CH-12-Personality Disorders – Comprehensive Study Notes

Chapter Structure & Learning Outcomes

• Textbook Chapter: Chapter 12 – Personality Disorders (pp. 448–482)
• APA-aligned Student Learning Outcomes (SLOs)
  • Identify biological, psychological & social components (APA\ SLO\ 2.1a)
  • Operationalise problems for empirical study (APA\ SLO\ 2.3a)
  • Correctly identify antecedents & consequences (APA\ SLO\ 1.3c)
  • Apply psychological principles to everyday life (APA\ SLO\ 1.3a)
• Overall Themes
  • Nature/definition of personality & when it becomes “disordered”
  • Chronic, pervasive patterns—originate in childhood, persist through adulthood
  • Categorical vs. dimensional debate; Big-Five dimensional alternative
  • DSM-5: 10 disorders in 3 clusters
  • Prevalence, gender ratios, comorbidity & developmental course
  • Ethical/diagnostic controversies: gender bias, Axis I vs II removal, diagnostic overlap

Conceptual Foundations

• Definition: Persistent pattern of emotions, cognitions & behaviours causing distress/impairment to self and/or others
• Chronicity: Start in childhood, stable across adulthood; not episodic
• Distress: Sometimes felt more by others than by the person (e.g., Antisocial PD)
• Therapist Counter-transference: Especially strong negative reactions with Cluster A & B clients ➔ must be managed
• DSM Evolution
  • DSM-IV-TR: Axis II separation ⇒ viewed as distinct & less treatable
  • DSM-5: Axes eliminated; PDs listed with all disorders
• Categorical vs. Dimensional Models
  • Categorical (DSM tradition): yes/no diagnosis; reification risk; convenience
  • Dimensional: traits on continua; retains more information; avoids arbitrary cut-offs
  • Five-Factor (“Big Five”) model: Extroversion, Agreeableness, Conscientiousness, Neuroticism, Openness; cross-cultural support
  • DSM-5 “Emerging Measures & Models”: alternative dimensional PD proposal—focus on disturbances in self & interpersonal functioning
• Prevalence & Demography
  • U.S. general pop: \approx 10\% meet criteria for at least one PD
  • Worldwide: \approx 6\%
  • Gender trends (approximate): Men more Antisocial/OCPD; women historically more Histrionic/Borderline, but newer surveys show parity
  • Age course: Some PDs remit or change diagnosis; Antisocial “burn-out” \sim age 40; Borderline symptoms may ease by 30s but suicide risk 8\%-10\%
• Comorbidity
  • High co-diagnosis rates; true population prevalence
  • Table 12.4 shows high odds ratios (e.g., Borderline ↔ Paranoid OR=12.3)
• Core Cognitive Schemas (Table 12.5)
  • Paranoid: “I cannot trust people.”
  • Schizoid: “Relationships are messy, undesirable.”
  • Schizotypal: “It’s better to be isolated.”
  • … etc.

DSM-5 Clusters Overview

1. Cluster A – Odd / Eccentric
   • Paranoid PD (PPD)
   • Schizoid PD (SPD)
   • Schizotypal PD (STPD)
2. Cluster B – Dramatic / Emotional / Erratic
   • Antisocial PD (ASPD)
   • Borderline PD (BPD)
   • Histrionic PD (HPD)
   • Narcissistic PD (NPD)
3. Cluster C – Anxious / Fearful
   • Avoidant PD (AvPD)
   • Dependent PD (DPD)
   • Obsessive-Compulsive PD (OCPD)

Cluster A Details

Paranoid Personality Disorder (PPD)

• Core: pervasive distrust & unjustified suspicion
• Cognitive triad: “People are malevolent/deceptive,” “They’ll attack,” “Be on guard.”
• Causes: modest genetic link to schizophrenia; early trauma/maltreatment; cultural factors (e.g., refugees, prisoners)
• Treatment: Rarely seek help; establish trust; CBT to challenge beliefs; low evidence base ➔ only 11\% therapists expect adequate duration

Schizoid Personality Disorder (SPD)

• Core: detachment, limited affect, preference for solitude
• Positive vs. Negative symptom profile: only negative (no ideas of reference)
• Etiology: childhood shyness, abuse/neglect, possible autism-spectrum overlap; low dopamine density
• Treatment: Teach value of relationships; social-skills & empathy training; limited data

Schizotypal Personality Disorder (STPD)

• Core: social deficits + cognitive/perceptual distortions; ideas of reference, magical thinking, eccentricity
• Considered schizophrenia spectrum phenotype
• Genetics: strong familial risk with schizophrenia; childhood maltreatment + PTSD interactions
• Neurobiology: left-hemisphere memory/learning deficits; generalized brain abnormalities
• Treatment: medication (low-dose antipsychotics), social-skills training, CBT; prevention focus to delay schizophrenia onset

Cluster B Details

Antisocial Personality Disorder (ASPD) & Psychopathy

• DSM Criteria: behavioural—violate norms, deceit, impulsivity, 18 yrs+, conduct disorder <15 yrs
• Psychopathy (Cleckley/Hare): 20-item PCL-R emphasizes traits—glib, grandiose, lack remorse, callous, manipulative
• Epidemiology: higher in men; high prison prevalence; conduct disorder precursor; comorbid substance abuse
• Etiology
  • Genetics: heritable trait impulsivity/aggression; gene × env (e.g., adoption + orphanage stress, MAOA interactions)
  • Neurobiological: under-arousal \rightarrow sensation-seeking; fearlessness; BIS/Reward imbalance; low skin conductance, slow-wave EEG, low HR
  • Psychology: reward-dominant set, poor fear conditioning (amygdala deficits)
  • Social: coercive parenting, inconsistent discipline, low SES, peer selection, early adversity
• Development: high in teens/20s, declines post-40 (“burn-out”)
• Treatment: generally ineffective; focus on prevention—parent training, preschool CBT; adult CBT modest; high PCL-R traits predict poor outcome

Borderline Personality Disorder (BPD)

• Hallmarks: instability in relationships, self-image & affect; frantic abandonment fears; chronic emptiness; impulsivity; recurrent suicidal/self-harm; 8\%-10\% suicide completion
• Comorbidity: >80\% MDD, \approx10\% Bipolar II, 25\% Bulimia, 20\% Anorexia, 64\% SUD
• Etiology
  • Genetics: familial mood disorders; serotonin dysfunction; limbic hyper-reactivity
  • Psych: heightened shame, memory bias to negative words; “triple vulnerability” (bio emotional reactivity + generalized psych vulnerability + specific trauma)
  • Social: \ge50\% report sexual/physical abuse; invalidating, chaotic environment; rapid cultural shifts (immigration)
• Treatment
  • Pharmacology: mood stabilisers, atypical antipsychotics for affect & impulsivity
  • Dialectical Behaviour Therapy (Linehan): hierarchy—life-threat, therapy-interfering, quality-of-life; mindfulness, emotion regulation, distress tolerance; evidence for ↓suicide, ↓hospitalisation, improved social adjustment
  • Neuroimaging: DBT normalises amygdala response to negative stimuli

Histrionic Personality Disorder (HPD)

• Traits: excessive emotionality, attention seeking, theatricality, suggestibility, shallow affect, seductive appearance/speech
• Controversy: gender bias; overlap with ASPD (possible sex-typed variant)
• Treatment: focus on interpersonal relations, long-term costs of manipulation; little empirical outcome data

Narcissistic Personality Disorder (NPD)

• Traits: grandiosity, need admiration, entitlement, exploitative, low empathy, envy, fragile self-esteem → depression
• Etiology: parental failure to model empathy; sociocultural changes emphasising individualism/competitiveness
• Treatment: CBT to de-emphasise fantasies, increase sensitivity to others, cope with criticism; research sparse

Cluster C Details

Avoidant Personality Disorder (AvPD)

• Core: social inhibition, feelings of inadequacy, hypersensitivity to negative evaluation; WANT relationships but fear rejection
• Distinction from Social Anxiety: broader low self-worth & avoidance across contexts; more stable trait-like course
• Etiology: possible schizophrenia linkage; temperament + parental rejection; childhood neglect, isolation, ridicule
• Treatment: similar to Social Phobia—CBT, graduated exposure, social-skills; therapeutic alliance crucial; evidence from controlled trials shows moderate success

Dependent Personality Disorder (DPD)

• Core: pervasive submissiveness & clinging, difficulty making decisions, fear of separation, urgently seeks replacement relationships
• Etiology: genetic component; early loss/rejection; temperament of attachment; cultural valorisation of interdependence (East Asia)
• Treatment: build independence & confidence; watch for transference dependence on therapist; limited empirical data

Obsessive-Compulsive Personality Disorder (OCPD)

• Core: preoccupation with orderliness, perfectionism, control; rigid, miserly, rule-bound; NO true obsessions/compulsions
• Epidemiology: slightly more common in men; associated traits found in gifted children, some serial offenders & pedophiles
• Etiology: moderate heritability; parental over-control & reinforcement for conformity; distant to OCD neurobiologically
• Treatment: CBT—target underlying fears, relaxation, cognitive re-appraisal; some support for effectiveness though gains modest

Ethical, Cultural & Diagnostic Controversies

• Gender Bias: Ford & Widiger (1989) vignette study—same antisocial case labelled female ⇒ over-diagnosed HPD
• Cultural Misdiagnosis: Religious/spiritual practices (speaking in tongues, voodoo) may mimic STPD; clinicians must be culturally competent
• Axis II Stigma: Perception of untreatability influences service provision; newer data show realistic but positive treatment outcomes (e.g., DBT, schema therapy)
• Proposed DSM-5 Changes: Eliminate 4 PDs & move to trait model; rejected due to complexity & clinical utility concerns

Examination Pointers & Mnemonics

• Cluster letters mnemonic: A = “Awkward (odd)”, B = “Bold/Bad (dramatic)”, C = “Cowardly (anxious)”
• Borderline suicide statistic: \text{Risk} \approx 50\times general pop; 8\%-10\% complete
• Antisocial course: childhood CD \rightarrow ASPD 18+ → burnout >40
• OCPD vs. OCD: “Ego-syntonic perfectionism” vs “Ego-dystonic obsessions”
• Avoidant desires connection; Schizoid doesn’t—“AvOIDs people despite wanting them; SchizOID doesn’t give a hoot.”

High-Yield Tables & Statistics (embed in memory)

• Prevalence highlights (general population): Paranoid 1.5\%-1.8\%; STPD 0.7\%-1.1\%; ASPD 1.0\%-1.8\%; BPD 1.4\%-1.6\%; AvPD 1.4\%-2.5\%
• Gender skews: ASPD (male ≫ female); HPD & BPD ≈ equal in community; DPD female ≫ male; OCPD slight male > female
• Comorbidity odds (Zimmerman et al.): BPD with STPD OR=15.2; ASPD with NPD OR=14.0

Practical & Ethical Implications

• PDs complicate treatment planning for Axis I disorders—must be assessed early
• Therapist self-care & supervision essential when working with high-risk PDs (BPD, ASPD)
• Early prevention (parent training, preschool CBT) may yield greatest public-health benefit for ASPD trajectory
• Cultural humility prevents over-pathologising normative behaviours; dimensional trait view may reduce stigma

Quick Self-Test (Flash-Style)

1. Which PD shows magical thinking but reality testing intact? → Schizotypal
2. \text{True/False}: All psychopaths meet DSM criteria for ASPD. → False (trait vs behaviour distinction)
3. Core DBT skill modules? → Mindfulness, Distress Tolerance, Emotion Regulation, Interpersonal Effectiveness
4. Fearlessness & low HR in childhood predict what adult PD? → Antisocial / Psychopathy

End-Note

• Personality disorders illustrate interaction of temperament, neurobiology, early environment & culture
• Despite historical pessimism, emerging integrative therapies & prevention offer realistic hope for improved functioning & reduced societal impact