Deconstructing PDs; Fact Versus Fiction
Lydia Kraszewski, LPC.
Why This Matters
Before being educated on and exposed to clinical work, the only example I had of what a personality disorder (PD) looked like was from movies such as Girl, Interrupted, Gone Girl and American Psycho. These films exposed me to a general idea of what a PD may look like, and in case you have not seen them, they do not depict PDs in the most flattering light. The reality is that historically, the media has created a stigma around the experience of having a PD. Interestingly enough, PDs have gained attention through social media outlets, and more people seem to be becoming aware of what they actually look like. PDs are being slowly destigmatized through open discussions, psychoeducation and relatability that the internet provides. Although there is more information out there to learn from, not all of it is completely accurate. As humans, we want to feel connected and understood, and with social media exposure, this has become more accessible in the world of mental health. It is my goal to zoom in on the actuality of what it means to have a PD and further destigmatize this misunderstood diagnosis.
So, What Exactly is a Personality Disorder?
As clinicians, we all assess and diagnose an individual through a lens that includes more than just a summary from the Diagnostic and Statistical Manual (DSM). Although the DSM is the holy grail for clinicians to ensure their clients meet the criteria for a disorder, clients are viewed through a holistic lens, which means assessing more than just blatant symptomatology. To understand the basis of personality disorders, it is important to take a peek into the DSM and gain insight as to what exactly clinicians are looking for while also assessing a client’s comprehensive background.
The DSM-5-TR (the most recent copy of the DSM) summarizes personality disorders by explaining common traits of PDs and indicating signs that one may be present. Consistent and pervasive themes in behavior that diverge from the norms of an individual’s cultural standards, begin (most likely) between adolescence and young adulthood, remain consistent over time, present as persistent, and lead to heightened stress and impairment in daily functioning are the baseline criteria for detecting a PD. Not only does someone have to meet the above qualifications, but their presentations must be demonstrated cognitively, through the range and intensity of their affect, the way they function in interpersonal relationships, and poor impulse control. There are three categories (DSM clusters)–cluster A, B, and C– which group the ten different kinds of PDs into their respective categories. Finally, it’s important to understand how a personality disorder differs from a personality trait. Traits become personality disorders when they are uncompromising, counterproductive, and cause noticeable psychological impairment. Keep in mind while reading below, just because someone may experience some of these traits to an extent, it does not mean they a PD.
DSM-5 Clusters
Cluster A
Cluster A traits can likely be perceived as strange or unfamiliar. They include: Paranoid Personality Disorder, Schizoid Personality Disorder, and Schizotypal Personality Disorder.
Paranoid Personality Disorder
People who have a Paranoid Personality Disorder interpret the actions of others as motivated by malice. They are likely to experience extreme distrust of others, believe that people around them intend to hurt them, have difficulties disclosing to others, may easily hold a grudge, and will internalize the reactions of others as undermining their character.
Schizoid Personality Disorder
Those with Schizoid PD share similarities to Paranoid PD in the sense that they also have extreme caution surrounding interpersonal relationships. Other common traits include coming off as emotionally detached, having a hard time taking an interest in activities, trouble experiencing sexual pleasure, and being uninterested in admiration from others.
Schizotypal Personality Disorder
Finally, Schizotypal PD is diagnosed when an individual struggles with cognitive and visual functioning (i.e., magical thinking & distorted perceptions) and unconventional behavior. Uneasiness in interpersonal and relational functioning, speech that is difficult for others to understand, and tendencies of paranoia are all defining criteria for diagnosing Schizotypal PD.
Cluster B
If you have ever heard the term Personality Disorder before, you’ve likely heard of one or more of the following, which include Antisocial Personality Disorder, Borderline Personality Disorder, Histrionic Personality Disorder, or Narcissistic Personality Disorder. These are the ones most often demonstrated through films, shows and high-profile true crime cases (think Ted Bundy or Charles Manson).
Antisocial Personality Disorder (APD)
Antisocial PD is often referred to as “sociopathic” or “psychopathic” when being discussed outside of a clinical setting– and side note, there is a difference between the two umbrella terms. Sociopaths are more prone to impulsiveness and do have the capability to experience empathy, while psychopaths have zero empathy and display behavior that will intentionally harm others. Those with APD are characterized by dishonesty, lack of guilt, contempt for others, and can be correlated with criminal behavior.
Borderline Personality Disorder (BPD)
People who are diagnosed with Borderline Personality Disorder are likely to have unstable and fanatical relationships, difficulties with emotional regulation, an intense and pervasive fear of abandonment, an inconsistent view on themselves and their identity, and are prone to displaying self-harming or suicidal behaviors. Most people who experience BPD have a history that involves some form of trauma (which is also applicable to a handful of other PDs).
Histrionic Personality Disorder (HPD)
Did anyone watch the Johnny Depp versus Amber Heard trial? A forensic psychologist testified on behalf of Depp and claimed Amber Heard’s behavior within their relationship met diagnostic criteria for both HPD, as well as BPD. (More on this later.) Anyways, the psychologist detailed Heard as having “a lot of anger, cruelty toward people less powerful and attention seeking” and behaviors “driven by an underlying fear of abandonment”. Seductive tendencies, being easily influenced by others, and limerence are all qualities possessed by someone with HPD, which the psychologist claimed were present in Heard.
Narcissistic Personality Disorder (NPD)
I have had multiple clients say to me, “I think I might be a narcissist” in response to a particular trait that coincides with narcissism. I have yet to actually diagnose anyone with a personality disorder so far in my clinical work, and I have to emphasize to clients (in particular with Narcissistic PD) that a questionable behavior does not equal NPD. Thinking that you look attractive does not equate to having NPD. People with diagnostic NPD exhibit extreme grandiosity, an intense desire to be admired, difficulty empathizing with others, a sense of superiority, and egotistical behavior.
Cluster C
Avoidant Personality Disorder
Avoidant traits include heightened sensitivity to perceived or actual rejection, feelings of low self-worth, difficulties socializing due to a fear of not being liked, and avoidance of others unless they feel confident they will be accepted. “I am not good enough”, and “I am better off alone” are common thought patterns for those with this PD because they create a sense of safety which protects them from embarrassment or harsh criticism.
Dependent Personality Disorder
Individuals who seek extreme forms of dependence from others, have a propensity to form intense attachments, engage in insistent reassurance seeking, deeply fear abandonment, and have poor conflict management skills may meet criteria for Dependent PD. * The word “May” is important*. These individuals’ core belief system involves themes of powerlessness and inadequacy, which increases the likelihood they will stray away from disagreements, decision-making, and will be constantly seeking relationships.
Obsessive Compulsive Personality Disorder
You have likely heard of Obsessive Compulsive Disorder (OCD), and it’s important to keep in mind that this is not the same as an Obsessive Compulsive PD. The difference is that someone with OCD struggles with intrusive thinking patterns and compulsive behavior, which comes as a result of their thoughts. The difference between a mood disorder (depression, for example) and a PD is the distinction between incongruent moods and pervasive personality traits. The disposition of someone with Obsessive PD involves being tremendously preoccupied with rules and structure, dealing with perfectionism to the point that tasks don’t end up getting completed and having unyielding belief systems surrounding principles, values and ethics.
Reality Versus Misunderstanding
Going back to the earlier example of the Amber Heard trial, what I didn’t mention was the cross-analysis she was given by her defense team’s witness, another forensic psychologist. The defense team refuted the diagnosis of multiple personality disorders and instead linked her behavior to trauma. The psychologist testified that Heard was a victim of intimate partner violence in her relationship and developed PTSD as a result. This back and forth in the courtroom paints a great picture of the importance of dual-diagnoses (two disorders presenting at the same time), differential diagnoses (another potential diagnosis), and the importance of evaluating any possible trauma.
Assessing trauma and understanding the potential links between trauma responses and traits of a personality disorder is both crucial and challenging when working in a clinical framework. Childhood trauma, developmental trauma, adverse childhood experiences, trauma later in life, and attachment trauma can all present similarly to PDs. Hypervigilance, avoidance, mistrust, fears of abandonment and rejection, engagement in dysfunctional relationships, sensitivity to perceived judgment, and emotional irregularity are both indicators of trauma, as well as various PDs.
The reality is, personality disorders are extremely hard to diagnose and require a lot of thorough assessment. Some researchers suggest they stem from genetic predispositions, disorganized attachment styles as a result of maladaptive caretaking, and childhood trauma. It is common for people with borderline PD to have also been victims of sexual abuse, while experiencing verbal abuse in childhood may lead to narcissistic PDs. While research continues to explore PDs, it is evident that there is still a lot to be learned.
References:
Fariba KA, Gupta V, Torrico TJ, et al. Personality Disorder. [Updated 2024 Jul 17]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK556058/