Definition of Personality

The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision [Washington DC, American Psychiatric Association, 2000] defines "personality" as:

"…enduring patterns of perceiving, relating to, and thinking about the environment and oneself … exhibited in a wide range of important social and personal contexts."

Characteristics common to all personality disorders

Patients with personality disorders share certain characteristics:

1. Except those suffering from the Schizoid or the Avoidant Personality Disorders, they are insistent and demand preferential and privileged treatment. They complain about numerous symptoms, though they frequently second guess the diagnosis and disobey the physician, his treatment recommendations and instructions.

2. They feel unique, are affected with grandiosity and a diminished capacity for empathy. Consequently, they regard the physician as inferior to them, alienate him and bore him with their self-preoccupation.

3. They are manipulative and exploitative, trust no one and find it difficult to love or share. They are socially maladaptive and emotionally labile.

4. Disturbed cognitive and, mainly, emotional development peaks in adolescence.

5. Personality disorders are stable and all-pervasive – not episodic or transient. They affect all the dimensions of the patient's life: his career, his interpersonal relationships, his social functioning.

6. Though the patient is sometimes depressed and suffers from mood and anxiety disorders - defenses - splitting, projection, projective identification, denial, intellectualization - are so strong, that the patient is unaware of the reasons for his distress. The character problems, behavioral deficits and emotional deficiencies and instability encountered by the patient with personality disorder are, mostly, ego-syntonic. This means that the patient does not, on the whole, find his personality traits or behavior objectionable, unacceptable, disagreeable, or alien to his self.

7. The patient is prone to suffer from other psychiatric disturbances, both personality disorders and Axis I disorders ("co-morbidity"). Substance abuse and reckless behaviors are also common ("dual diagnosis").

8. Defenses are alloplastic: patients tend to blame the external world for their misfortune and failures. In stressful situations, they try to preempt a (real or imaginary) threat, change the rules of the game, introduce new variables, or otherwise influence the external world to conform to their needs.

9. The personality-disordered are not psychotic. They have no hallucinations, delusions or thought disorders (except those who suffer from a Borderline Personality Disorder and who experience brief psychotic "microepisodes", mostly during treatment). They are also fully oriented, with clear senses (sensorium), good memory and general fund of knowledge.

Differential Diagnoses

The classification of Axis II personality disorders - deeply ingrained, maladaptive, lifelong behavior patterns - in the Diagnostic and Statistical Manual, fourth edition, text revision [American Psychiatric Association. DSM-IV-TR, Washington, 2000] - or the DSM-IV-TR for short - has come under sustained and serious criticism from its inception in 1952.

The DSM IV-TR adopts a categorical approach, postulating that personality disorders are "qualitatively distinct clinical syndromes" (p. 689). This is widely doubted. Even the distinction made between "normal" and "disordered" personalities is increasingly being rejected. The "diagnostic thresholds" between normal and abnormal are either absent or weakly supported.

The polythetic form of the DSM's Diagnostic Criteria - only a subset of the criteria is adequate grounds for a diagnosis - generates unacceptable diagnostic heterogeneity. In other words, people diagnosed with the same personality disorder may share only one criterion or none.

The DSM fails to clarify the exact relationship between Axis II and Axis I disorders and the way chronic childhood and developmental problems interact with personality disorders;

The differential diagnoses are vague and the personality disorders are insufficiently demarcated. The result is excessive co-morbidity (multiple Axis II diagnoses);

The DSM contains little discussion of what distinguishes normal character (personality), personality traits, or personality style (Millon) - from personality disorders;

A dearth of documented clinical experience regarding both the disorders themselves and the utility of various treatment modalities;

Numerous personality disorders are "not otherwise specified" - a catchall, basket "category";

Cultural bias is evident in certain disorders (such as the Antisocial and the Schizotypal);

The emergence of dimensional alternatives to the categorical approach is acknowledged in the DSM-IV-TR itself:

“An alternative to the categorical approach is the dimensional perspective that Personality Disorders represent maladaptive variants of personality traits that merge imperceptibly into normality and into one another” (p.689)

The following issues - long neglected in the DSM - are likely to be tackled in future editions as well as in current research:

The longitudinal course of the disorder(s) and their temporal stability from early childhood onwards

The genetic and biological underpinnings of personality disorder(s)

The development of personality psychopathology during childhood and its emergence in adolescence

The interactions between physical health and disease and personality disorders

The effectiveness of various treatments - talk therapies as well as psychopharmacology.

Psychological Testing for Personality Disorders

A qualified mental health diagnostician administers lengthy tests and personal interviews to determine the existence and virulence of a personality disorder.

The predictive power of these tests - often based on literature and scales of traits constructed by scholars - is hotly disputed. Still, they are far preferable to subjective impressions of the diagnostician which are often amenable to manipulation.

The Minnesota Multiphasic Personality Inventory. Diagnostic test composed of 567 true-or-false questions arranged in three validity scales and ten dimensional clinical scales. The latter

measure hypochondriasis, depression, hysteria, psychopathic deviation, masculinity-femininity, paranoia, psychasthenia, schizophrenia, hypomania, and social introversion. There are also scales for alcoholism, post-traumatic stress disorder, and personality disorders.

The interpretation of the MMPI-II is now fully computerized. The computer is fed with the patients' age, sex, educational level, and marital status and does the rest.

The Millon Clinical Multiaxial Inventory-III (MCMI-III) tests for personality disorders and attendant anxiety and depression. The third edition was formulated in 1996 by Theodore Millon and Roger Davis.

Millon Clinical Multiaxial Inventory. Diagnostic test composed of 157 true-or-false items.

The MCMI-III consists of 24 clinical scales and 3 modifier scales. The modifier scales serve to identify Disclosure (a tendency to hide a pathology or to exaggerate it), Desirability (a bias towards socially desirable responses), and Debasement (endorsing only responses that are highly suggestive of pathology). Next, the Clinical Personality Patterns (scales) which represent mild to moderate pathologies of personality, are: Schizoid, Avoidant, Depressive, Dependent, Histrionic, Narcissistic, Antisocial, Aggressive (Sadistic), Compulsive, Negativistic, and Masochistic. Millon considers only the Schizotypal, Borderline, and Paranoid to be severe personality pathologies and dedicates the next three scales to them.

The last ten scales are dedicated to Axis I and other clinical syndromes: Anxiety Disorder, Somatoform Disorder, Bipolar Manic Disorder, Dysthymic Disorder, Alcohol Dependence, Drug Dependence, Posttraumatic Stress, Thought Disorder, Major Depression, and Delusional Disorder.

Scoring is easy and runs from 0 to 115 per each scale, with 85 and above signifying a pathology. The configuration of the results of all 24 scales provides serious and reliable insights into the tested subject.

The Narcissistic Personality Inventory (NPI) is used to spot narcissistic traits.

The Borderline Personality Organization Scale (BPO) was designed in 1985. It sorts the responses of respondents into 30 relevant scales. It indicates the existence of identity diffusion, primitive defenses, and deficient reality testing.

To these one may add the Personality Diagnostic Questionnaire-IV, the Coolidge Axis II Inventory, the Personality Assessment Inventory (1992), the excellent, literature-based, Dimensional assessment of Personality Pathology, and the comprehensive Schedule of Nonadaptive and Adaptive Personality and Wisconsin Personality Disorders Inventory.

The next diagnostic aim is to understand the way the patient or client functions in relationships, copes with intimacy, and responds to triggers.

The Relationship Styles Questionnaire (RSQ) (1994) contains 30 self-reported items and identifies distinct attachment styles (secure, fearful, preoccupied, and dismissing). The Conflict Tactics Scale (CTS) (1979) is a standardized scale of the frequency and intensity of conflict resolution tactics - especially abusive stratagems - used by members of a dyad (couple).

The Multidimensional Anger Inventory (MAI) (1986) assesses the frequency of angry responses, their duration, magnitude, mode of expression, hostile outlook, and anger-provoking triggers.

The Rorschach Inkblot Test is a diagnostic test comprised of 10 ambiguous inkblots printed on 18X24 cm. cards, in both black and white and color. The cards and the diagnostician's questions provoke free associations in the test subject. These are recorded verbatim together with the inkblot's spatial position and orientation. The patient can then add details and comment on his choices.

Scoring is based on the parts of the cards referred to in the subject's responses (location), the correspondence between the blot and the answers provided (determinant), the content of the responses, how unique or common they are (popularity), how coherent are the patient's narratives (organizational activity), and how well does the patient's percept fit the card (form quality).

The interpretation of the test relies on both the scores obtained and on what we know about mental health disorders. The test teaches the skilled diagnostician how the subject processes information and what is the structure and content of his internal world. These provide meaningful insights into the patient's defenses, reality test, intelligence, fantasy life, and psychosexual make-up.
The Thematic Appreciation Test (TAT) is a diagnostic test comprised of 31 cards. One card is blank and the other thirty include blurred but emotionally powerful (or even disturbing) photographs and drawings. Subjects are asked to tell a story based on the content of the cards. The TAT was developed in 1935 by Morgan and Murray.

The patient's reactions (in the form of brief narratives) are recorded by the tester verbatim. Some examiners prompt the patient to describe the aftermath or outcomes of the stories, but this is a controversial practice.

The TAT is scored and interpreted simultaneously. Murray suggested to identify the hero of each narrative (the figure representing the patient); the inner states and needs of the patient, derived from his or her choices of activities or gratifications; what Murray calls the "press", the hero's environment which imposes constraints on the hero's needs and operations; and the thema, or the motivations developed by the hero in response to all of the above.

The Structured Clinical Interview (SCID-II) was formulated in 1997 by First, Gibbon, Spitzer, Williams, and Benjamin. It is based on the language of criteria for personality disorders in the the DSM-IV. Its 12 groups of questions correspond to the 12 personality disorders. The scoring is simple: either the trait is absent, subthreshold, true, or there is "inadequate information to code".

The SCID-II can be administered to third parties (a spouse, an informant, a colleague) or self-administered (in a reduced format with 119 questions).

The Structured Interview for Disorders of Personality (SIDP-IV) was composed by Pfohl, Blum and Zimmerman in 1997. It also covers the self-defeating personality disorder from the DSM-III. It is conversational and the questions are grouped into 10 topics such as Emotions or Interests and Activities. There is a version of the SIDP-IV in which the questions are grouped by personality disorder. The scoring classifies items as present, subthreshold, present, or strongly present.

Yet, even a complete battery of tests, administered by experienced professionals sometimes fails to identify personality disorders. Such patients are uncanny in their ability to deceive their evaluators.


1. - Personality Disorders common features
2. - Personality Disorders
3. - eMedicine Personality Disorders
4. - PTypes Personality Disorders
5. - The DSM and Personality Disorders
6. - Theodore Millon on Personality Disorders
7. - Psychological Testing and Assessment of Personality Disorders
8. - The Myth of Mental Illness