Personality disorder is not about personality traits

Because traits are about all psychopathology

In this post, I explore whether disorders of ‘personality’ can be meaningfully defined using ‘personality traits’. To do this, I first outline the ‘trait’ definition of ‘personality disorders’, as endorsed and promoted by various personality researchers (such as Donald Widiger, Donald Lynam, Daniel Garcia, Douglas Samuel, Joshua Miller, and plenty others). I then show how this definition leads to the striking conclusion that either all mental disorders are personality disorders or there are no personality disorders.^a Finally, I conclude by providing an alternative-to-the-dominant definition of ‘personality trait disorder’.

Before we reach this alternative definition, let us first consider the key premise of the existing ‘trait’ perspective: namely, that ‘disorders of personality’ can be defined based on ‘extreme and maladaptive variants’ of adaptive personality traits.^1–5 Adaptive personality traits here are the well-known ‘five-factor’ traits: namely, neuroticism, openness, conscientiousness, extraversion, and agreeableness. By contrast, maladaptive personality traits are the ‘socially undesirable’ versions of adaptive traits: namely, negative affectivity, psychoticism, disinhibition, detachment, and antagonism, respectively.⁶

According to the (five-factor) trait perspective, personality disorder simply emerges when people score extremely on measures of maladaptive personality traits. Thus, a person who scores extremely on ‘negative affectivity’ and ‘antagonism’ (and is thus emotionally unstable and disagreeable) could receive a diagnosis of ‘borderline personality’.⁷ Conversely, a person who scores extremely on ‘detachment’ and ‘psychoticism’ (and is thus detached and psychotic) could receive a diagnosis of ‘schizotypal personality’.⁸ That is how ‘disorders of personality’ are currently defined from the ‘trait’ perspective: by extreme and maladaptive personality traits.

On first reading, this definition of personality pathology appears elegant and intuitive: of course, it is the ‘maladaptive’ traits of personality that should define the ‘disorders’ of personality. On second reading, however, this definition is found to be rather problematic for the following simple yet under-appreciated reason: Extreme and maladaptive traits are found in all mental disorders, broadly, implying that they cannot define the personality disorders, specifically. To briefly illustrate this point, consider the following pieces of evidence that clearly showcase how extreme and maladaptive traits are present in virtually all mental disorders:

(1) According to meta-analytic evidence, mood disorders (like depression and anxiety) are strongly associated with at least three traits: namely, high neuroticism, low extraversion, and low conscientiousness.⁹

(2) According to longitudinal evidence, the development of post-traumatic stress disorder is influenced by at least three personality traits: namely, high neuroticism, low extraversion, and low conscientiousness.¹⁰

(3) According to meta-analytic evidence, obsessive-compulsive disorder shows the strongest relationship with trait neuroticism (d=2.07).⁹

(4) According to meta-analytic evidence, substance use disorders are most robustly associated with trait disinhibition.¹¹

(5) According to meta-analytic evidence, attention-deficit hyperactivity disorder exhibits extremely high associations with at least three traits: namely, conscientiousness (d = -0.95), neuroticism (d=0.85) and agreeableness (d=-0.64).¹²

(6) According to meta-analytic and longitudinal evidence, psychosis is most robustly associated with thought disorder, aka, psychoticism, at the cross-sectional level¹¹, and neuroticism, at the longitudinal level.¹³

(7) Likewise, but based on limited meta-analytic findings, bipolar disorder is robustly associated with the same two traits: neuroticism and psychoticism.¹¹

(8) According to meta-analytic evidence, autism spectrum disorder is associated with all five-factor personality traits, most notably, introversion and neuroticism.¹⁴

(9) According to meta-analytic evidence, somatoform disorders are robustly associated with neuroticism.¹⁵

(10) According to meta-analytic evidence, eating disorders are strongly associated with at least three traits: neuroticism, perfectionism, and introversion.¹⁶

Finally, it is worth noting that in several cases, personality traits are, paradoxically, more robustly associated with the abovementioned mental disorders than with the personality disorders (see my argument later).

This evidence clearly illustrates that extreme and maladaptive traits are found in all mental disorders, implying that indeed all ‘mental’ disorders can be viewed as ‘personality’ disorders (under the trait definition of personality disorder). In other words: If personality disorder is just a disorder of extreme and maladaptive traits, then all mental disorders are personality disorders because all such disorders inherently entail personality trait extremeness.

Interestingly, although somewhat counterintuitive, this logical possibility used to be a reality back in the 19^th century. Indeed, at the time, the concept of ‘personality’ was synonymous with the concept of ‘consciousness’, which was used to define all mental disorders (as ‘disorders of consciousness’).¹⁷ In that sense, all mental disorders were viewed as personality disorders because all mental disorders inherently entailed alterations in consciousness: that is, alterations in the ‘patterns of perceiving, relating to, and thinking about the environment and oneself’ to use the DSM-5 definition of ‘personality disorder’.¹⁸

This historical fact, along with the aforementioned evidence, leaves us with the following take-home message: So long as the concept of ‘personality’ is broad and non-specific (as the trait definition makes it to be), it will never be able to define a specific ‘disorder of personality’ without painting all other psychopathologies as personality pathologies.

Which begs the question, then: If the concept of ‘personality’ is too broad to define specific ‘disorders of personality’, then what should be used to define these disorders, specifically? Here, I would like to offer an idea: Instead of using the entire tapestry of personality to define the disorders of ‘personality’, we only use the most relevant traits to define these pathologies. We also perhaps only use the most relevant traits to define all other psychopathologies—since, as I have seen previously, all of these psychopathologies can be equally viewed as ‘personality’ pathologies. Doing this, however, reveals that there is no basis for labelling any of these psycho-pathologies as ‘personality’ pathologies because all of them can be more specifically defined using the following specific (personality) traits.

Specifically:

(1) Neuroticism can be used to define the internalising disorders because it is most robustly associated with them (average Cohen’s d = 1.71)⁹ not with the personality disorders (average Cohen’s d = 0.56).¹⁹ This, of course, makes sense: Internalizing disorders (like major depression, anxiety, and post-traumatic stress disorder) are fundamentally emotional as they are characterised by extreme and uncontrollable emotions. In that sense, we can define these disorders (intuitively and perhaps circularly) as emotional (or neurotic) disorders.

(2) Psychoticism (a maladaptive variant of trait openness) is most robustly associated with psychotic disorders, including psychosis, bipolarity, and, curiously, schizotypal personality, which is now notably part of the psychosis spectrum.^20,21 This also makes sense: psychotic disorders are fundamentally about cognition and perception as they involve delusions and hallucinations.²² In that sense, we can define these disorders (also intuitively and circularly) as cognitive-perceptual disorders.

(3) Unconscientiousness (aka disinhibition) is most robustly associated with substance use (mean Cohen’s d = 1.09)⁹ and attention-deficit hyperactivity disorders (mean Cohen’s d = 0.95)¹², not personality disorders (mean Cohen’s d = 0.22)¹⁹.This, again, makes sense: substance use and attention-deficit problems are fundamentally problems of impulse (behavioural) control.^23,24 In that sense, we can define these disorders as behavioural (impulse) disorders.

(4) Disagreeableness (or antagonism) and introversion (or detachment) are most robustly associated with the personality disorders (average factor loadings = 0.35 and 0.50, respectively; see¹¹) though some exceptions do exist (e.g., schizotypal personality being a psychotic disorder and antisocial personality being likely a behavioural, or impulse, disorder). Antagonistic and detached traits involve relational themes, which, in the words of trait theorists themselves entail “to navigate relationships based on either mutual exchange or dominance-exploitation (antagonism)” and “to establish bonds with mates, kin, or friends (detachment)”¹. This again makes sense: the fundamental problems of ‘personality disorders’ are relational problems.^25,26 In that sense, we can define these disorders as relational disorders.

We can therefore see that even when we categorise most psychopathologies in terms of personality, we still end up with the following non-personality categories: the emotional disorders (neuroticism), the impulse disorders (disinhibition), the cognitive-perceptual disorders (psychoticism), and the relational disorders (antagonism and detachment).

Astute readers may, at this point, have noticed that this organisation matches the well-known organisation from the hierarchical taxonomy of psychopathology (HiTOP)²⁷. For those unfamiliar with this topic, HiTOP is an empirically derived model that organizes all forms of psychopathology into a hierarchy of dimensions that range from broad domains (such as internalizing and externalizing) to narrower domains (such as fear vs. distress in internalising disorders)²⁸. This hierarchical taxonomy was developed to address long-standing problems inherent to traditional categorical models (e.g., arbitrary boundaries between mental disorders, comorbidity across them, and high heterogeneity within them). In the end, however, this hierarchical taxonomy ended up revealing that the psychological themes used to define mental disorders, broadly, are the same as the psychological themes used to define ‘personality pathologies’: namely, neuroticism (aka ‘emotional dysregulation’ which defines the emotional disorders), psychoticism (aka ‘thought disorder’ which defines the cognitive-perceptual disorders), disinhibition (which defines the behavioural disorders), and detachment and antagonism (which define the relational disorders).²⁹

This equivalence suggests that there is nothing unique about the association between personality traits and the putative disorders of ‘personality’. Instead, all psychopathologies are invariably associated with personality traits that match their underlying pathologies. In that sense, all psychopathologies both are and are not personality pathologies.

To briefly summarize, I have so far shown how the trait-based definition of ‘personality pathology’ leads to the following paradoxical yet also logical outcome: Either all mental disorders are personality disorders (because all mental disorders are equally ‘personality trait disordered’) or there are no personality disorders (because all mental disorders can be primarily defined based on specific ‘personality trait problems’). In the remainder of this post, I attempt to resolve this paradoxical definition of personality pathology by offering what I believe to be a more logically coherent alternative. To clarify, I offer my alternative definition in a rather tentative way—I would love to hear what others make of it, particularly those who define personality pathology using personality traits.

Back to my viewpoint: In my eyes, trait-based definitions of ‘maladaptive’ personality can only be logically coherent when they follow their corresponding definitions of ‘adaptive’ personality. To elaborate, from a trait perspective, ‘adaptive personality’ has at the very least two key properties: first, it is ‘relatively stable over time’;³⁰ second, it is typified by ‘adaptive’ ways of ‘thinking, feeling, behaving, and relating’.^5,b Based on this definition of ‘adaptive personality’, ‘maladaptive personality’ must have, at least, the two following properties: first, it needs to be ‘relatively stable over time’; second, it needs to be typified by ‘maladaptive’ ways of ‘thinking, feeling, behaving, and relating’.

Defined in this way, personality pathology not only makes more sense but also reveals two interesting patterns. First, all ‘mental’ disorders can still be viewed as ‘personality’ disorders; however, that only happens when they last longer (that is, when they are ‘relatively stable’ over time). Second, there can be no unique diagnostic category of ‘personality disorder’ since every mental disorder can ‘become’ a ‘personality disorder’ if it simply lasts longer. In that sense, every mental disorder could be either a ‘mental state’ disorder (when it is more transient and ‘state-like’) or a ‘personality trait’ disorder (when it is more chronic and ‘trait-like’).

To briefly illustrate this clinically, consider two patients who both feel depressed. One, however, has been depressed for only two weeks and in response to a severely negative life event (for instance, losing their partner in a tragic accident) while the other has always been depressed and in response to more chronic life problems (for instance, having to deal with a neglectful parent). Under my definition of personality disorder, the first patient may be best understood as having an exogenous, state-based disorder—one that may be better defined as a ‘major depressive (or grief) episode’. Conversely, the second patient may be best understood as having a more endogenous, trait-based disorder—one that may be better defined as a ‘treatment-resistant depression’ (or, more traditionally, a ‘depressive’ or even ‘masochistic’ personality). To be sure, real-life clinical cases are never this stark; nevertheless, this rudimentary contrast serves to illustrate how the same phenomenology (low mood, anhedonia, hopelessness, and so on) can be classified differently depending on how long it persists—and thereby how structurally embedded it is with one’s ‘personality’.

Importantly, the same personality dynamics can, in principle, operate in all other psychopathologies. Indeed, various psychopathologies are typically chronic, including psychosis (due to trait ‘psychoticism’), bipolarity (due to traits ‘psychoticism’ and ‘neuroticism’), attention-deficit and hyperactivity (due to traits ‘disinhibition’ and ‘sensation-seeking’), and high-functioning autism (due to traits like ‘detachment’ and ‘anankastia’). Moreover, even other psychopathologies that are more ‘state-like’ still have the ‘potential’ to be chronic and trait-like (think extreme neuroticism vs. psychoticism leading, respectively, to classic cases of ‘the neurotic person’ vs. ‘the psychotic person’). Ergo, all long-lasting mental disorders could be understood as ‘personality-based’ disorders—because, arguably, the longer the last, the more synonymous they become the notion of personality (i.e., one’s characteristic way of ‘thinking, feeling, behaving, and relating’).^c

I appreciate that this way of thinking may appear rather peculiar at first sight. To avoid any misunderstandings then, allow me to clarify at least three important points. First, the reason I am writing about this alternative proposal of ‘personality trait pathology’ is not to suggest that we start labelling every long-term mental disorder as ‘personality’ disorder. Instead, the reason I am writing about this alternative proposal is to suggest that if one wishes to use ‘personality traits’ to define a ‘personality pathology’, then one must reconcile with the only logical way of doing this: namely, by defining every long-term mental disorder as a ‘personality trait’ disorder. Perhaps this term—‘personality trait disorder’—may clarify this viewpoint better and may also help with destigmatising the existing ‘personality disorders’ (by replacing some of them with the ‘relational disorders’ and others with ‘personality trait disorders’; see my argument later). However, I acknowledge that more work is needed before such a radically different proposal is implemented in diagnostic systems.

Second, if one wishes to develop such a research agenda on this alternative proposal of ‘personality trait disorder’, one should strive to diagnostically integrate some basic facts about personality traits, including, but not limited to the ideas that:

(1) Personality traits are independent of value judgements of health versus illness because they can lead to both thriving and impairing consequences. In other words, there can never be a trait that is purely ‘maladaptive’ or purely ‘adaptive’ because, regardless of its extremity, a trait will always lead to both positive and negative consequences (e.g., extreme neuroticism leading to emotional volatility, but also protecting oneself from harmful stimuli).³¹

(2) Personality traits are fundamentally contextual as they can lead to positive outcomes in one context but negative outcomes in another context. For instance, a creative person typified by extreme openness (bordering on psychoticism) and neuroticism (bordering on bipolarity) may be particularly ‘adaptive’ in unstructured contexts (typified by creative work) but be incredibly ‘maladaptive’ in more structured contexts (typified by repetitive work). Here, the problem is not ‘the person’ (as current neurodiversity paradigms highlight), but rather the ‘mismatch between the person and their world’.³¹

(3) Personality traits can change over time. The literature on this is so extensive that it would require an entire essay to review all evidence in full. For the sake of completing my argument, however, at least three pieces of evidence should be noted: (a) personality traits can change in response to psychological interventions,³² (b) personality traits can change in response to life events (both positive and negative),³³ and (c) personality traits can change across adulthood in ways that reflect increasing ‘maturity’ (that is, increasing emotional stability, conscientiousness, and agreeableness).³⁴

Appreciating these established findings may lead to a more neutral and precise classification system: one that does not pathologize people suffering from long-term mental health problems but rather delineates precisely the reasons why such people tend to suffer over time.

Finally, it is worth noting that this alternative proposal of mine is not original in any way as it is something that was already considered during the development of DSM-5. Indeed, in the first meeting of the DSM-5 Research Planning Conference (chaired by Drs. Darrel Regier and Steve Hyman), it was suggested that personality disorders be converted into ‘early-onset, chronic variants of Axis I disorders’.³⁵ Although considered, however, this proposal was eventually rejected as it was acknowledged that not all personality disorders can be simply converted into long-term variants of existing mental disorders. For example, while obsessive-compulsive and schizotypal personality disorders can be readily re-conceptualised as chronic variants of existing mental disorders (i.e., obsessive-compulsive and psychotic disorders), narcissistic, dependent, and perhaps even borderline personality disorders are not sufficiently similar to existing mental disorders to be converted as chronic variants of them. It is this definitional asymmetry across personality pathologies that led to the rejection of this proposal and the retention of individually-defined personality disorders.

Yet my argument would be that this asymmetry in the definition of individual personality disorders reveals a deeper conceptual problem—one that I believe few, if any, researchers appreciate. This problem is the fact that different theorists define ‘personality’ (and therefore ‘personality pathology’) in vastly different ways, effectively leading to the notation of different psychological difficulties as ‘personality pathologies’ for vastly different reasons. As we have seen in this post, one of those reasons is that certain psychological difficulties are best defined in terms of stable maladaptive traits (e.g., schizotypal difficulties being defined based on stable psychotic traits). Other reasons, however, may be that certain difficulties are best defined based on one’s character (e.g., psychopathy) or general personality functioning (e.g., borderline). I shall leave those reasons to be explored in other Substack posts.

Footnotes

^aTo clarify, my use of ‘personality disorders’ [plural] is not to endorse traditional definitions of categorically distinct disorders of ‘personality’. Instead, and in line with existing evidence, my use of ‘personality disorders’ is to imply that these legacy diagnoses reflect distinct dimensions of personality (e.g., schizoid personality reflecting the extreme end of introversion, histrionic personality reflecting the extreme end of extraversion, borderline personality reflecting the extreme end of antagonism, and so on). The idea then is that each of these legacy diagnoses might belong to, or reflect, a particular dimension of personality experience (with some cross-loadings to other dimensions being also evident).

^bI must note that my definition of ‘adaptive personality’ is circular but will suffice for the purposes of this essay. A more complete definition would require an illustration of what is meant by ‘adaptive’ but that is beyond the scope of the current conceptual analysis.

^cInterestingly, this definition of personality (pathology) matches rather strikingly contemporary psychoanalytic definitions of personality which define it, roughly speaking, as ‘a person’s characteristic and enduring patterns of thinking, feeling, fantasizing, desiring, fearing, coping, defending, attaching, relating, and experiencing self and others’.³⁶

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