Personality disorder classification

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief:  Ayesha Anwar, M.B.B.S[2]

## Overview

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There are two approaches used to classify personality disorders; categorical and dimensional. Categorical classification is based on distinct operational criteria depending on behavioral characteristics. DSM-5 and ICD-10 both uses this approach. As compared to this, dimensional classification is based on the personality traits and using a quantitative distinction. It places normality at one end and disorder at other. DSM-5 classifies 10 personality disorders into three clusters due to similar characteristics: CLUSTER A is defined as odd and eccentric and include Paranoid, Schizoid, and Schizotypal. CLUSTER B is defined by erratic and emotional behavior and includes Antisocial, Borderline, Histrionic and Narcissist. CLUSTER C PDs patients are anxious and fearful and incorporate Avoidant, Dependent and Obsessive-Compulsive. ICD-10 classifies into 3 clusters as well, which are A, Odd/eccentric and includesParanoid and Schizoid, B, Dramatic and includes Dissocial, Emotionally unstable borderline type, Emotionally unstable impulsive type and Histrionic, and C, Anxious/fearful that include Anxious, Dependent and Anankastic.

## Classification

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### List of Personality Disorders Defined in the DSM

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* DSM-5 classifies 10 personality disorders into three clusters due to similar characteristics:
* CLUSTER A: odd and eccentric
* Paranoid-distrust and suspiciousness
* Schizoid-detachment from social relationships
* Schizotypal-distortion in interpersonal relationships and cognition, and behavioural eccentrism
* CLUSTER B: erratic and emotional
* Antisocial-disregard and violation of rights of others
* Borderline-instability in interpersonal relationships, and impulsivity
* Histrionic-eccessive emotionality and attention-seeking behaviour
* Narcissist-grandiosity and lack of empathy
* CLUSTER C: anxious and fearful
* Avoidant-social inhibition and fear of criticism
* Dependent-submissive and excessive need for reassurance
* Obsessive-Compulsive-preoccupation with perfectionism and orderliness
* ICD-10 classifies into 3 clusters as well, which are as follows:
* A: Odd/eccentric
* Paranoid
* Schizoid
* B: Dramatic
* Dissocial
* Emotionally unstable borderline type
* Emotionally unstable impulsive type
* Histrionic
* C: Anxious/fearful
* Anxious
* Dependent
* Anankastic

The DSM-IV lists ten personality disorders, grouped into three clusters. The DSM also contains a category for behavioral patterns that do not match these ten disorders, but nevertheless exhibit characteristics of a personality disorder. This category is labeled Personality Disorder NOS (Not Otherwise Specified).

Cluster A (odd or eccentric disorders)

* Paranoid personality disorder
* Schizoid personality disorder
* Schizotypal personality disorder

Cluster B (dramatic, emotional, or erratic disorders)

* Antisocial personality disorder
* Borderline personality disorder
* Histrionic personality disorder
* Narcissistic personality disorder

Cluster C (anxious or fearful disorders)

* Avoidant personality disorder
* Dependent personality disorder (not the same as Dysthymia)
* Obsessive-compulsive personality disorder (not the same as Obsessive-compulsive disorder)

#### Revisions and Exclusions from Past DSM Editions

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The revision of the previous edition of the DSM, DSM-III-R, also contained the Passive-aggressive Personality Disorder, the Self-defeating Personality Disorder, and the Sadistic Personality Disorder. Passive-Aggressive Personality Disorder is a pattern of negative attitudes and passive resistance in interpersonal situations. Self-defeating personality disorder is characterised by behaviour that consequently undermines the person's pleasure and goals. Sadistic Personality Disorder is a pervasive pattern of cruel, demeaning, and aggressive behavior. These categories were removed in the current version of the DSM, because it is questionable whether these are separate disorders. Passive-aggressive Personality Disorder and Depressive personality disorder were placed in an appendix of DSM-IV for research purposes.

### World Health Organization

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The ICD-10 section on mental and behavioral disorders includes categories of personality disorder and enduring personality changes. They are defined as ingrained patterns indicated by inflexible and disabling responses that significantly differ from how the average person in the culture perceives, thinks and feels, particularly in relating to others.[1]

The specific personality disorders are: paranoid, schizoid, dissocial, emotionally unstable (borderline type and impulsive type), histrionic, anankastic, anxious (avoidant) and dependent.[2]

There is also an 'Other' category involving conditions characterized as eccentric, haltlose (derived from "haltlos" (German) = drifting, aimless and irresponsible),[3] immature, narcissistic, passive-aggressive or psychoneurotic. An additional category is for unspecified personality disorder, including character neurosis and pathological personality.

There is also a category for Mixed and other personality disorders, defined as conditions that are often troublesome but do not demonstrate the specific pattern of symptoms in the named disorders. Finally there is a category of Enduring personality changes, not attributable to brain damage and disease. This is for conditions that seem to arise in adults without a diagnosis of personality disorder, following catastrophic or prolonged stress or other psychiatric illness.

### Other

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Some types of personality disorder were in previous versions of the diagnostic manuals but have been deleted. This includes two types that were in the DSM-III-R appendix as "proposed diagnostic categories needing further study" without specific criteria, namely sadistic personality disorder (a pervasive pattern of cruel, demeaning and aggressive behavior) and Self-defeating personality disorder (masochistic personality disorder) (characterised by behaviour consequently undermining the person's pleasure and goals).[4] The psychologist Theodore Millon and others consider some relegated diagnoses to be equally valid disorders, and may also propose other personality disorders or subtypes, including mixtures of aspects of different categories of the officially accepted diagnoses.[5]

Personality disorder diagnoses in each edition of American Psychiatric Association's Diagnostic Manual[6]

DSM-I | DSM-II | DSM-III | DSM-III-R | DSM-IV(-TR) | DSM-V Proposals
Personality |  |  |  |  |
Pattern disturbance: |  |  |  |  |
Inadequate  | Inadequate  |  |  |  |
Schizoid  | Schizoid  | Schizoid  | Schizoid  | Schizoid  |
Cyclothymic  | Cyclothymic  |  |  |  |
Paranoid  | Paranoid  | Paranoid  | Paranoid  | Paranoid  |
|  | Schizotypal  | Schizotypal  | Schizotypal  | Schizotypal*
Personality |  |  |  |  |
Trait disturbance: |  |  |  |  |
Emotionally unstable  | Hysterical  | Histrionic  | Histrionic  | Histrionic  |
|  | Borderline  | Borderline  | Borderline  | Borderline
Compulsive  | Obsessive-compulsive  | Compulsive  | Obsessive-compulsive  | Obsessive-compulsive  | Obsessive-compulsive
Passive-aggressive: |  |  |  |  |
Passive-depressive subtype  |  | Dependent  | Dependent  | Dependent  |
Passive-aggressive subtype  | Passive-aggressive  | Passive-aggressive  | Passive-aggressive  |  |
Aggressive subtype  |  |  |  |  |
| Explosive  |  |  |  |
| Asthenic  |  |  |  |
|  | Avoidant  | Avoidant  | Avoidant  | Avoidant
|  | Narcissistic  | Narcissistic  | Narcissistic  | Narcissistic**
Sociopathic personality |  |  |  |  |
Disturbance: |  |  |  |  |
Antisocial reaction  | Antisocial  | Antisocial  | Antisocial  | Antisocial  | Antisocial-psychopathic
Dyssocial reaction  |  |  |  |  |
Sexual deviation  |  |  |  |  |
Addiction |  |  |  |  |
|  |  | Appendix: | Appendix: | Appendix:
|  |  | Self-defeating  | Negativistic  | Dependent
|  |  | Sadistic  | Depressive  | Histrionic
|  |  |  |  | Paranoid
|  |  |  |  | Schizoid
|  |  |  |  | Negativistic
|  |  |  |  | Depressive

* – Not actually to be classified as a personality disorder; classified instead as a form of schizophrenia-spectrum disorder.
** – Originally proposed for deletion; status remains unclear for DSM-5.

### Millon's Description of Personality Disorders

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Psychologist Theodore Millon, who has written numerous popular works on personality, proposed the following description of personality disorders:

Millon's brief description of personality disorders[7]

Type of personality disorder  | Description
Paranoid | Guarded, defensive, distrustful and suspiciousness. Hypervigilant to the motives of others to undermine or do harm. Always seeking confirmatory evidence of hidden schemes. Feels righteous, but persecuted.
Schizoid | Apathetic, indifferent, remote, solitary, distant, humorless. Neither desires nor need human attachments. Withdrawal from relationships and prefer to be alone. Little interest in others, often seen as a loner. Minimal awareness of feelings of self or others. Few drives or ambitions, if any.
Schizotypal | Eccentric, self-estranged, bizarre, absent. Exhibits peculiar mannerisms and behaviors. Thinks can read thoughts of others. Preoccupied with odd daydreams and beliefs. Blurs line between reality and fantasy. Magical thinking and strange beliefs.
Antisocial | Impulsive, irresponsible, deviant, unruly. Acts without due consideration. Meets social obligations only when self-serving. Disrespects societal customs, rules, and standards. Sees self as free and independent.
Borderline | Unpredictable, manipulative, unstable. Frantically fears abandonment and isolation. Experiences rapidly fluctuating moods. Shifts rapidly between loving and hating. Sees self and others alternatively as all-good and all-bad. Unstable and frequently changing moods.
Histrionic | Dramatic, seductive, shallow, stimulus-seeking, vain. Overreacts to minor events. Exhibitionistic as a means of securing attention and favors. Sees self as attractive and charming. Constant seeking for others' attention.
Narcissistic | Egotistical, arrogant, grandiose, insouciant. Preoccupied with fantasies of success, beauty, or achievement. Sees self as admirable and superior, and therefore entitled to special treatment.
Avoidant | Hesitant, self-conscious, embarrassed, anxious. Tense in social situations due to fear of rejection. Plagued by constant performance anxiety. Sees self as inept, inferior, or unappealing. Feels alone and empty.
Dependent | Helpless, incompetent, submissive, immature. Withdraws from adult responsibilities. Sees self as weak or fragile. Seeks constant reassurance from stronger figures.
Obsessive–compulsive | Restrained, conscientious, respectful, rigid. Maintains a rule-bound lifestyle. Adheres closely to social conventions. Sees the world in terms of regulations and hierarchies. Sees self as devoted, reliable, efficient, and productive.
Depressive | Somber, discouraged, pessimistic, brooding, fatalistic. Presents self as vulnerable and abandoned. Feels valueless, guilty, and impotent. Judges self as worthy only of criticism and contempt.
Passive–aggressive (Negativistic) | Resentful, contrary, skeptical, discontented. Resist fulfilling others’ expectations. Deliberately inefficient. Vents anger indirectly by undermining others’ goals. Alternately moody and irritable, then sullen and withdrawn.
Sadistic | Explosively hostile, abrasive, cruel, dogmatic. Liable to sudden outbursts of rage. Feels selfsatisfied through dominating, intimidating and humiliating others. Is opinionated and closeminded.
Self-defeating (Masochistic) | Deferential, pleasure-phobic, servile, blameful, self-effacing. Encourages others to take advantage. Deliberately defeats own achievements. Seeks condemning or mistreatful partners.

### Additional Classification Factors

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Except for classifying by category and cluster, it is possible to classify personality disorders using such additional factors as severity, impact on social functioning, and attribution.[8]

## References

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1. ↑ WHO (2010) ICD-10: Specific Personality Disorders
2. ↑ "International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD-10) Version for 2010 (Online Version)". Apps.who.int. Retrieved on 2013-04-16.
3. ↑ Langmaack, C. (2000). "'Haltlose' type personality disorder (ICD-10 F60.8)". The Psychiatrist. 24 (6): 235–236. doi:10.1192/pb.24.6.235-b.
4. ↑ Fuller, AK, Blashfield, RK, Miller, M, Hester, T (1992). "Sadistic and self-defeating personality disorder criteria in a rural clinic sample". Journal of Clinical Psychology. 48 (6): 827–31. doi:10.1002/1097-4679(199211)48:6<827::AID-JCLP2270480618>3.0.CO;2–1 Check `|doi=` value (help). PMID 1452772.CS1 maint: Multiple names: authors list (link)
5. ↑ Millon, Theodore (2004) Personality Disorders in Modern Life, John Wiley & Sons, ISBN 0471668508.
6. ↑ Widiger, Thomas (2012). The Oxford Handbook of Personality Disorders. Oxford University Press. ISBN 978-0199735013.
7. ↑ Millon, Theodore (2004). Personality Disorders in Modern Life, p. 4. John Wiley & Sons, Inc., Hoboken, New Jersey. ISBN 0-471-23734-5.
8. ↑ Murray, Robin M. et al (2008). Psychiatry. Fourth Edition. Cambridge University Press. ISBN 978-0-521-60408-6.

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