From the Guidelines
Personality disorders according to the DSM-5 are diagnosed based on persistent patterns of inner experience and behavior that deviate significantly from cultural expectations, causing distress or impairment. The DSM-5 organizes personality disorders into three clusters:
- Cluster A (odd/eccentric) includes paranoid, schizoid, and schizotypal
- Cluster B (dramatic/emotional) includes antisocial, borderline, histrionic, and narcissistic
- Cluster C (anxious/fearful) includes avoidant, dependent, and obsessive-compulsive personality disorders. However, it's worth noting that the ICD-11 has shifted towards a more dimensional approach for personality disorders, characterizing them by problems in functioning of aspects of the self and/or interpersonal dysfunction, and differentiating according to severity into mild, moderate, and severe 1. Treatment typically involves psychotherapy as the primary approach, with cognitive-behavioral therapy, dialectical behavior therapy, schema therapy, and psychodynamic therapy showing effectiveness for different disorders. Medication is used adjunctively to target specific symptoms rather than the personality disorder itself. For example, selective serotonin reuptake inhibitors (SSRIs) like fluoxetine or sertraline may help with mood instability or impulsivity in borderline personality disorder, while low-dose antipsychotics such as quetiapine might address cognitive-perceptual symptoms. A comprehensive approach combining psychotherapy, possible medication for specific symptoms, and development of coping skills yields the best outcomes, as personality patterns are deeply ingrained and treatment is typically long-term, often lasting years 1. The biological basis for these disorders involves complex interactions between genetic predisposition, neurobiological factors, and environmental influences, particularly early life experiences that shape personality development. In clinical practice, dimensional information such as severity of illness is regularly taken into consideration for selecting treatments, mirroring the approach seen in ICD-11 1.
From the Research
Diagnosis of Personality Disorders
- According to the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5), personality disorders are divided into three clusters based on descriptive commonalities 2
- Cluster A personality disorders are characterized by odd or eccentric behavior
- Cluster B personality disorders are characterized by dramatic and emotional behavior, and erratic behavior
- Cluster C personality disorders are characterized by anxious and fearful behavior
Treatment Options for Personality Disorders
- Management of personality disorders consists mainly of psychotherapy 2
- Cognitive-behavioral therapy (CBT) has been identified as a time-limited treatment approach for personality disorders 3
- Dialectical behavior therapy (DBT) is a structured outpatient treatment developed for the treatment of borderline personality disorder (BPD) and is currently the only empirically supported treatment for BPD 4
- DBT is based on cognitive-behavioral principles and has been shown to be effective in treating other psychiatric disorders, such as substance use disorders, mood disorders, posttraumatic stress disorder, and eating disorders 4
- Pharmacotherapy may be considered as adjunctive care for patients with personality disorders, particularly those with comorbid psychiatric symptoms 4
Specific Treatment Approaches
- DBT is structured into four components: skills training group, individual psychotherapy, telephone consultation, and therapist consultation team 4
- The skills taught in DBT include mindfulness, interpersonal effectiveness, emotion regulation, and distress tolerance 4
- Adaptations of DBT have been developed to target cognitive-behavioral rigidity and emotional constriction in patients with personality disorders, such as paranoid personality disorder and obsessive-compulsive personality disorder 5