Chpt 15: Personality Disorders

Involve problems in thinking, affect, impulse control and interpersonal functioning that persists for years and influences many domains of life

Personality Disorder

What 3 clusters are the 10 personality disorders classified into?

1. Odd/Eccentric (cluster A)

2. Dramatic/Erratic (cluster B)

3. Anxious/Fearful (cluster C)

An inflexible pattern of inner experience and behaviour that is distinct from cultural expectations, and influences at least two of the following:

• Cognition about the self and others

• Affect

• Interpersonal functioning

• Impulse control

General Personality Disorder

The pattern

• Causes significant distress or impairment

• Is inflexible

• Is pervasive across situations

General Personality Disorder

When is the onset for GPD?

Early adulthood and persists for a long duration

Can GPD be explained by another mental disorder, by a substance, or by a medical condition?

No

What are the three disorders within cluster A (the odd/eccentric cluster)?

Paranoid Personality Disorder

Schizoid Personality Disorder

Schizotypal Personality Disorder

*Different from schizophrenia in that bizarre thinking and functional impairments are less severe and hallucinations and full-blown delusions are not present

Suspicious of others

• Strangers, casual acquaintances, family members

• Unjustified suspiciousness (DSM-5)

• Reluctant to confide in others because of suspiciousness (DSM-5)

• Unwarranted suspiciousness (DSM-5)

• Read hidden meanings into the benign actions of others (DSM-5)

Expectation for mistreatment or exploitation

• Secretive and continually on the lookout for signs of trickery and abuse

• Hostile and angry in response to perceived insults

• Unwarranted doubts about loyalty or trustworthiness of friends (DSM-5)

Seen as difficult and critical

• Social world filled with conflict, which perpetuates paranoia

• Angry reactions to perceived attacks (DSM-5)

• Bear grudges for perceived arongs (DSM-5)

Paranoid Personality Disorder

Do not desire or enjoy social relationships

• No close friends

Aloof and show no warm, tender feelings when interacting with others

Rarely experience strong emotions

• No interest in sex

• Enjoy few activities

Indifferent to praise or criticism

Schizoid Personality Disorder

Presence of 5 or more of the following signs of unusual thinking, eccentric behaviour, and interpersonal deficits

• Ideas of reference

• Odd beliefs or magical thinking, e.g., belief in extrasensory perception

• Unusual perceptions

• Odd thought and speech

• Suspiciousness or paranoia

• Inappropriate or restricted affect

• Odd or eccentric behaviour or appearance

• Lack of close friends

• Social anxiety and interpersonal fears that do not diminish with familiarity

Schizotypal Personality Disorder

What personality disorders does cluster B (dramatic/erratic) include?

Antisocial Personality Disorder

Borderline Personality Disorder

Histrionic Personality Disorder

Narcissistic Personality Disorder

Pervasive disregard for the rights of others

• Aggressive, impulsive, and callous traits

Pattern of irresponsible behaviours

• Working inconsistently, breaking laws, being irritable and physically aggressive, defaulting on debts, being reckless and impulsive, neglecting to plan ahead

• Little regard for truth and little remorse for misdeeds

• 5x more common in men

• 75% also meet criteria for another disorder

  • Substance use is very common

• Age at least 18 and evidence of conduct disorder before age 15

Antisocial Personality Disorder

Focuses on internal thoughts and feelings

• Poverty of emotion (negative and positive)

• Impulsivity

Psychopathy

Problems with research

• Differences in diagnosis (APD vs. psychopathy)

• Conducted mostly with criminals

Interactions of genes and the social environment

Etiology of Antisocial Personality Disorder

Insensitivity to fear and threat:

• Unable to learn from experience to avoid trouble

• Lower levels and less reactive skin conductance

• Blunted neural responsivity

Poor attention to treat when pursuing rewards/goals

Deficits in empathy

• Not in tune with the emotional reactions of others

Psychological Risk of Antisocial Personality Disorder

Common in clinical settings, very hard to treat, and associated with recurrent periods of suicidality

Impulsivity and instability in relationships and mood

• E.g., gambling, reckless spending, indiscriminate sexual activity, and substance abuse

High levels of stress (e.g., relationship conflicts)

Unstable sense of self

Cannot bear to be alone, fears of abandonment, chronic feelings of depression and emptiness

Suicidal behaviour

• Also likely to engage in nonsuicidal self-injury

Borderline Personality Disorder

Diminished connectivity of brain regions involved in emotion experience

• Prefrontal cortex, anterior cingulate cortex, amygdala

• Could help explain poor control over emotions and impulsivity when emotions are present

Etiology BPD

Diathesis of emotional dysregulation interacts with a family environment that is invalidating

• Person’s feelings are discounted and disrespected

Emotional dysregulation and invalidation interact with each other in a dynamic fashion

Biological diathesis —> Emotional dysregulation in the child —> Great demands on the family —> Invalidation by parents through punishing or ignoring the demands —> Emotional outbursts by child to which parents attend

Linehan’s Diathesis-Stress Theory

Overly dramatic and attention-seeking behaviour

Often use their physical appearance to draw attention to themselves

Self-centered, overly concerned with their physical attractiveness, and uncomfortable when not the center of attention

Inappropriately sexually provocative and seductive

Easily influenced by others

Misreads relationships as more intimate than they are

Histrionic Personality Disorder

Grandiose view of self

• Preoccupied with fantasies of great success

Self-centered

• Demands constant attention and admiration

• Lacks empathy

• Feelings of arrogance, envy, entitlement

• View themselves as superior to others

Primary goal of interaction with others is to bolster their own self-esteem

• Value being admired more than gaining closeness

• Tendency to seek out high status partners

Highly likely to be vindictive and aggressive when faced with a competitive threat or a put-down

Narcissistic Personality Disorder

Overly indulgent parents foster children’s belief that they are special

Parental tendencies to see their children as highly superior to others predicts children’s narcissistic traits

Inflated self-worth and denigration of others defend against feelings of shame

Sensitivity to negative social interactions

Associated with higher levels of neuroticism and depression

Etiology of Narcissistic Personality Disorder

Cluster C (anxious/fearful) includes what personality disorders?

Avoidant Personality Disorder

Dependent Personality Disorder

Obsessive Compulsive Personality Disorder

*Prone to worry and distress

Fearful of criticism, rejection, and disapproval

Avoids social situations due to fear of negative feedback

Restrained and inhibited in social situations

• Feelings of inadequacy, inferiority

Beliefs of incompetence and inferiority

• Avoids taking risks or trying new activities

High comorbidity with social anxiety disorder

• Similar genetic vulnerability

Avoidant Personality Disorder

Excessive reliance on others

Intense need to be taken care of

• Discomfort with being alone

Subordinate needs to ensure protective relationships are not threatened

Difficulty disagreeing with others for fear of losing their support

Urgently seek new relationship when one ends

View themselves as weak

• Turn to others for support and decision-making

• Need others to take responsibility for most major areas of life

Likely to develop depression after interpersonal losses

Dependent Personality Disorder

A perfectionist

Preoccupied with rules, details, schedules, and organization

• Often to the extreme of being unable to finish projects

• Serious, rigid, formal, and inflexible

Overly focused on work

• Little time for leisure, family, and friends

Reluctant to make decisions or delegate

Inflexibility about morals and values

Difficulty discarding worthless items

Reluctance to delegate unless others conform to one’s standards

Miserliness

Rigidity and stubbornness

*Compared to OCD:

• Does not have the obsessions/compulsions of OCD

• Symptoms often co-occur and share genetic vulnerability

Obsessive-Compulsive Personality Disorder

Often enter treatment for a condition other than PD

Presence of PD predicts slower improvement in psychotherapy (treatment of choice)

• Evidence that personality traits do change

• Often supplemented with medications

• Psychodynamic theory: childhood problems at the root of PD

• Cognitive theory: Negative cognitive beliefs are at the root of PD, help person become more aware of beliefs and challenge maladaptive cognitions

Treatment of Personality Disorder (PD)

If people get to know the real me, they will reject me

Maladaptive cognition for Avoidant Personality Disorder

If things get disorganized, horrible mistakes will happen

Maladaptive cognition for Obsessive-Compulsive Personality Disorder

People ask for exploitations—they let down their guard

Maladaptive cognition for Antisocial Personality Disorder

I am better than others, and people who can’t understand that don’t deserve my time

Maladaptive cognition for Narcissistic Personality Disorder

Antipsychotic and antidepressant medications

• Helpful for reducing unusual thinking

Schizotypal PD Treatment

Same treatments as social anxiety disorder

Antidepressant medications

CBT

• Challenge negative beliefs

• Social skills training

• Exposure to feared situations

Avoidant PD Treatment

Difficult to treat

• Interpersonal problems play out in therapy

• Therapists often endorse feeling overwhelmed, inadequate, and at the same time, overly involved

• Suicide is always a serious risk

Goals of treatment: Reduce symptoms, suicidality, and risk of self-harm

Psychodynamic therapy: Transference based therapy (Helps client consider parallels between response to therapist and experiences in other relationships)

Mentalization therapy (Helps client to be more reflective about feelings, and those of other people, so as to not automatically act without thinking when emotions or interpersonal stressors occur)

Borderline PD Treatment

Combines client-centered empathy and acceptance with cognitive behavioural problem solving, emotion-regulation techniques, and social skills training

Dialectics

• Constant tension between any phenomenon and its opposite, which is resolved by creating a new phenomenon

Borderline PD Treatment

The four stages of Dialectical Behaviour Therapy (Treatment for Borderline PD)

1. Addressing dangerously impulsive behaviours (e.g., suicidal actions)(All)

2. Modulating extreme emotionality and coaching the client to tolerate emotional distress(Money)

3. Improving relationships and self-esteem(In)

4. Promoting connectedness and happiness(Pit)

What disorder is this?

Jordan is a 29-year-old who has ongoing difficulties in relationships and work. Jordan often interprets neutral comments as personal attacks and reacts with anger or withdrawal. Relationships start intensely but end quickly due to frequent conflicts and fear of abandonment. At work, Jordan struggles with feedback, believing supervisors are unfair, and changes jobs often. Jordan’s emotions are intense and hard to manage, and there is little awareness of how personal behavior contributes to repeated problems.

General Personality Disorder

What disorder is this?

Sam consistently distrusts others and assumes people have hidden, harmful motives. At work, Sam believes coworkers are trying to undermine them, despite no clear evidence. Innocent jokes or feedback are interpreted as insults. Sam avoids sharing personal information, holds grudges for a long time, and becomes defensive or angry when questioned, insisting others cannot be trusted.

Paranoid Personality Disorder

What disorder is this?

Lena prefers being alone and shows little interest in close relationships, including with family. At work, Lena completes tasks independently and avoids social interaction. Praise or criticism from others seems to have little emotional impact. Lena rarely expresses strong feelings and spends free time on solitary activities, appearing detached and indifferent to social connections.

Schizoid Personality Disorder

What disorder is this?

Ethan has odd beliefs and unusual thinking patterns. He often talks about strange coincidences or “gut feelings” as if they have special meaning. His clothing and mannerisms are eccentric, and he feels uncomfortable in social situations, avoiding eye contact and struggling to connect with others. Friends notice he is socially anxious and behaves in ways that seem odd or quirky.

Schizotypal Personality Disorder

What disorder is this?

Mike repeatedly lies to friends and coworkers for personal gain. He has a history of stealing, breaking rules, and taking risks without concern for consequences. He shows little remorse when others are hurt by his actions and often blames them instead.

Antisocial Personality Disorder

What disorder is this?

Alex has intense and unstable relationships, quickly idolizing someone and then feeling they are cruel or abandoning. Emotions shift rapidly—from anger to sadness to anxiety—often in response to minor events. Alex fears being alone, struggles with self-image, and sometimes engages in impulsive behaviors like spending sprees or risky actions to cope with emotional distress. Even after conflicts, Alex feels deep emptiness and worries others will leave permanently.

Borderline Personality Disorder

What disorder is this?

Maya seeks constant attention and approval from others. She dresses flamboyantly and uses dramatic gestures to be noticed. In conversations, she often exaggerates stories and emotions to keep the focus on herself. Maya feels uncomfortable when she is not the center of attention and may quickly form shallow relationships to maintain admiration.

Histrionic Personality Disorder

What disorder is this?

Daniel believes he is exceptionally talented and expects others to recognize his superiority. He often exaggerates his achievements and seeks praise, becoming irritated or dismissive when he doesn’t receive it. Daniel shows little empathy for coworkers or friends, prioritizing his own needs and taking credit for others’ successes.

Narcissistic Personality Disorder

What disorder is this?

Emma avoids social situations because she fears criticism or rejection. She wants friendships but worries others will judge her harshly, so she often stays silent or declines invitations. At work, she hesitates to take on new tasks unless she is sure she will succeed, and she feels extremely self-conscious in group settings.

Avoidant Personality Disorder

What disorder is this?

Liam has difficulty making everyday decisions without excessive advice and reassurance from others. He fears being alone and goes to great lengths to maintain relationships, even tolerating mistreatment. Liam struggles to express disagreement, quickly seeks support when stressed, and feels helpless when left to care for himself.

Dependent Personality Disorder

What disorder is this?

Sophie is highly perfectionistic and insists that tasks are done exactly her way. She spends excessive time organizing and planning, often missing deadlines because nothing feels “just right.” Sophie struggles to delegate work, is rigid about rules and procedures, and feels anxious when routines are disrupted, valuing control and order above flexibility.

Obsessive-Compulsive Personality Disorder