Personality disorders are long-term patterns of thoughts, feelings, and behaviors that differ from cultural expectations and affect how an individual relates to others, manages their emotions, and perceives themselves.
Because these patterns are deeply ingrained and appear across many life situations, not just during crises, they are often mistaken as an individual having a “difficult” personality, rather than a very complex mental health condition. As a result, personality disorders are often misrepresented and stigmatized, though they can cause significant distress and impairment in functioning across different areas of life.
Definition and DSM-5 Criteria
According to the DSM-5, for a personality disorder diagnosis:
- An individual must present with a pattern of behavior across at least two key areas: cognition, affectivity, interpersonal functioning, or impulse control.
- The behavior must be long-term (often since early adulthood), and result in significant impairment or distress.
- The behavior must be stable over time and across different situations.
- The behavior must be distinct from cultural norms and can’t be better explained by another mental health condition.
The DSM-5 divides ten specific personality disorders into three clusters, based on their predominant traits: Cluster A (odd/eccentric), Cluster B (dramatic/erratic), and Cluster C (anxious/fearful).
Cluster A – Odd or Eccentric
Individuals with personality disorders included in this cluster often feel socially detached, suspicious, or eccentric in their thinking patterns and behavior, making building connections and trust difficult.
Personality disorders in this cluster include:
- Paranoid Personality Disorder is characterized by deep mistrust of others and interpreting ordinary events as threatening or malicious (ex. believing coworkers are plotting against them without any evidence).
- Schizoid Personality Disorder presents as a detachment from relationships, preference for solitary activities, and emotional coldness (ex. a relative who avoids all family gatherings and seems indifferent to compliments or criticism).
- Schizotypal Personality Disorder is defined by discomfort in close relationships, magical beliefs, and strange speech and mannerisms (ex. believing a special magical ritual can heal their loved one from a medical condition).
Due to their psychotic features, clinicians are careful when diagnosing disorders from Cluster A as they can be closely tied to Schizophrenia, Bipolar Disorder, or Depressive Disorder.
Treatment
People with Cluster A disorders rarely seek treatment unless symptoms interfere with daily functioning. Some therapeutic approaches used for treatment include:
- Cognitive Behavioral Therapy (CBT) helps individuals challenge their paranoid thoughts, improve social engagement, and reduce mistrust.
- Psychodynamic Therapy explores early childhood experiences that may have contributed to suspicious or detached behaviors, fostering insight and self-awareness.
- Group therapy is probably one of the more challenging approaches for individuals struggling with a disorder from this cluster due to their mistrust and social detachment/anxiety. In order to be successful, group therapy needs to be carefully structured, for example using smaller, more supportive groups. Therapists need to create psychological safety and gradually work on trust-building.
Although no medication directly treats these disorders, low-dose antipsychotics can be prescribed to manage paranoia or perceptual distortions. If there are co-occurring mood symptoms, antidepressants (SSRIs) can be used to manage them.
Cluster B – Dramatic, Emotional, or Erratic
This cluster contains Personality Disorders characterized by strong emotional reactions, turbulent relationships, and impulsive or attention-seeking behavior, which usually leads to interpersonal conflict:
- Antisocial Personality Disorder is characterized by disregard for others’ rights, deceitfulness, problems with authority, and a lack of remorse (ex. constant lying, conning others to get their way, and manipulating without feeling guilt).
- Borderline Personality Disorder presents with instability in mood, self-image, and relationships, fear of abandonment, and self-harm behaviors (ex. repeatedly texting their partner and threatening with self-harm if they don’t respond).
- Histrionic Personality Disorder is characterized by extreme sensitivity, attention-seeking behavior, and a need to be the center of attention (ex. dramatic outbursts or inappropriate flirting).
- Narcissistic Personality Disorder has two subtypes, overt and covert narcissism. Overt narcissistic behavior shows feelings of grandiosity and a need for open admiration, while covert narcissistic behavior is more subtle. However, both types involve fragile self-esteem (ex. becoming furious when not praised for doing something, even when putting in minimal effort).
Treatment
Treatment of Cluster B personality disorders is often difficult because patients may experience frequent crises, fluctuate between devaluing and idealizing their therapist, and struggle with unstable or chaotic lifestyles.
Consistent, structured therapy is often an essential part of treatment. Different approaches include:
- Dialectical Behavior Therapy (DBT) can be especially useful in the treatment of Borderline Personality Disorder. It teaches emotional regulation, distress tolerance, mindfulness, and interpersonal effectiveness.
- Cognitive Behavioral Therapy (CBT) can help modify impulsive behaviors and distorted thinking, particularly in Narcissistic and Antisocial Personality Disorders.
- Schema Therapy addresses and replaces deeply ingrained maladaptive patterns with more healthy ones. These can include entitlement, fear of abandonment, or unstable self-image.
- Family and Couples Therapy supports relational dynamics. It plays a big part in the treatment of disorders in this particular cluster due to their symptoms often leading to interpersonal conflict. It helps establish boundaries and provides guidance for family members and partners in managing volatile interactions.
Just like for Cluster A (and later on Cluster C), no medication is used to directly treat Cluster B disorders. However, antidepressants (SSRIs), mood stabilizers, or atypical antipsychotics can be used to target co-occurring symptoms of depression, anxiety, mood swings, or aggression.
Cluster C – Anxious or Fearful
Individuals struggling with Personality Disorders in this category often prioritize safety, control, and approval in ways that restrict their lives. They tend to be excessively anxious, fearful, perfectionistic, or dependent.
Disorders in this cluster include:
- Avoidant Personality Disorder is characterized by extreme fear of rejection, leading to social withdrawal, although the person does want social connection. Individuals often feel inadequate, excessively shy, and are preoccupied with rejection or criticism (ex. avoiding a romantic relationship or friendships unless they are completely certain they will be accepted and liked).
- Dependent Personality Disorder often leads to submissive behavior due to individuals needing constant reassurance and guidance. They need to be taken care of and have difficulties making decisions, no matter how small, in their daily life (ex. they will ask for advice on what to wear or eat, or they may tolerate abuse in order to maintain a relationship).
- Obsessive-Compulsive Personality Disorder (OCPD) can sometimes be confused with Obsessive-Compulsive Disorder (OCD), however they are different conditions. OCPD is a personality disorder characterized by preoccupation with orderliness, perfectionism, and control, while OCD is an anxiety disorder consisting of intrusive thoughts and repetitive behaviors, which can manifest in different ways. Individuals with OCPD tend to be very stubborn and rigid, prioritizing rules, control, and details over the bigger picture, sacrificing any flexibility (ex. constantly checking their work for errors, leading to missed deadlines).
Treatment
Disorders in Cluster C are generally more responsive to therapy, with Cognitive Behavioral Therapy being the most effective approach. It focuses on reducing avoidance behaviors, increasing assertiveness, and addressing perfectionistic or dependent patterns.
Some other approaches include:
- Psychodynamic Therapy focuses on underlying fears of rejection, inadequacy, or loss of control through the exploration of early life experiences.
- Group Therapy offers a safe space for social interaction (especially for Avoidant Personality Disorder) and builds confidence in interpersonal relationships.
- Family or Couples Therapy helps relatives establish a supportive but non-enabling environment and improve communication patterns.
When it comes to medication, antidepressants (SSRIs) and anti-anxiety medications can be prescribed in order to manage co-occurring anxiety or depression, especially in Avoidant and Obsessive-Compulsive Personality Disorders.
Further resources
- New England Personality Disorder Association – a nonprofit organization providing support and education for people struggling with Personality Disorders and their families.
- American Psychiatric Association (APA) – Help for Personality Disorders.
- National Alliance on Mental Illness (NAMI) – Family to Family (an educational program).
- 988 Lifeline – A 24/7 support for anyone in crisis or emotional distress, which can be reached by dialing 988 or via web chat.
