People who meet the criteria for personality disorders tend to show extreme and/or rigid personality traits. This behavior can lead to difficulties in social and work settings, as well as within relationships. A national survey found that about 9% of the U.S. population has some kind of personality disorder. 

Personality disorder was once thought of as a problem that would define a person for life. However, current research reveals that it may be a condition that can improve with specific treatment. “If an individual meets the criteria for one personality disorder, and you assess them carefully, they often meet criteria for as many as four personality disorders,” says Yale Medicine psychiatrist Seth Axelrod, PhD.

Researchers and clinicians are still finding the best methods to categorize and diagnose personality disorders. The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) currently divides personality disorders into three distinct "clusters."  

• Paranoid, schizoid, or schizotypal. These personality disorders include a range of odd thinking, including high suspicion of others, little or no emotions, and magical thinking. 
• Antisocial, borderline, histrionic, or narcissistic. These personalities can be summarized as unpredictable thinking, impulsivity, paranoia, and an exaggeration of one’s abilities. 
• Avoidant, dependent, obsessive-compulsive. All three of these personality disorders revolve around severe social anxiety and difficulty with relationships. 

Patients with borderline personality disorder tend to have unstable and chaotic relationships because of their emotional difficulties. 

“Also, their emotions are often set off by difficulties in their relationships, so these problems tend to feed off each other,” Axelrod says. “They have a relationship conflict or challenge, and then, because they become emotional and react impulsively, the impulsivity can negatively affect the relationship.” 

These patients also struggle with issues of identity, because they can’t trust themselves to feel the same way about things or act consistently over time. They also often have a history of frustrating the clinicians they’ve seen in the past and exhibiting unusual responses to therapy.

Personality disorders can have biological and emotional origins. Clinical studies have examined the personality traits underlying these disorders, and the disorders themselves, have found a considerable genetic component. Trauma is highly associated with personality disorders. The relationship between sexual abuse and borderline personality disorder is particularly strong, but it’s also not exact. 

“Having a history of sexual abuse isn’t necessary nor sufficient for developing borderline personality disorder,” Axelrod says. “Kids who go on to develop personality disorders might have experienced ‘traumatic betrayal’ related to trauma from their caretakers or from caretakers being non-responsive to their trauma. But it can also be that they experienced normative stress as traumatic."

A psychologist or psychiatrist will interview a patient to see if he or she meets the criteria for a personality disorder.

“If an individual meets the criteria for one personality disorder, and you assess them carefully, they often meet criteria for as many as four personality disorders,” Axelrod says. In fact, the most common diagnosis, he adds, is unspecified personality disorder. 

Psychiatrists and therapists assess a patient’s high-risk behaviors and determine whether he or she has not responded well to other therapies in the past. 

The difficulties that many patients with personality disorders face, such as an inability to control their emotions, can be eased substantially with therapies such as Dialectic Behavior Therapy (DBT). It's “the treatment that has, by far, the most research supporting its effectiveness,” Axelrod says. DBT balances behavioral skill changes with acceptance, which is drawn from Zen philosophy.

Yale Medicine offers DBT as an intensive outpatient level of care in a hospital. The therapy includes skills training to help patients manage their emotions and interactions with people. Patients also develop individualized behavioral plans that outline how they will respond to problems more effectively. The plans support the patient in avoiding self-destructive coping, better engaging in treatment, and gaining control over aspects of their lives that are chaotic. 

Patients enrolled in the program have access to the DBT clinicians by phone outside of the program hours. This helps them face unexpected situations and successfully bring their new skills into their lives.

Yale-New Haven Hospital’s Intensive Outpatient Program has had great success in helping patients with borderline personality disorder learn skills to adapt and look forward to satisfying and productive lives.

Yale Medicine takes a group-based approach to treating patients with personality disorders. “There’s been a lot of research focusing on applying DBT in individual therapy, with only group-base skills training,” Axelrod says. “Individuals coming to our program also get behaviorally-focused therapy in a group format. They’re getting the benefit of each other’s wisdom and learning to see problems they struggle with from the other’s perspectives.” 

“These are individuals who come to us very hopeless,” Axelrod adds. “They’ve tried everything they know to have the life they want, and that’s why they’re often ambivalent about living. Some are so caught in misery that they can’t stand their experience. We help map out what would be needed for their lives to be good enough for them to want to fight for it.”