Personality Disorders

Understanding Personality Disorders: When Personality Patterns Become Problems

What Are Personality Disorders?

Personality disorders represent enduring patterns of inner experience and behavior that deviate markedly from cultural expectations, are pervasive and inflexible, begin in adolescence or early adulthood, remain stable over time, and lead to significant distress or impairment. Unlike episodic mental health conditions such as depression or anxiety that come and go, personality disorders reflect deeply ingrained ways of thinking, feeling, and relating that have become so rigid or extreme that they interfere with functioning and cause suffering—either to the individual themselves or to those around them.

It’s crucial to understand that personality disorders aren’t simply “bad personalities” or character flaws. They typically develop as adaptations to difficult early environments—often involving trauma, neglect, invalidation, or unpredictable caregiving. The patterns that become problematic usually started as survival strategies that made sense in the person’s original context but have become overgeneralized, inflexible, and maladaptive in current circumstances. A child who learns to trust no one in an abusive environment has adapted intelligently to danger—but if that mistrust persists rigidly into all adult relationships, it becomes a disorder.

Personality disorders are traditionally organized into three clusters in the DSM-5:

  • Cluster A (odd/eccentric)
  • Cluster B (dramatic/emotional/erratic)
  • Cluster C (anxious/fearful).

However, understanding these disorders through the lens of the Five-Factor Model provides a more nuanced and clinically useful perspective. Each personality disorder reflects extreme positions on one or more of the five personality dimensions and their thirty facets, helping us understand not just what’s wrong but specifically which aspects of personality have become problematic.

Personality Disorders and the Five-Factor Model

Cluster A Personality Disorders: Problems with Openness and Agreeableness

Paranoid Personality Disorder reflects severe deficits in the trust facet of agreeableness, combined with heightened anxiety (neuroticism). Key features include:

  • Pervasive suspiciousness and mistrust of others
  • Belief that others have malicious intent without evidence
  • Reluctance to confide in anyone due to fear information will be used against them
  • Persistent grudges and inability to forgive perceived slights
  • Perception of attacks on character that others don’t see

Disturbed personality domains: Trust (agreeableness), anxiety (neuroticism)

Treatment goals: Reality-testing suspicious thoughts, examining evidence for beliefs about others’ intentions, gradually taking small interpersonal risks in safe relationships, understanding how past experiences shaped current mistrust

Effective approaches: Cognitive-Behavioral Therapy for examining and testing paranoid beliefs

Schizoid Personality Disorder involves very low emotionality (openness), low warmth (extraversion), and often low artistic interests. Key features include:

  • Detachment from relationships and preference for solitary activities
  • Restricted emotional expression and limited emotional experience
  • Apparent indifference to praise or criticism
  • Little desire for close relationships including family
  • Choosing solitary activities consistently

Disturbed personality domains: Emotionality (openness), warmth and gregariousness (extraversion), artistic interests (openness)

Treatment goals: Ensuring sufficient connection to prevent complete isolation, functioning in necessary social contexts, distinguishing between authentic preference for solitude and avoidance based on fear

Effective approaches: Therapy focused on distinguishing preference from anxiety-driven avoidance, not forcing sociability but preventing harmful isolation

Schizotypal Personality Disorder features extremely high openness (particularly imagination and liberalism) combined with low agreeableness and high neuroticism. Key features include:

  • Odd beliefs and magical thinking
  • Unusual perceptual experiences
  • Eccentric behavior and appearance
  • Ideas of reference (believing unrelated events have personal meaning)
  • Social anxiety and paranoid ideation

Disturbed personality domains: Imagination and liberalism (openness—excessive to point of impaired reality testing), trust (agreeableness), anxiety (neuroticism)

Treatment goals: Grounding techniques to anchor thinking in consensus reality, social skills training to reduce isolation, cognitive restructuring of odd beliefs, managing anxiety that fuels withdrawal

Effective approaches: CBT with reality testing, social skills training, low-dose antipsychotic medication when perceptual disturbances are prominent

Cluster B Personality Disorders: Problems with Agreeableness, Neuroticism, and Conscientiousness

Antisocial Personality Disorder reflects profound deficits across multiple agreeableness facets combined with low conscientiousness and often high anger. Key features include:

  • Disregard for and violation of others’ rights
  • Deceitfulness and repeated lying for personal gain
  • Impulsivity and failure to plan ahead
  • Irritability and aggressiveness
  • Reckless disregard for safety of self or others
  • Consistent irresponsibility
  • Lack of remorse for harming others

Disturbed personality domains: Trust, morality, altruism, cooperation, and sympathy (agreeableness), dutifulness and deliberation (conscientiousness), anger (neuroticism)

Treatment goals: Recognizing that behavior has consequences affecting own interests, developing pragmatic (if not empathetic) reasons to treat others better, managing impulsivity and anger

Effective approaches: Cognitive-Behavioral Therapy focused on criminal thinking patterns and concrete consequences (challenging because disorder undermines motivation for change)

Borderline Personality Disorder involves multiple neuroticism facets at extreme levels combined with low agreeableness and low conscientiousness. Key features include:

  • Frantic efforts to avoid real or imagined abandonment
  • Pattern of unstable and intense interpersonal relationships
  • Identity disturbance and unstable self-image
  • Impulsivity in self-damaging areas (spending, sex, substance use, reckless driving, binge eating)
  • Recurrent suicidal behavior, gestures, threats, or self-mutilation
  • Emotional instability and intense episodic dysphoria
  • Chronic feelings of emptiness
  • Inappropriate, intense anger or difficulty controlling anger
  • Transient stress-related paranoid ideation or severe dissociative symptoms

Disturbed personality domains: Anger, depression, anxiety, immoderation, and vulnerability (neuroticism), cooperation and modesty (agreeableness), deliberation (conscientiousness)

Treatment goals: Developing emotion regulation skills, distress tolerance, interpersonal effectiveness, reducing life-threatening behaviors, building stable identity

Effective approaches: Dialectical Behavior Therapy (DBT) is the gold-standard treatment, specifically designed for borderline personality disorder. DBT teaches:

  • Mindfulness (present-moment awareness and acceptance)
  • Distress tolerance (surviving crises without making things worse)
  • Emotion regulation (understanding and managing intense feelings)
  • Interpersonal effectiveness (getting needs met while maintaining relationships and self-respect)

Also effective: Mentalization-Based Therapy (MBT), Transference-Focused Psychotherapy (TFP), Schema Therapy

Histrionic Personality Disorder features extremely high extraversion combined with high neuroticism, low deliberation, and sometimes low modesty. Key features include:

  • Excessive emotionality and attention-seeking
  • Inappropriate sexually seductive or provocative behavior
  • Rapidly shifting and shallow expression of emotions
  • Using physical appearance to draw attention
  • Impressionistic speech lacking detail
  • Self-dramatization and theatrical expression
  • Suggestibility and easily influenced by others
  • Considering relationships more intimate than they actually are

Disturbed personality domains: Warmth, gregariousness, excitement-seeking (extraversion—excessive), self-consciousness and emotionality (neuroticism—displayed theatrically), deliberation (conscientiousness), modesty (agreeableness)

Treatment goals: Developing stable self-esteem independent of others’ attention, learning to identify and tolerate genuine emotions beneath theatrical displays, building more authentic relationships

Effective approaches: Cognitive-Behavioral Therapy and psychodynamic approaches to examine attention-seeking patterns and develop healthier sources of validation

Narcissistic Personality Disorder involves extremely low modesty and low sympathy, sometimes low emotionality, and often paradoxically high vulnerability beneath grandiose presentation. Key features include:

  • Grandiose sense of self-importance
  • Preoccupation with fantasies of unlimited success, power, brilliance, beauty, or ideal love
  • Belief in being special and unique
  • Need for excessive admiration
  • Sense of entitlement
  • Interpersonally exploitative behavior
  • Lack of empathy
  • Envy of others or belief that others are envious of them
  • Arrogant, haughty behaviors or attitudes

Disturbed personality domains: Modesty and sympathy (agreeableness—severely low), emotionality (openness—sometimes low), vulnerability (neuroticism—paradoxically high beneath grandiose facade)

Treatment goals: Developing realistic self-appraisal, building genuine self-esteem based on actual accomplishments and relationships rather than superiority, developing empathy and concern for others, managing vulnerability beneath grandiose facade

Effective approaches: Schema Therapy and Mentalization-Based Therapy addressing underlying shame and childhood wounds beneath grandiosity (treatment challenging because disorder involves difficulty acknowledging problems)

Cluster C Personality Disorders: Problems with Neuroticism and Low Extraversion

Avoidant Personality Disorder features extremely high self-consciousness, anxiety, and vulnerability combined with very low warmth, gregariousness, and assertiveness. Key features include:

  • Avoidance of occupational activities involving interpersonal contact due to fear of criticism or rejection
  • Unwillingness to get involved with people unless certain of being liked
  • Restraint within intimate relationships due to fear of being shamed or ridiculed
  • Preoccupation with being criticized or rejected in social situations
  • Inhibition in new interpersonal situations due to feelings of inadequacy
  • View of self as socially inept, personally unappealing, or inferior
  • Reluctance to take personal risks or engage in new activities

Disturbed personality domains: Self-consciousness, anxiety, and vulnerability (neuroticism—extremely high), warmth, gregariousness, and assertiveness (extraversion—very low)

Treatment goals: Gradually facing feared social situations, examining and challenging beliefs about rejection and inadequacy, developing social skills and confidence, recognizing that feared catastrophes rarely occur

Effective approaches: Cognitive-Behavioral Therapy with exposure to social situations (highly effective), social skills training, group therapy for safe practice environments

Dependent Personality Disorder involves extremely low assertiveness and activity, high anxiety and vulnerability, and very low competence (belief in own capabilities). Key features include:

  • Difficulty making everyday decisions without excessive advice and reassurance
  • Need for others to assume responsibility for major areas of life
  • Difficulty expressing disagreement due to fear of loss of support or approval
  • Difficulty initiating projects or doing things independently
  • Going to excessive lengths to obtain nurturance and support from others
  • Feeling uncomfortable or helpless when alone
  • Urgently seeking another relationship when one ends
  • Unrealistic preoccupation with fears of being left to care for oneself

Disturbed personality domains: Assertiveness and activity (extraversion—extremely low), anxiety and vulnerability (neuroticism—high), competence (conscientiousness—very low belief in own capabilities)

Treatment goals: Building self-efficacy and confidence, making independent decisions starting with small matters, developing assertiveness, tolerating disagreement, recognizing one’s own competence

Effective approaches: Cognitive-Behavioral Therapy addressing dependent beliefs, behavioral experiments testing independence, gradual reduction of reassurance-seeking

Obsessive-Compulsive Personality Disorder (distinct from OCD) features extremely high conscientiousness that has become rigid and perfectionistic, combined with low openness and sometimes low emotionality. Key features include:

  • Preoccupation with details, rules, lists, order, organization, or schedules
  • Perfectionism that interferes with task completion
  • Excessive devotion to work and productivity to exclusion of leisure and friendships
  • Over-conscientiousness, scrupulousness, and inflexibility about matters of morality, ethics, or values
  • Unable to discard worn-out or worthless objects
  • Reluctance to delegate tasks or work with others unless they submit exactly to one’s way
  • Miserly spending style toward self and others
  • Rigidity and stubbornness

Disturbed personality domains: Orderliness, dutifulness, and deliberation (conscientiousness—extremely high and rigid), adventurousness and liberalism (openness—low), emotionality (openness—sometimes low)

Treatment goals: Developing flexibility, accepting “good enough” rather than perfect, balancing work with relationships and leisure, tolerating uncertainty and loss of control

Effective approaches: Cognitive-Behavioral Therapy addressing perfectionistic beliefs and rigid rules, exposure to imperfection and uncertainty to reduce need for control

Core Treatment Goals: Converting Problems into Non-Problems

The overarching goal in treating personality disorders is not to change someone’s fundamental personality but to increase psychological flexibility—the ability to adapt one’s responses to different contexts rather than rigidly applying the same patterns regardless of circumstances. Specific goals include:

  • Increasing Self-Awareness – Understanding one’s own patterns, triggers, and the origins of problematic behaviors. Many people with personality disorders lack insight into how their behavior affects others or creates their own suffering.
  • Developing Emotional Regulation – Learning to identify, tolerate, and effectively manage intense emotions without resorting to destructive behaviors. This is particularly crucial for Cluster B disorders.
  • Building Interpersonal Skills – Developing the capacity to form stable, satisfying relationships; communicate needs effectively; set appropriate boundaries; and resolve conflicts constructively.
  • Reducing Rigid Patterns – Creating flexibility in thinking and behavior so the person can respond appropriately to different situations rather than applying the same maladaptive pattern everywhere.
  • Improving Reality Testing – Developing accurate perceptions of self, others, and situations rather than distorted views shaped by personality pathology.
  • Enhancing Distress Tolerance – Building capacity to experience discomfort, uncertainty, or negative emotions without immediately acting to escape them through destructive means.
  • Developing Adaptive Coping Strategies – Replacing maladaptive behaviors (self-harm, substance use, aggression, avoidance) with healthier ways of managing stress and meeting needs.
  • Building Stable Identity – Developing coherent sense of self, values, and life direction, particularly important for borderline and dependent patterns.

Evidence-Based Treatment Modalities for Personality Disorders

  • Dialectical Behavior Therapy (DBT) – Gold-standard, empirically-supported treatment specifically developed for Borderline Personality Disorder. DBT addresses the core problems of emotional dysregulation, impulsivity, unstable relationships, and self-harm through four components: individual therapy, skills training group, phone coaching for crisis situations, and consultation team for therapists. The four skill modules teach mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness. DBT has been adapted for other conditions involving emotion dysregulation and impulsivity. The approach balances acceptance (validating the person’s experience and difficulty) with change (actively building new skills).
  • Schema Therapy – Integrates cognitive-behavioral, attachment, psychodynamic, and experiential approaches to address the deep-rooted patterns (“schemas”) formed in childhood that underlie personality disorders. Particularly effective for Narcissistic, Avoidant, and Borderline Personality Disorders. Schema Therapy identifies maladaptive schemas (such as “I’m unlovable,” “Others will hurt me,” “I’m special and above rules”), explores their childhood origins, and works to modify them through cognitive techniques, behavioral experiments, imagery work, and the therapeutic relationship. The approach uses “limited reparenting” where the therapist provides some of what was missing in childhood within appropriate professional boundaries.
  • Mentalization-Based Therapy (MBT) – Developed specifically for Borderline Personality Disorder and effective for other personality disorders involving interpersonal difficulties. Mentalization refers to the capacity to understand one’s own and others’ mental states—thoughts, feelings, desires, and beliefs. Many personality disorders involve impaired mentalization—difficulty understanding why they or others feel and act as they do. MBT helps develop this capacity through structured exploration of mental states in session, particularly in moments of emotional intensity when mentalization typically breaks down.
  • Transference-Focused Psychotherapy (TFP) – A psychodynamic approach specifically designed for Borderline Personality Disorder and other severe personality disorders. TFP focuses on the patterns that emerge in the therapeutic relationship itself (transference) as a window into the person’s internal world and relationship patterns. The therapist carefully interprets these patterns, helping the person develop more integrated and realistic views of self and others.
  • Cognitive-Behavioral Therapy (CBT) – Adapted for personality disorders by focusing on the core dysfunctional beliefs that maintain problematic patterns. For each personality disorder, CBT identifies the central beliefs (such as “Others will exploit me” in paranoid PD, “I’m inadequate” in avoidant PD, “Others exist to meet my needs” in narcissistic PD) and uses cognitive restructuring and behavioral experiments to test and modify these beliefs. CBT for personality disorders is typically longer-term than CBT for other conditions and focuses more on underlying assumptions than surface-level thoughts.
  • Systems Training for Emotional Predictability and Problem Solving (STEPPS) – A group-based treatment for Borderline Personality Disorder that combines cognitive-behavioral techniques with skills training and systems approach. It teaches emotion regulation and behavior management skills while involving the person’s support system to reinforce these skills in daily life.
  • Psychodynamic Psychotherapy – Explores how early experiences shaped current patterns, brings unconscious processes into awareness, and uses the therapeutic relationship to understand and modify relational patterns. Long-term psychodynamic therapy can be effective for various personality disorders, particularly when the person has good insight and motivation for deep exploration.

Medication as Adjunctive Treatment

Personality disorders themselves are not treated with medication, but medications can help manage specific symptoms:

  • Antidepressants (SSRIs) may help with depression, anxiety, and impulsivity
  • Mood stabilizers can reduce emotional instability and impulsivity
  • Low-dose antipsychotics may help with transient stress-related paranoia or severe cognitive distortions
  • Medication should always be combined with psychotherapy as medication alone does not address the core personality patterns

Treatment Challenges and Realistic Expectations

Treating personality disorders requires patience, persistence, and realistic expectations:

  • These patterns developed over decades and won’t change quickly
  • Treatment typically requires one to three years of consistent work, sometimes longer
  • Progress often includes setbacks
  • The person’s characteristic patterns will sometimes emerge in therapy itself—mistrust, emotional crises, idealization followed by devaluation, avoidance, rigidity
  • Working through these patterns in therapy becomes part of the treatment
  • Many people with personality disorders have difficulty recognizing their patterns as problematic, making engagement challenging
  • Building and maintaining the therapeutic relationship is often the most crucial and difficult aspect of treatment
  • The therapeutic relationship itself becomes a laboratory for developing new relational patterns

However, outcomes can be very positive. Research shows that with appropriate treatment, many people with personality disorders can achieve significant improvement in functioning, relationships, and quality of life. Even when core traits remain, people can develop sufficient flexibility and skills to prevent these traits from causing continued impairment.

A Compassionate, Hopeful Perspective

If you recognize yourself in descriptions of personality disorders, or if others have suggested you might benefit from understanding these patterns, it’s important to know that personality disorders are among the most treatable mental health conditions despite their reputation for being intractable. The key is finding a therapist specifically trained in treating personality disorders who can provide consistent, long-term, structured treatment using evidence-based approaches.

Personality patterns developed as adaptations—they made sense at one time even if they’re causing problems now. Treatment isn’t about judging these patterns as bad but about understanding them, appreciating their origins, and developing new, more flexible patterns that serve you better in your current life. The goal is freedom—freedom to respond to situations based on what’s actually happening rather than being trapped in rigid patterns, freedom to have satisfying relationships, and freedom to live according to your values rather than being controlled by fear, emotional intensity, or habitual reactions.

Effective treatment can help you feel calmer, more confident, and more in control of your life. I invite you to reach out to discuss how we can work together toward the relief you’re seeking. Phone: 410-970-4917; Email: edgewaterpsychotherapy@gmail.com; I look forward to hearing from you and helping you on your journey toward greater peace and wellbeing