Quartz 5

Personality Disorders

5 min read

**Personality Disorders

A personality disorder is an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture, and is:

  • pervasive and inflexible
  • has an onset in adolescence or early adulthood
  • is stable over time
  • leads to distress or impairment.

Personality disorders must be distinguished from personality traits that do not reach the threshold for a personality disorder. Personality traits are diagnosed as a personality disorder only when they are inflexible, maladaptive, and persisting and cause significant functional impairment or subjective distress.

ICD-11 has a diagnosis for Personality Difficulty (QE50.7), which 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.

Historical Overview

10 types in DSM-5TR Section II (outdated and criticized) (5)
Carried over from DSM IV. Criticism and limitations have led to updated systems.

  • Cluster A (odd/eccentric): Paranoid, Schizoid, Schizotypal

  • Cluster B (dramatic/emotional/erratic): Borderline, Narcissistic, Antisocial, Histrionic

  • Cluster C (anxious/fearful): Avoidant, Dependent, Obsessive-Compulsive

  • Some types (antisocial, borderline) found to lessen or resolve as people age; others (eg, obsessive/compulsive, schizotypal) are less likely to do so.

  • About 9% of the general population and up to half of psychiatric patients in hospital units and clinics have a personality disorder

  • no clear distinctions in terms of sex, socioeconomic class, and race with 2 exceptions. (3,4)

  • for antisocial personality disorder, males outnumber females 3:1  

  • For borderline personality disorder, females outnumber males 3:1 (but only in clinical settings, not in the general population)

  • 50% heritable 

Criticisms: evidence for continuity between normal and abnormal personalities, heterogeneity within diagnostic categories, high co-occurrence among different personality disorders, high prevalence of “personality disorder not otherwise specified,” arbitrary diagnostic thresholds, and restricted ability to predict treatment efficacy. (1,6)

These limitations prompted development of the Alternative Model for Personality Disorders (AMPD) in DSM-5 Section III, which uses a hybrid categorical-dimensional approach. (5)

  • retained only 6 of the 10 traditional categories (schizotypal, antisocial, borderline, narcissistic, avoidant, and obsessive-compulsive)

  • proposes a combination of categorical and “dimensional” approaches, forming a hybrid diagnostic scheme. The dimensional approach recognizes individual differences in the manifestation of personality traits - from mild to moderate to severe - with underlying dimensions (constructs) that account for high levels of overlap between personality disorders.
    Requires Criterion A and B for diagnosis:

  • A: Moderate or greater impairment in personality (1 self / 1 interpersonal).

  • B: One or more pathological personality traits.

    • Pathological personality traits are organized into five broad domains: Negative Affectivity, Detachment, Antagonism, Disinhibition, and Psychoticism. Within the five broad trait domains are 25 specific trait facets
      Section III includes diagnostic criteria for antisocial, avoidant, borderline, narcissistic, obsessive-compulsive, and schizotypal personality disorders. Each personality disorder is defined by typical impairments in personality functioning (Criterion A) and characteristic pathological personality traits (Criterion B).

Overview of the 6 AMPD diagnoses:

  • Typical features of antisocial personality disorder are a failure to conform to lawful and ethical behavior, and an egocentric, callous lack of concern for others, accompanied by deceitfulness, irresponsibility, manipulativeness, and/or risk taking.
  • Typical features of avoidant personality disorder are avoidance of social situations and inhibition in interpersonal relationships related to feelings of ineptitude and inadequacy, anxious preoccupation with negative evaluation and rejection, and fears of ridicule or embarrassment.
  • Typical features of borderline personality disorder are instability of self-image, personal goals, interpersonal relationships, and affects, accompanied by impulsivity, risk taking, and/or hostility.
  • Typical features of narcissistic personality disorder are variable and vulnerable self-esteem, with attempts at regulation through attention and approval seeking, and either overt or covert grandiosity.
  • Typical features of obsessive-compulsive personality disorder are difficulties in establishing and sustaining close relationships, associated with rigid perfectionism, inflexibility, and restricted emotional expression.
  • Typical features of schizotypal personality disorder are impairments in the capacity for social and close relationships, and eccentricities in cognition, perception, and behavior that are associated with distorted self-image and incoherent personal goals and accompanied by suspiciousness and restricted emotional expression.

The ICD-11 took this further, discarding all historical categories

(except borderline personality disorder - this category has been retained as a specifier for the purpose of giving mental health services time to adjust their systems to the dimensional model, after which the BPD specifier is expected to be removed.)

Two required diagnostic steps in the new classification:

  • Step 1: Assess whether the individual meets the general criteria for a personality disorder.
  • Step 2: If criteria are met, determine the severity of the personality disorder.
    • Mild Personality Disorder
    • Moderate Personality Disorder
    • Severe Personality Disorder

Two optional additional steps (if needed):

  • Step 3: (optional): Assess personality trait domains to more fully characterize the individual’s personality disturbance.
         Trait domain specifiers that may be recorded include the following
    • Negative Affectivity
    • Detachment
    • Dissociality
    • Disinhibition
    • Anankastia
  • Step 4: (optional): Apply a borderline pattern specifier, when applicable.

Summary:

Recent research on ICD-11 personality disorder model and AMPD con firms that both frameworks show good clinical utility in inpatient and outpatient settings. (6) At this point in the evolution of the way that personality disorders are diagnosed, clinicians can likely utilize either the AMPD or ICD-11 frameworks with equal evidentiary basis. 

References

  1. Sharp, C. (2022). Personality Disorders. The New England Journal of Medicine, 387(10), 916-923. https://doi.org/10.1056/NEJMra2120164
  2. World Health Organization. ICD-11 for Mortality and Morbidity Statistics: Personality disorder. Updated 2025. Accessed December 15, 2025. https://icd.who.int/browse/2025-01/mms/en#941859884
  3. Alegria AA, Blanco C, Petry NM, et al: Sex differences in antisocial personality disorder: Results from the National Epidemiological Survey on Alcohol and Related Conditions. Personal Disord 4(3):214-222, 2013. doi: 10.1037/a0031681
  4. Sansone RA, Sansone LA: Gender patterns in borderline personality disorder. Innov Clin Neurosci 8(5):16-20, 2011. PMID: 21686143
  5. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed, text rev (DSM-5-TR). American Psychiatric Association Publishing; 2022. Accessed December 15, 2025. doi:10.1176/appi.books.9780890425596
  6. Bornstein, R. (2026). From categories to traits: assessing personality dysfunction in ICD-11 and the DSM-5 alternative model for personality disorders. Current Opinion in Psychiatry, 39 (1), 58-66. doi: 10.1097/YCO.0000000000001040.

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