Personality disorders: general diagnostic principles; paranoid and schizoid personality disorders; dissocial (antisocial), emotionally unstable (borderline), and histrionic personality disorders
Lasting, inflexible patterns of thinking, feeling and relating that begin by early adulthood and cause distress or harm. How ICD-10, DSM-5 and ICD-11 define and classify them, then the paranoid, schizoid, dissocial (antisocial), emotionally unstable (borderline) and histrionic types, their assessment, the psychological treatments that work and the small place of drugs.
- 14 min read
- 5 questions
- Checked 26 Oct 2026
Contents6 sections
At a glance
- A personality disorder is a lasting, inflexible pattern of experience and behaviour that departs from cultural norms, begins by adolescence or early adulthood, causes distress or impairment and is not explained by another disorder, a substance or brain disease.
- ICD-10 and DSM-5 describe types, grouped by DSM-5 into clusters A, B and C. ICD-11 has one personality disorder, graded mild, moderate or severe, with five trait domains and an optional borderline pattern.
- Paranoid personality is suspicious and grudge-bearing; schizoid personality is detached and solitary by choice. Schizotypal disorder sits with schizophrenia in ICD-10.
- Dissocial (antisocial) personality disorder is a callous disregard for others and for rules, which DSM-5 requires to have begun as conduct disorder before 15. Psychopathy (PCL-R) is a narrower group at higher risk of violence.
- Borderline personality disorder is unstable mood, self-image and relationships, with impulsivity, fear of abandonment and recurrent self-harm. Around 5 to 10 per cent die by suicide, so every crisis is assessed afresh.
- Treatment is psychological, best supported for dialectical behaviour therapy and mentalisation-based treatment. No drug is licensed for borderline personality disorder; drugs treat comorbid disorders, polypharmacy is avoided, and a crisis plan replaces repeated admissions.
- Most people with borderline personality disorder no longer meet its criteria ten years later, though functioning recovers more slowly.
Definition and overview
Everyone is suspicious, impulsive or dramatic at times. A personality disorder is diagnosed only when such traits are extreme and rigid enough, for long enough, to cause the person distress or to damage their relationships, their work and the people around them. It is separate from mental illness, although the two often come together.
General diagnostic principles
ICD-10's general criteria come first; a specific type is diagnosed only when they are met:
- deviation: the person's habitual ways of experiencing and behaving depart markedly from what their culture expects, in more than one area (thinking and perceiving, emotion, impulse control, relating to others);
- pervasiveness: the pattern is inflexible and maladaptive across a broad range of situations, not a reaction to one setting or stress;
- distress or impairment: it causes the person distress, harm to others, or both;
- stability and early onset: it is long-standing and began in late childhood or adolescence, so a diagnosis before about 16 or 17 is seldom appropriate;
- not another disorder: it is not the expression of another mental disorder, a substance, or brain disease or injury (an organic personality disorder).
DSM-5-TR uses the same principles. It allows a diagnosis under 18 when the traits have lasted at least a year, except for antisocial personality disorder, which needs an age of 18.
Types and clusters
| ICD-10 | ICD-10 name | DSM-5 name and cluster |
|---|---|---|
| F60.0 | Paranoid | Paranoid, cluster A (odd or eccentric) |
| F60.1 | Schizoid | Schizoid, A |
| F21, in the schizophrenia block | Schizotypal disorder | Schizotypal, A |
| F60.2 | Dissocial | Antisocial, cluster B (dramatic, emotional or erratic) |
| F60.30 | Emotionally unstable, impulsive type | no equivalent |
| F60.31 | Emotionally unstable, borderline type | Borderline, B |
| F60.4 | Histrionic | Histrionic, B |
| F60.8 | Other specific, which includes narcissistic | Narcissistic, B |
| F60.5 to F60.7 | Anankastic, anxious (avoidant), dependent | Obsessive-compulsive, avoidant, dependent, cluster C (anxious or fearful) |
The clusters are a convenience, not a finding: people often meet the criteria for several types. Cluster C and narcissistic personality disorders have their own topic.
Point at a name or a part to light it.
The ten personality disorders are grouped in three clusters by their likeness: odd or eccentric, dramatic, emotional or erratic, and anxious or fearful. The clusters come from DSM; ICD-10 uses the same types under its own names, but files schizotypal disorder with schizophrenia and narcissistic personality disorder among the other specific types. The clusters are a convenience, not a finding: many people meet the criteria for several types.
Simplified: the clusters are a convenience for learning, not a finding: many people meet the criteria for types in more than one; ICD-11 drops the types and diagnoses one personality disorder by its severity, described with trait domains.
3 sources
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 5th edition, text revision (DSM-5-TR). APA, 2022. Personality disorders.
- World Health Organization. The ICD-10 Classification of Mental and Behavioural Disorders: Clinical Descriptions and Diagnostic Guidelines. WHO, 1992. F60, Specific personality disorders; F21, Schizotypal disorder.
- Semple D, Smyth R. Oxford Handbook of Psychiatry, 4th edition. Oxford University Press, 2019. Chapter 12, Personality disorders.
ICD-11's dimensional model
ICD-11, in force since 2022 (most European health systems are still moving over from ICD-10), drops the types. Personality disorder (6D10) is one diagnosis: a lasting disturbance, usually of 2 years or more, in how a person functions as a self (identity, self-worth, self-direction) and with others (closeness, seeing other points of view, handling conflict), causing distress or impairment. It has no age-of-onset rule. Its main dimension is severity:
| Level | What it means |
|---|---|
| Personality difficulty | traits causing problems only at times; recorded outside the mental disorders |
| Mild | problems in some areas; usually no substantial harm to self or others |
| Moderate | problems in many areas and most relationships; harm at times |
| Severe | serious problems in almost every area, often with severe harm to self or others |
The disorder can then be described with any of five trait domains (6D11): negative affectivity, detachment, dissociality, disinhibition and anankastia. A borderline pattern specifier keeps patients' access to the treatments built for borderline personality disorder. DSM-5-TR keeps its ten types and puts a similar model, level of functioning plus five trait domains, in Section III for further study.
Etiology and pathophysiology
No single cause is known. Personality traits are about 30 to 50 per cent heritable, and a disorder seems to arise when an inherited temperament meets an unfavourable upbringing: childhood abuse and neglect, harsh or inconsistent parenting, loss, and insecure, especially disorganised, attachment.
Paranoid and schizoid
Both are commoner in relatives of people with schizophrenia and delusional disorder, suggesting a place at the mild end of the schizophrenia spectrum.
Dissocial (antisocial)
Antisocial behaviour is about half heritable. The strongest predictor is conduct disorder that starts early, especially with ADHD and callous, unemotional traits, in a family marked by harsh discipline, maltreatment, parental crime and substance misuse. Psychopathy goes with low autonomic arousal (a low resting heart rate), poor fear conditioning and a weak amygdala response to other people's distress. In a New Zealand cohort, maltreated boys with a low-activity variant of the MAOA gene were more often violent as adults.
Emotionally unstable (borderline)
Heritability is about 40 per cent. Many patients report childhood abuse or neglect, though not all, and most abused children do not develop the disorder. The biosocial model behind dialectical behaviour therapy:
- 1
Vulnerability
An intense, quickly aroused emotional temperament that is slow to settle. - 2
Invalidation
A childhood in which feelings are dismissed or punished, so they are never learned, named or regulated. - 3
Dysregulation
Emotion surges out of control under stress, above all at the threat of rejection. - 4
Escape
Self-harm, substances, bingeing or rage bring brief relief, which reinforces them.
The mentalising model behind mentalisation-based treatment holds that disorganised attachment leaves a fragile capacity to understand one's own and others' states of mind, which collapses under stress. Imaging shows an amygdala that over-reacts to emotional faces with weak prefrontal control; low serotonin function goes with impulsive aggression. Histrionic personality is the least studied type.
Clinical features
Paranoid personality disorder
A pervasive distrust in which others' motives are read as hostile. Patients rarely see it as a problem and present through conflict, complaints or litigation.
| Feature | What it looks like |
|---|---|
| Sensitivity to setbacks | criticism or a rebuff taken as an attack |
| Grudges | insults and injuries not forgiven |
| Suspicion | neutral or friendly acts misread as hostile |
| Combative sense of rights | disputes pursued far beyond the situation, sometimes in court |
| Jealousy | recurrent, unjustified suspicion of a partner's fidelity |
| Self-reference | events seen as aimed at them; conspiracies behind ordinary events |
The beliefs are overvalued ideas; if fixed delusions appear, delusional disorder or schizophrenia is considered.
Schizoid personality disorder
A detachment from relationships that the person does not mind, with a narrow range of feeling.
| Feature | What it looks like |
|---|---|
| Little pleasure | few activities enjoyed, little interest in sex with another person |
| Emotional coldness | flat, detached; little warmth or anger shown |
| Indifference | unmoved by praise or criticism |
| Solitude by choice | no close friends or confidants, or only one |
| Inner life | absorbed in fantasy and introspection; unconcerned by social conventions |
The differential is autism (social communication difficulties from early childhood), schizotypal disorder (odd thinking and perception), avoidant personality (longs for company but fears rejection) and the negative symptoms of schizophrenia.
Dissocial (antisocial) personality disorder
A pervasive disregard for the rights and feelings of others, usually visible since childhood.
| ICD-10 dissocial features | DSM-5 antisocial requirements |
|---|---|
| callous unconcern for others' feelings | since 15, three or more of: unlawful acts, deceit, impulsivity, aggression, recklessness, irresponsibility, lack of remorse |
| persistent irresponsibility and disregard for rules | age at least 18 |
| relationships easily made but not kept | conduct disorder before the age of 15 |
| low tolerance of frustration, low threshold for violence; no guilt, no learning from punishment; blaming others | not only during schizophrenia or bipolar disorder |
Substance misuse, depression and ADHD are common. Violence to partners and children is the harm that matters most, so violence and safeguarding risks are always assessed.
Psychopathy is narrower and more severe, measured with Hare's Psychopathy Checklist–Revised (PCL-R): 20 items scored 0 to 2, to a maximum of 40, covering interpersonal and affective traits (superficial charm, grandiosity, lying, manipulation, no remorse, callousness) and an antisocial lifestyle (impulsivity, irresponsibility, early behaviour problems, delinquency, criminal versatility). The cut-off is 30 in North America and about 25 in the UK. Only a minority with antisocial personality disorder are psychopathic, and a high score predicts violence and reoffending.
Emotionally unstable (borderline) personality disorder
ICD-10's impulsive type (F60.30) is emotional instability with poor impulse control and outbursts of anger or violence, often on being criticised. The borderline type (F60.31) adds a disturbed self-image, chronic emptiness, intense and unstable relationships, efforts to avoid abandonment and recurrent self-harm. DSM-5 diagnoses borderline personality disorder with five or more of nine features:
| Domain | DSM-5 features |
|---|---|
| Relationships | frantic efforts to avoid abandonment; intense relationships swinging between idealising and devaluing |
| Self | unstable self-image; chronic emptiness |
| Emotion | mood reacting sharply to events, for hours rather than days; intense, poorly controlled anger |
| Behaviour | impulsivity in at least two self-damaging areas (spending, sex, substances, driving, binge eating); recurrent suicidal behaviour or self-harm |
| Cognition | transient, stress-related paranoid ideas or severe dissociation |
Most patients self-harm, mainly by cutting and overdose, and many attempt suicide. Brief psychotic-like experiences, such as a critical voice under stress, are common; they are short and stress-linked, without thought disorder. Comorbidity is the rule: depression, PTSD, substance misuse, bulimia and anxiety disorders.
Histrionic personality disorder
A pervasive need to be the centre of attention, with shallow, rapidly shifting emotion.
| Feature | What it looks like |
|---|---|
| Self-dramatisation | theatrical, exaggerated emotion; impressionistic speech lacking detail |
| Suggestibility | easily swayed by others or by circumstances |
| Shallow, labile affect | emotions that switch quickly and seem insincere |
| Attention-seeking | uncomfortable when not the centre of attention; seeks excitement |
| Seductiveness and appearance | inappropriately seductive; over-concerned with attractiveness |
Somatic presentations and unnecessary investigations are common.
Diagnosis and management
Assessment
The diagnosis rests on the person's adult life as a whole: a history from adolescence of relationships, work, offending, self-harm and substances, an informant's account, and more than one interview away from crises and acute illness, which distort personality. Structured interviews (IPDE, SCID-5-PD) and short screens such as the SAPAS support the judgement. Risk to self, to others and to children is assessed. Common mistakes are diagnosing from one crisis or from a dislike of the patient, and using the label to withhold care.
| May look like a personality disorder | Points to the other diagnosis |
|---|---|
| Bipolar disorder | mood episodes lasting days or weeks with less need for sleep, not shifts over hours triggered by people |
| Complex PTSD (ICD-11) | re-experiencing and avoidance of trauma; a stable sense of worthlessness; less fear of abandonment |
| Autism or ADHD | difficulties present from early childhood, in every setting |
| Organic personality change | onset in adult life after head injury, a frontal lesion, dementia or substance use |
Principles for every personality disorder
- 1
Engage
The diagnosis is explained honestly, as difficulties that can change, and realistic goals are shared. - 2
Treat comorbidity
Depression, anxiety, PTSD, ADHD and substance misuse are treated as usual. - 3
Therapy
A structured psychological therapy from a supervised team, over months to years. - 4
Crisis plan
Written with the patient and followed by every service.
Borderline personality disorder
Structured psychological therapy is the treatment; a Cochrane review found it reduces severity compared with usual care (moderate-certainty evidence), and probably self-harm and suicide-related outcomes too (low certainty).
| Therapy | What it does |
|---|---|
| Dialectical behaviour therapy (DBT) | a year of individual therapy, a skills group (mindfulness, distress tolerance, emotion regulation, interpersonal skills) and phone coaching; suggested in the UK for women for whom reducing self-harm is the priority |
| Mentalisation-based treatment (MBT) | psychodynamic, individual and group, about 18 months; strengthens understanding of minds under stress |
| Schema therapy | changes the lasting beliefs formed in childhood, such as "I will be abandoned" |
| Transference-focused psychotherapy | works on distorted views of self and others as they appear with the therapist |
| Generalist approaches | good psychiatric management or structured clinical management, delivered by trained general staff |
No drug is licensed for borderline personality disorder, and none treats it. UK guidance advises against drugs for the disorder or its symptoms (self-harm, instability, transient psychotic symptoms) and against long-term antipsychotics; a Cochrane review found no drug that consistently helps. Comorbid illnesses are treated by their own guidance, and the several drugs many patients arrive on are reviewed and reduced. Drugs are dispensed in small quantities, because overdose is common. Benzodiazepines are avoided, and so is valproate in a woman who could become pregnant.
In a crisis the team follows the crisis plan (triggers, what the person can do, whom to call, what each service will do); a calm, validating assessment and quick follow-up do more than a new drug. If one is needed, a sedative antihistamine such as promethazine is given for no more than a week. Admission is brief and goal-focused, kept for high risk or comorbid illness. After self-harm, risk scales are not used to predict suicide or to ration care.
Dissocial (antisocial) personality disorder
UK guidance offers group-based cognitive and behavioural programmes to reduce offending, in the community or in prison, with the usual treatment of comorbid substance misuse, depression and ADHD. Drugs are not used routinely for the disorder or its aggression and impulsivity. Violence risk is assessed with structured professional judgement, such as the HCR-20, and shared with probation and other agencies. The best prospect is prevention: parent training for young children with conduct problems, and family-based treatments such as multisystemic therapy for adolescents.
Paranoid, schizoid and histrionic personality disorders
These patients seldom seek help for their personality, but present with depression, anxiety or conflict. Paranoid patients need a straightforward clinician who explains everything, without over-familiarity or confrontation; schizoid patients are helped at the distance they choose; histrionic patients need consistent boundaries and one coordinating doctor.
Epidemiology
About 4 to 12 per cent of adults in community surveys have a personality disorder (4.4 per cent in a British survey), often of more than one type. The share rises to a third or more of psychiatric outpatients and about two-thirds of male prisoners, and falls with age, most clearly for cluster B.
| Type | Approximate community prevalence | Notes |
|---|---|---|
| Paranoid | 1 to 3 per cent | more men |
| Schizoid | below 1 to a few per cent | rarely seen in clinics |
| Antisocial | 1 to 3 per cent | men three to five times more often; about half of male prisoners |
| Borderline | 1 to 2 per cent | 10 per cent of outpatients, 15 to 20 per cent of inpatients; women about 3 to 1 in clinics, near equal in the community |
| Histrionic | 1 to 2 per cent | diagnosed more often in women |
Prognosis
Personality disorders are long-lasting but not unchangeable. Borderline personality disorder has the best-studied course:
- no longer meet the criteria after 10 years, in two long follow-up studies
- 85–93per cent
- reach full recovery, with good work and relationships, within 10 years
- about 50per cent
- died by suicide over 24 years in one cohort, with more dying early of other causes
- 5.9per cent
Self-harm and substance misuse settle first; emptiness, anger and fear of abandonment last longer. Remission usually lasts, but good work and relationships are harder to reach and to keep. Repeated hospitalisation, severe self-harm, childhood sexual abuse, substance misuse and antisocial traits predict a worse course. Early death from natural causes is commoner than suicide, so physical health needs attention too.
In antisocial personality disorder, offending often lessens after 40, but relationship problems, substance misuse and domestic violence may continue, and violent and accidental death is common. Cluster A traits do not soften with age and may become more marked. Any personality disorder worsens the outcome of comorbid depression, anxiety and substance misuse.
Check yourselfAnswer, then say how sure you were: a lucky guess still counts as a weak point.
1A 24-year-old woman has had unstable relationships, intense anger, a chronic sense of emptiness and repeated cutting since the age of 15. She meets the criteria for borderline personality disorder and asks which treatment will help most. What is the best answer?
2How does ICD-11 classify personality disorder?
3A 30-year-old man has repeated convictions for assault and fraud, has never kept a job, lies easily and shows no remorse. Which finding does DSM-5 require before antisocial personality disorder can be diagnosed?
4A 45-year-old man has lived alone all his life, has no friends and no wish for any, takes no pleasure in most activities and seems indifferent to praise or criticism. He has no odd beliefs, unusual experiences or eccentric speech. Which is the most likely diagnosis?
5A woman with known borderline personality disorder comes to the emergency department the night her relationship ends. She is distressed and has thoughts of overdosing, but has not harmed herself and is not psychotic. She asks for something to calm her down. What is the most appropriate approach?