Personality disorders

Last updated: October 30, 2023

Summarytoggle arrow icon

Personality disorders are characterized by deeply rooted, egosyntonic behavioral traits that differ significantly from the expected and accepted norms of an individual's culture. Consequently, regional and cultural characteristics should always be considered before diagnosing a patient with a personality disorder. Personality disorders usually arise during adolescence and are difficult to treat. A key feature of personality disorders is that they must cause impairment in social and/or occupational functioning. Personality disorders are associated with a higher risk of developing other psychiatric disorders, especially in times of stress. In acute care settings, individuals with personality disorders may present with somatic or psychiatric (e.g., self-harm or suicidal ideation) symptoms. Physician-patient encounters may be challenging, and steps should be taken to establish a productive therapeutic relationship.

Overviewtoggle arrow icon


  • Personality trait: a stable, repetitive pattern of thoughts, feelings, and behaviors characteristics of a particular individual as expressed in a wide range of social and personal contexts
  • The Big Five dimensions of personality [1]
    • The most widely recognized personality model that maps personality according to five distinct dimensions, namely the degree of conscientiousness, agreeableness, neuroticism, openness to experience, and extraversion expressed by an individual.
    • The dimensions are equally determined by genetic and environmental factors and remain stable throughout adulthood.
    • Each dimension is the sum of several factors or characteristics and should not be assessed in binary categories of presence and absence but rather as traits on a spectrum.
The Big Five dimensions of personality [1]
Acronym Dimension Components
  • Openness to experience
  • Curiosity, fantasy, preferences towards abstract thoughts, aesthetics, and ideas
  • Conscientiousness
  • Sense of duty, order, self-discipline, competence
  • Extraversion
  • Activity, sociability, excitement seeking, assertiveness
  • Agreeableness
  • Friendliness, trust, modesty, altruism, degrees of cooperation
  • Neuroticism
  • Resilience, self-consciousness, impulsiveness, anxiety, hostility, depression

Think OCEAN to remember the Big Five personality traits: Openness to experience, Conscientiousness, Extraversion, Agreeableness, and Neuroticism.

Personality disorders

  • Definition: pervasive, inflexible, and maladaptive personality patterns that lead to significant distress and/or functional impairment
  • Epidemiology
    • Age of onset: late childhood or adolescence
    • Antisocial and narcissistic personality disorders are more commonly diagnosed in male individuals.
    • Histrionic and borderline personality disorders are more commonly diagnosed in female individuals.
  • Etiology
    • Multifactorial
    • Caused by a combination of hereditary (e.g., personality disorders in parents) and psychosocial factors (e.g., child neglect, abuse)
  • Classification: : The DSM-5 divides personality disorders into three clusters (A, B, and C).
Classification of personality disorders according to the DSM-5 [2]
Cluster Characteristic behavior Personality disorders Commonly associated conditions
Cluster A
  • Odd
  • Eccentric
  • Unable to form close interpersonal relationships
  • Typically: no psychosis
Cluster B
  • Dramatic
  • Emotional
  • Erratic
Cluster C
  • Fearful
  • Avoidant
  • Anxious

Personality disorders are associated with a high risk of psychiatric comorbidities, especially during times of stress.

For the general character of each cluster, remember WWW: Weird (A), Wild (B), Worried (C)


Cluster Atoggle arrow icon


Overview of cluster A personality disorders

Characteristic features

Additional distinguishing features
Paranoid personality disorder
  • Excessive suspicion and distrust of others
  • Perception of benign events or remarks as attacks
  • Holding grudges
Schizoid personality disorder
  • Social detachment and constricted affect
  • Comfortable with social isolation
  • Lack of interest in sexual contacts with others
Schizotypal personality disorder
  • Excessive discomfort in social relations, eccentric behavior

Cluster A: paranoid people are Accusatory, schizoid people are Aloof, and schizotypal people are Awkward.

Cluster A personalities

Paranoid personality disorder [2]

Schizoid personality disorder [2]

  • Diagnostics: according to the DSM-5
    • At least 4 of the following criteria have to be met:
      • Voluntary detachment from social relationships (e.g., family)
      • Enjoys few activities
      • Prefers solitary activities
      • No or little interest in sexual relationships
      • Lacks people to trust or close friends
      • Indifferent to praise or criticism
      • Restricted emotional expression, flattened affect
  • Other features: comfortable with social isolation (unlike in avoidant personality disorder)
  • Differential diagnoses

Schizotypal personality disorder (a schizophrenia spectrum disorder) [2]

People with schizO-TYPE-al personality disorder are Odd TYPEs.


Cluster Btoggle arrow icon


Overview of cluster B personality disorders

Characteristic features

Additional distinguishing features
Antisocial personality disorder
  • Lack of respect for and transgressions against the rights of others
  • Deceitfulness
  • Lack of remorse
  • Age ≥ 18 years and evidence of conduct disorder with onset ≤ 15 years
Borderline personality disorder
  • Excessive impulsivity and unstable self-image, emotions, and relationships with others
  • Fear of abandonment
  • Suicidal behavior
  • Feelings of emptiness
  • Intense anger
  • Episodes of paranoid ideation and/or dissociative symptoms
Histrionic personality disorder
  • Attention-seeking and excessively emotional behavior
  • Inappropriate, sexually provocative, and/or seductive behavior during interactions with others
  • Shallow and rapidly shifting emotions
  • Easily influenced by others or circumstances
  • Overestimation of the degree of intimacy in relationships
Narcissistic personality disorder
  • Sense of grandiosity, excessive need for attention and admiration, low empathy
  • Taking advantage of others to achieve own goals
  • Envy
  • Difficulties dealing with criticism

Cluster B: antisocial people are Bad, some people are Borderline, histrionic people are flamBoyant, and narcissistic people must be the Best.

Antisocial personality disorder [2]

  • Epidemiology: : more common in men
  • Diagnostics: according to the DSM-5
    • The patient is at least 18 years of age.
    • Three or more of the following symptoms of conduct disorder are present from at least 15 years of age.
      • Deceitfulness, manipulation
      • A history of hostility and repeated aggression
      • Repeatedly engaging in criminal activity
      • Impulsivity/failure to plan ahead
      • A reckless disregard for one's own safety and/or the safety of others
      • A failure to fulfill work-related or financial obligations
      • A lack of remorse and/or emotional indifference to the plight of others
    • Antisocial behavior that is not only due to manifestations of bipolar disorder or schizophrenia
  • Differential diagnoses
  • Treatment: : extremely difficult to treat
    • The aim of treatment is usually to prevent existing symptoms from progressing.
    • Older individuals with antisocial personality disorder are typically incarcerated.

People with antiSOCIal personality disorders are SOCIopaths.

“Travel to CONey (CONduct disorder) island before age 15 and you will be sent to ANTarctica (ANTisocial personality disorder) after age 18

Borderline personality disorder [2]

Histrionic personality disorder [2]

  • Diagnostics: according to the DSM-5
    • At least 5 of the following criteria have to be met:
      • Attention-seeking: drawing attention to oneself by way of physical appearance
      • Uses dramatic speech
      • Exaggerated emotional expression
      • Not being the center of attention causes discomfort
      • Feelings are often shallow and unstable.
      • Exhibiting inappropriate, sexually provocative, and/or seductive behavior during interactions with others
      • Easily influenced by others or circumstances
      • Overestimating the degree of intimacy in relationships
  • Differential diagnoses

Narcissistic personality disorder [2]

  • Diagnostics: according to the DSM-5
    • At least 5 of the following criteria have to be met:
      • Excessive sense of self-importance (e.g., exaggerates achievements)
      • Fantasizes disproportionately about success, power, etc.
      • Believe in being special and a feeling of superiority
      • Great need for admiration
      • Expecting favorable treatment from others
      • Exploitation of others to achieve their own goals
      • Lack of empathy
      • Often envious of others
      • Often behaves arrogant and/or snobbish
    • Important to distinguish from manic or hypomanic episodes in bipolar disorder
  • Other features: : difficulty dealing with criticism (e.g., reacts with anger and/or defensiveness), fragile self-esteem
  • Classification: 3 subtypes
    • Grandiose, overt
    • High-functioning
    • Vulnerable/covert
  • Differential diagnoses


Cluster Ctoggle arrow icon


Overview of cluster C personality disorders

Characteristic features

Additional distinguishing features
Avoidant personality disorder
  • Excessive shyness and sensitivity to criticism, low self-esteem
  • Avoiding risks and new activities for fear of failure
  • Strong desire for social relationships hampered by involuntary social withdrawal
Dependent personality disorder
  • Fears of separation, clingy behavior, and excessive need for the support of others
  • Difficulty initiating projects or doing things alone
  • History of abusive relationships
  • Increased risk of suicide
Obsessive-compulsive personality disorder
  • Excessive sense of and need for order and control associated with low flexibility, openness, and efficiency
  • Excessive attachment to worn-out/worthless items
  • Excessive frugality

Avoidant personality disorder [2]

  • Diagnostics: according to the DSM-5
    • At least 4 of the following criteria have to be met:
      • Avoidance of interpersonal contact due to fear of criticism or rejection
      • Only interacts with people if certain of being liked by them
      • Restrained in intimate relationships due to fear of being shamed
      • Preoccupation with and hypersensitivity to criticism
      • Feelings of inadequacy resulting in involuntary social withdrawal
      • Low self-esteem (sees themself as socially awkward, unappealing, or inferior to others)
      • Avoids taking risks and seldomly engages in new activities
    • Strong desire for social relationships (unlike schizoid personalities), but limited by extreme shyness and social anxiety
  • Differential diagnoses

Dependent personality disorder [2]

  • Diagnostics: according to the DSM-5
    • At least 5 of the following criteria have to be met:
      • Disproportionate need for support
      • Difficulty making everyday decisions (often requiring others to assume responsibility)
      • Avoids disagreeing with others due to fear of losing their support
      • Difficulty initiating projects (e.g., applying for jobs) because of a lack of self-confidence
      • Makes extreme efforts to obtain support from others even if these efforts are unpleasant
      • Feelings of helplessness when alone
      • Urgently seeking new relationships when one fails
      • Both afraid of being abandoned and afraid to abandon their partner
  • Other features
    • Often stuck in abusive relationships
    • Associated with an increased risk of suicide
  • Differential diagnoses

Obsessive-compulsive personality disorder [2]

  • Diagnostics: according to the DSM-5
    • At least 4 of the following criteria have to be met:
      • Excessive preoccupation with rules, lists, details, etc.
      • Obsession with work and productivity that often occurs at the expense of occupational success (e.g., missing deadlines), social relationships (e.g., excluding social activities to complete tasks), and pleasurable activities (e.g., not taking a vacation)
      • Perfectionism that often interferes with task completion
      • Unwillingness to delegate work or to collaborate with other people
      • Great conscientiousness and fastidiousness, inflexible about matters of morality or ethics
      • Cling to worn-out/worthless items (even if they have no sentimental value)
      • Often show miserliness (e.g., obsessed with saving money for future disasters)
      • Rigid routines
    • In contrast to obsessive-compulsive disorder (OCD), intrusive thoughts and repetitive behaviors are not present.
  • Other features: Perfectionism and obsession with control are often egosyntonic.
  • Differential diagnoses

Cluster C: avoidant people act Cowardly, some people are obsessive-Compulsive, and dependent people are Clingy.


Acute medical caretoggle arrow icon

General principles [4][5][6]

  • Personality disorders are associated with an increased risk of depression, suicide, substance use disorders, accidents, and physical illness. [7]
  • Individuals with personality disorders may seek acute care for somatic and/or psychiatric concerns (e.g., self-harm).
  • A physician-patient relationship may be particularly difficult to establish because:
    • Patients may be perceived as difficult, demanding, or self-destructive.
    • Acute stressors may result in increased maladaptive behavior.
    • Clinicians may feel overwhelmed by patient behavior and respond with withdrawal, aggression, or overinvolvement.

Beware of implicit biases when caring for patients with personality disorders.

Somatic presentations

Challenging patient encounters [5][6]

The following strategies may help to make patient encounters productive:

  • Management of negative reactions
    • Maintain emotional distance while remaining empathetic.
    • Avoid reciprocating negative behaviors.
    • Recognize that countertransference is likely and may affect clinical judgment.
    • If necessary, leave the room to regain composure.
  • Effective communication
    • Set expectations (e.g., regarding time limits, interruptions, behavior).
    • Use active listening and avoid passing judgment.
    • Validate the patient's concerns and emotions.
    • Gently redirect the patient if the conversation moves off-topic.
    • Try to ensure consistent messaging from all providers.

Beware of countertransference, listen actively, and set clear boundaries when interviewing and counseling patients with personality disorders.

Agitation or violent behavior [6]

See “Approach to the agitated or violent patient” for a complete approach.

Psychiatric presentations

The primary goals in acute settings are addressing suicidality and/or self-harm and stabilizing mental function. [7][8]

Management of suicidality and self-harm [9][10]

Be wary of conflating nonsuicidal self-injury with suicidal ideation, as this may result in unnecessary hospitalizations and/or emergency department visits. [9]

Supportive management and counseling [5][9]

  • Showing support and validating the patient's feelings can help reduce anxiety and agitation.
  • Attempt to reduce situational and environmental stressors as much as possible.
  • If considering medication for symptomatic relief:
    • Prescribe only as needed to facilitate care (e.g., to enhance patient cooperation and communication). [9]
    • Avoid polypharmacy.
    • Avoid changing existing medication regimens while the patient is in crisis.
  • Consider providing families and/or caretakers with resources to help with care.

Consults and disposition [5][9]

  • Determine the need for psychiatric hospitalization and consult psychiatry for:
  • If psychiatric hospitalization is not indicated:
    • Discuss the patient's care with their outpatient provider and/or support system members and arrange for close follow-up.
    • Refer patients without outpatient care to a suitable provider and/or case manager.
    • Provide the patient with return precautions.
    • Form a suicide safety plan with the patient including the following elements:

Referencestoggle arrow icon

  1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. American Psychiatric Publishing ; 2013: p. 947
  2. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. American Psychiatric Association ; 2013
  3. Chepenik LG. Difficult Patient Encounters: Medical Education and Modern Approaches. Curr Emerg Hosp Med Rep. 2015; 3 (4): p.195-201.doi: 10.1007/s40138-015-0084-8 . | Open in Read by QxMD
  4. Riddle M, Meeks T, Alvarez C, Dubovsky A. When personality is the problem: Managing patients with difficult personalities on the acute care unit. J Hosp Med. 2016; 11 (12): p.873-878.doi: 10.1002/jhm.2643 . | Open in Read by QxMD
  5. Walls R, Hockberger R, Gausche-Hill M, Erickson TB, Wilcox SR. Rosen's Emergency Medicine 10th edition- Concepts and Clinical Practice E-Book. Elsevier Health Sciences ; 2022
  6. Zaheer J, Links PS, Liu E. Assessment and Emergency Management of Suicidality in Personality Disorders. Psychiatr Clin North Am. 2008; 31 (3): p.527-543.doi: 10.1016/j.psc.2008.03.007 . | Open in Read by QxMD
  7. Cases C, Lafont Rapnouil S, Gallini A, Arbus C, Salles J. Evidence of practice gaps in emergency psychiatric care for borderline personality disorder: how can this be explained?. BMC Psychiatry. 2020; 20 (1).doi: 10.1186/s12888-020-02892-7 . | Open in Read by QxMD
  8. Hong V. Borderline Personality Disorder in the Emergency Department: Good Psychiatric Management. Harv Rev Psychiatry. 2016; 24 (5): p.357-366.doi: 10.1097/hrp.0000000000000112 . | Open in Read by QxMD
  9. Broadbear JH, Rotella J, Lorenze D, Rao S. Emergency department utilisation by patients with a diagnosis of borderline personality disorder: An acute response to a chronic disorder. Emerg Med Australas. 2022; 34 (5): p.731-737.doi: 10.1111/1742-6723.13970 . | Open in Read by QxMD
  10. Matthews G, Deary IJ, Whiteman MC. Personality Traits (2nd ed.). Cambridge University Press ; 2003

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