or so rigid that they refuse to participate in any but an extremely narrow range of situations; self view may be characterized by self-contempt or be grandiose or highly eccentric). Problems in interpersonal functioning seriously affect virtually all relationships and the ability and willingness to perform expected social and occupational roles is absent or severely compromised. Specific manifestations of personality disturbance are severe and affect most, if not all, areas of personality functioning. Severe Personality Disorder is often associated with harm to self or others, and is associated with severe impairment in all or nearly all areas of life, including personal, family, social, educational, occupational, and other important areas of functioning.

## Diagnostic Requirements
### Essential (Required) Features:

* All general diagnostic requirements for Personality Disorder are met.
* There are severe disturbances in multiple areas of functioning of the self (e.g., sense of self may be so unstable that individuals report not having a sense of who they are or so rigid that they refuse to participate in any but an extremely narrow range of situations; self view may be characterized by self-contempt or be grandiose or highly eccentric; See Table 6.18).
* Problems in interpersonal functioning seriously affect virtually all relationships and the ability and willingness to perform expected social and occupational roles is severely compromised or absent.
* Specific manifestations of personality disturbance are severe (see below for examples) and affect most, if not all, areas of personality functioning.
* Severe Personality Disorder is often associated with harm to self or others.
* Severe Personality Disorder is associated with severe impairment in all or nearly all areas of life, including personal, family, social, educational, occupational, and other important areas of functioning.

## Examples of specific personality disturbances in Severe Personality Disorder

Note: This list of examples is not exhaustive and not intended to suggest that all items will be present in any single individual.

* The individual's self-view is very unrealistic and typically is highly unstable or contradictory.
* The individual has serious difficulty with regulation of self-esteem, emotional experience and expression, and impulses, as well as other aspects of behaviour (e.g., perseveration, indecision).
* The individual is largely unable to set and pursue realistic goals.
* The individual's interpersonal relationships, if any, lack mutuality; are shallow, extremely one-sided, unstable, or highly conflictual, often to the point of violence. Family relationships are absent (despite having living relatives) or marred by significant conflict.
* The individual has extreme difficulty acknowledging difficult or unwanted emotions (e.g., does not recognize or acknowledge experiencing anger, sadness, or other emotions).
* The individual is unwilling or unable to sustain regular work due to lack of interest or effort, poor performance (e.g., failure to complete assignments or perform expected roles, unreliability), interpersonal difficulties, or inappropriate behaviour (e.g., fits of temper, insubordination).
* Under stress, there are extreme distortions in the individual's situational and interpersonal appraisals. There are often dissociative states or psychotic-like beliefs or perceptions (e.g., extreme paranoid reactions).
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Present the second diagnostic requirement of 6D10.2
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The second diagnostic requirement of 6D10.2 Severe Personality Disorder is:

**2. Problems in interpersonal functioning seriously affect virtually all relationships and the ability and willingness to perform expected social and occupational roles is absent or severely compromised.**<|eot_id|>