Personality disorders are deeply ingrained patterns of thinking, feeling, and behaving that deviate markedly from the expectations of an individual’s culture, are pervasive and inflexible, begin in adolescence or early adulthood, are stable over time, and lead to distress or impairment. Within the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association, 2013), ten distinct personality disorders are recognized, each with varying levels of empirical support for their diagnostic criteria. A core feature shared across all personality disorders is a maladaptive personality style that is pervasive, long-lasting, and originates from adolescence onwards.
Borderline Personality Disorder (BPD) and Antisocial Personality Disorder are the most frequently diagnosed personality disorders. Narcissistic Personality Disorder (NPD) presents unique challenges in primary care settings, both in diagnosis and management.
Borderline Personality Disorder: Diagnostic Criteria
Diagnosing Borderline Personality Disorder (BPD) requires a patient to meet at least five out of the nine criteria outlined in the DSM-5. This diagnostic threshold allows for significant heterogeneity in symptom presentation among individuals with BPD. The mnemonic IMPULSIVE serves as a useful tool for recalling the diagnostic criteria for BPD:
- Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating).
- Mood instability due to marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days).
- Paranoia or dissociation symptoms that are transient and stress-related.
- Unstable and intensely interpersonal relationships characterized by alternating between extremes of idealization and devaluation.
- Labile affectivity, characterized by rapidly shifting moods.
- Suicidal behavior, gestures, or threats, or self-mutilating behavior.
- Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights).
- Vulnerability to abandonment, frantic efforts to avoid real or imagined abandonment.
- Emptiness, chronic feelings of emptiness.
Narcissistic Personality Disorder: Diagnostic Criteria
Narcissistic Personality Disorder (NPD) is characterized by a pervasive pattern of grandiosity, a need for admiration, and a lack of empathy that begins by early adulthood and is present in a variety of contexts.
A diagnosis of NPD necessitates meeting five or more of the following nine DSM-5 criteria:
- A grandiose sense of self-importance (e.g., exaggerates achievements and talents, expects to be recognized as superior without commensurate achievements).
- Preoccupation with fantasies of unlimited success, power, brilliance, beauty, or ideal love.
- Belief that he or she is “special” and unique and can only be understood by, or should associate with, other special or high-status people (or institutions).
- A need for excessive admiration.
- A sense of entitlement (i.e., unreasonable expectations of especially favorable treatment or automatic compliance with his or her expectations).
- Interpersonally exploitive behavior (i.e., takes advantage of others to achieve his or her own ends).
- Lack of empathy: is unwilling to recognize or identify with the feelings and needs of others.
- Envy of others or belief that others are envious of him or her.
- Arrogant, haughty behaviors or attitudes.
DSM-5 Diagnostic Changes and Personality Disorders
Personality Disorder Diagnosis in Transition-Age Youth
The DSM-5 acknowledges that personality disorder features typically emerge during adolescence or early adulthood. While previous DSM iterations restricted personality disorder diagnoses to individuals aged 18 and older, the DSM-5 permits diagnosis in individuals under 18 if personality disorder features have been evident for at least one year. This modification facilitates earlier intervention and treatment, particularly relevant for Borderline Personality Disorder (BPD). Research supports the reliability of BPD diagnosis in youth, highlighting the potential for early intervention to improve long-term outcomes (Kaess et al., 2014). Antisocial Personality Disorder remains the sole personality disorder that cannot be diagnosed in individuals under the age of 18.
Shift from Multiaxial System: Axis I and Axis II Disorders
A significant structural change in DSM-5 was the removal of the multiaxial diagnostic system used in DSM-IV. DSM-IV utilized five axes, with Axis I encompassing major clinical disorders and Axis II housing personality disorders and intellectual disability. Axis I disorders included conditions such as:
- Major Depressive Disorder
- Bipolar Affective Disorder
- Schizophrenia
- Generalized Anxiety Disorder
- Panic Disorder
- Posttraumatic Stress Disorder
- Obsessive-Compulsive Disorder
- Substance Use Disorders.
The multiaxial system was initially implemented to ensure personality disorders and intellectual disabilities received adequate clinical and research attention. However, with the evolution of the field, DSM-5 deemed the multiaxial system no longer necessary. Despite this structural change, DSM-5 retained all ten personality disorders, with minor adjustments to the wording of diagnostic criteria (APA, 2013).
Although the Axis I and Axis II distinction is no longer formally recognized in DSM-5, these terms remain conceptually useful in discussions regarding the diagnosis and treatment of personality disorders, particularly in understanding comorbidity.
Navigating Diagnostic Challenges in Personality Disorders
Co-occurring Axis I and Personality Disorder Diagnoses
Comorbidity between personality disorders and Axis I disorders is frequently observed, especially in Borderline Personality Disorder (BPD). Research indicates a high rate of lifetime Axis I comorbidity in individuals with BPD, with one study reporting that 96% of BPD patients will experience a comorbid Axis I disorder: mood disorders (9%), anxiety disorders (88%), post-traumatic stress disorder (55%), eating disorders (53%), and substance use disorders (64%) (Zanarini et al., 1998).
The challenge lies not only in accurately diagnosing and managing the personality disorder but also in identifying and addressing co-occurring Axis I conditions. While primary care practitioners may be more immediately comfortable managing Axis I disorders, comprehensive treatment plans for patients with both Axis I and Axis II disorders must address both sets of conditions for optimal outcomes.
Challenges in Identifying Comorbid Axis I Disorders
Clinicians, including those in primary care, may inadvertently overlook comorbid Axis I diagnoses in patients with personality disorders. The often-chaotic presentation of these patients, coupled with potential clinician reactions, can hinder the assessment and diagnosis of Axis I disorders. Clinician frustration with disruptive behaviors, self-harm threats, or emotional reactivity can impede a thorough review of the patient’s longitudinal history, which is crucial for clarifying Axis I diagnoses. Failure to recognize comorbid Axis I disorders can result in patients not receiving appropriate and necessary treatment for these conditions.
Differentiating Between Personality Disorders and Axis I Disorders
To differentiate between a personality disorder and an Axis I disorder, it is essential to evaluate the chronicity of maladaptive behaviors. Determine whether these behaviors represent a longstanding pattern or are limited to periods coinciding with the onset of an Axis I disorder.
Stressful life events can exacerbate personality traits, potentially mimicking a personality disorder presentation. For instance, individuals experiencing depression may exhibit heightened demands, inappropriate persistence, emotional reactivity, and irritability, superficially resembling a personality disorder. However, if historical information or reports from support systems indicate that maladaptive behaviors are confined to periods of significant stress, a personality disorder diagnosis may not be accurate. If personality difficulties are of recent onset, consider whether an underlying Axis I disorder is the primary diagnosis, as these conditions can sometimes present in a manner suggestive of a personality disorder.
It’s crucial to remember that clinical assessments are often cross-sectional, while personality disorder diagnoses necessitate a longitudinal perspective on functioning. It is advisable to postpone personality disorder assessments until any acute Axis I disorders are effectively treated.
Inquire about the patient’s typical personality functioning prior to the onset of depression or other Axis I conditions. Obtain collateral information from family members or significant others to ascertain whether maladaptive behaviors are solely associated with Axis I diagnostic states or represent long-standing patterns dating back to childhood.
Regardless of the suggestive nature of a patient’s presentation, a personality disorder diagnosis is less likely if there is no corroborating evidence of these patterns from earlier in life.
Further Reading: Personality Disorders
