Chapter Sixteen: Personality Disorders

• Personality: A set of uniquely expressed characteristics that influence our behaviors, emotions, thoughts, and interactions
• Personalities are flexible
• Personality Disorder: When people display an enduring, rigid pattern of inner experience and outward behavior that impairs their sense of self, emotional experiences, goals, capacity for empathy, and/or capacity for intimacy
    * Have personality traits that are much more extreme and dysfunctional
    * Leads to significant problems and psychological pain for themselves or others
• Symptoms last for years
• Typically becomes recognizable in adolescence or early adulthood
• Among the most difficult psychological disorders to treat
• Many people with these disorders aren’t even aware of their personality problems
• Around 15% of all adults in the US display a personality disorder at some point
• Comorbidity: When a person with a personality also suffers from another disorder
• Categorical approach
    * Problematic personality traits are either present or absent in people
    * A personality disorder is either displayed or not displayed by a person
    * A person who suffers from a personality disorder is not markedly troubled by personality traits outside of that disorder
• Symptoms of personality disorders overlap so much that clinicians often find it hard to distinguish between disorders
• Dimensional Approach: Disorders are classified by the severity of personality traits rather than by the presence or absence of specific traits

“Odd” Personality Disorders

• Typically have odd or eccentric behaviors
• Extreme suspiciousness, social withdrawal, and peculiar ways of thinking and perceiving things
• Related to schizophrenia
    * Often qualify for an additional diagnosis of schizophrenia
    * Often have close relatives with schizophrenia

Paranoid Personality Disorder

• People deeply distrust other people and are suspicious of others’ motives
• Believe that everyone intends them harm
• Shun close relationships
• More likely to read hostile intentions into the actions of others
• More often choose anger as the appropriate response
• Remain cold and distant
• Suspicions are not usually delusional
• Critical of weakness and fault in others
• Unable to recognize their own mistakes
• Extremely sensitive to criticism
• Blame others for the things that go wrong in their lives
• More common in men than in women
• Theories
    * Psychodynamic theories
      * Distant, rigid fathers
      * Overcontrolling, rejecting mothers
      * Some people come to view their environment as hostile as a result of their parents’ persistently unreasonable demands
    * Cognitive-behavioral theories: People hold broad maladaptive assumptions
    * Biological theories: Genetic causes
• Treatments
    * Do not typically see themselves as needing help, and few come to treatment willingly
    * View the role of patient as inferior and distrust and rebel against their therapists
    * Object Relations Therapists: Try to see past the patient’s anger and work on what they view as their deep wish for a satisfying relationship
    * Self-therapists: Try to help clients reestablish self-cohesion
    * Cognitive-Behavioral Therapy
      * Master anxiety-reduction techniques
      * Improve skills at solving interpersonal problems
      * Develop more realistic interpretations of other people’s words and actions
      * Become more aware of other people’s POVs
    * Antipsychotic drug therapy is of limited help

Schizoid Personality Disorder

• People persistently avoid and are removed from social relationships and demonstrate little in the way of emotion
• Don’t have close ties with other people
• Genuinely prefer to be alone
• Make no effort to start or keep friendships, take little interest in having sexual relationships, and seem indifferent even to their families
• Social skills tend to be weak
• Focus mainly on themselves and are generally unaffected by praise or criticism
• Rarely show any feelings
• Seem to have no need for attention or acceptance
• Men are slightly more likely to experience it
• Men may be more impaired
• Theories
    * Psychodynamic theories
      * Schizoid personality disorder has its roots in an unsatisfied need for human contact
      * Parents have been unaccepting or abusive of their children
      * Children left unable to give or receive love and cope by avoiding all relationships
    * Cognitive-behavioral theories
      * Suffer from deficiencies in their thinking
      * Unable to pick up emotional cues from others
      * Cannot respond to emotions
      * Develop language and motor skills very slowly
• Treatments
    * Social withdrawal prevents most people with this disorder from entering therapy
    * Likely to remain emotionally distant from the therapist, seem not to care about their treatment, and make limited progress at best
    * Cognitive-behavior therapists
      * With this therapy, clients experience more positive emotions and more satisfying social interactions
      * Present clients with lists of emotions to think about
      * Have them write down and remember pleasurable experiences
      * Teach social skills
    * Group therapy is useful when it offers a safe setting for social contact
    * Drug therapy is of limited help

Schizotypal Personality Disorder

• People display a range of interpersonal problems marked by extreme discomfort in close relationships, very odd patterns of thinking and perceiving, and behavioral eccentricities
• Seek isolation
• Have few close friends
• More severe than the paranoid and schizoid personality disorders
• Thoughts and behaviors can be noticeably disturbed
    * Ideas of Reference: Beliefs that unrelated events pertain to them in some important way
    * Bodily Illusions: Sensing an external force or presence
    * See themselves as having special extrasensory abilities
    * Believe that they have magical control over others
• Emotions may be inappropriate, flat, or humorless
• Often have great difficulty keeping their attention focused
• Conversation is typically digressive and vague
• Tend to drift aimlessly and lead an idle, unproductive life
• Slightly more males than females
• Theories
    * Symptoms are often linked to family conflicts and to psychological disorders in parents
    * Defects in attention and short-term memory may contribute
    * Perform poorly on backward masking - have a hard time shutting out the first stimulus in order to focus on the second
    * Linked schizotypal personality disorder to some of the same biological factors found in schizophrenia
    * Also been linked to disorders of mood
      * Around ⅔ of ppl with schizotypal personality disorder also suffer from major depressive disorder or bipolar disorder
      * Relatives of ppl with depression have a higher than usual rate of schizotypal personality disorder and vice versa
• Treatments
    * Need to help these clients reconnect with the world and recognize the limits of their thinking and their powers
    * Work on helping the clients recognize where their views end and those of the therapist begin
    * Increase positive social contacts, ease loneliness, reduce overstimulation, help the individuals become more aware of their personal feelings
    * Cognitive-behavioral therapists
      * Help people function more effectively
      * Cognitive interventions
      * Evaluate their unusual thoughts or perceptions objectively
      * Ignore the inappropriate thoughts and perceptions
    * Antipsychotic drugs in low doses reduces certainty of their thought problems

“Dramatic” Personality Disorders

• More commonly diagnosed than the others

Antisocial Personality Disorder

• A personality disorder marked by a general pattern of disregard for and violation of other people’s rights
• Most closely linked to adult criminal behavior
• A person must be at least 18 to receive this diagnosis
• People with antisocial personality disorder lie repeatedly
• Usually careless with money
• Often impulsive
• Irritable, aggressive, and quick to start fights
• Little regard for their own safety or for that of others
• Self-centered
• Likely to have trouble maintaining close relationships
• Think of their victims as weak and deserving
• Four times more common among men than women
• At least 35% of people in prison meet the diagnostic criteria
• Criminal behavior of many people with this disorder declines after age 40
• People with antisocial personality disorder have higher rates of alcoholism and other substance use disorders than do the rest of the population
    * More than 80% of ppl with this disorder display a substance use disorder at some point in their lives
    * A number also display gamblind disorder
• Children with conduct disorder and ADHD have a heightened risk of developing antisocial personality disorder
    * Conduct Disorder - Persistently lie and violate rules and other people’s rights
    * ADHD - Lack foresight and judgment and fail to learn from experience
• Theories
    * Psychodynamic Factors
      * Begins with an absence of parental love during infancy, leading to a lack of basic trust
      * Some children respond to the early inadequacies by becoming emotionally distant, and they bond with others through the use of power and destructiveness
      * People with this disorder are more likely than others to have had significant stress in their childhoods
    * Cognitive-Behavioral Factors
      * May be learned through principles of modeling and imitation
      * Operant conditioning - Some parents unintentionally teach antisocial behavior by regularly rewarding a child’s aggressive behavior
        * Parents may give in to restore peace
        * May be teaching the child to be stubborn and violent
      * Hold attitudes that trivialize the importance of other people’s needs
      * People with this disorder have genuine difficulty recognizing POVs or feelings other than their own
    * Biological Factors
      * People may inherit a biological predisposition to the disorder
      * May be linked to particular genes
      * Lower serotonin activity
        * Linked to impulsivity and aggression
      * Deficient functioning in their prefrontal cortex and anterior cingulate cortex
        * Help people to plan and execute realistic strategies
        * Help people to have personal characteristics
      * Deficient functioning in the amygdala, hippocampus, and temporal cortex
        * Contributes to the individual’s inability to follow rules
      * Often respond to warnings or expectations of stress with low brain and bodily arousal
        * Enables them to readily tune out threatening or emotional situations
        * Makes them unaffected by them
        * More likely than others to take risks and seek thrills
      * Ultimately related to poor functioning by a brain circuit
        * Poor communication between the structures in this circuit may produce chronic low reactions to stress
• Treatments
    * Typically ineffective
    * Most of those in therapy have been forced to participate
    * Cognitive-behavioral therapists try to guide clients to think about moral issues and about the needs of other people
    * Psychotropic drugs
    * Antipsychotic drugs

Borderline Personality Disorder

• People display great instability, including major shifts in mood, an unstable self-image, and impulsivity
• Relationships are very unstable
• Swing in and out of very depressive, anxious, and irritable states
• Emotions seem to always be in conflict with the world around them
• Prone to bouts of anger
• Direct their impulsive anger inward and inflict bodily harm on themselves
• 85% also experience another psychological disorder
• Impulsive, self-destructive activities
• Many engage in self-injurious or self-mutilation behaviors
• Those with bpd often feel as if the physical discomfort offers relief from their emotional suffering
• 75% of ppl with bpd attempt suicide at least once
• Frequently form intense, conflict-ridden relationships in which their feelings aren’t necessarily shared by the other person
    * Come to idealize another person’s qualities and abilities after just a brief first encounter
    * Violate the boundaries of relationships
    * Quickly feel rejected and become furious when their expectations aren’t met
    * Have recurrent fears of impending abandonment
• Dramatic identity shifts
    * Unstable sense of self
    * Occasionally have a sense of dissociation from their own thoughts or bodies
• 75% are women
• Instability and risk of suicide peaks during young adulthood and gradually wanes with advancing age
• Tends to interfere with job performance even more than most other personality disorders
• Theories
    * Psychological Factors
      * Object Relations Theorists: Early lack of acceptance by parents may lead to a loss of self-esteem, increased dependence, and an inability to cope with separation
      * Their parents neglected or rejected them, verbally abused them, or otherwise behaved inappropriately
      * Early sexual abuse is a common contributor to the development of BPD
    * Biological Factors
      * Biological predisposition to develop BPD
      * Lower brain serotonin activity
        * Linked repeatedly to depression, suicide, aggression, and impulsivity
      * Tied to abnormal activity and anatomy of certain brain structures
    * Sociocultural Factors
      * Cases of bpd are particularly likely to emerge in cultures that change rapidly
      * As a culture loses its stability, it leaves many of its members with problems of identity
    * Integrative Explanations
      * Biosocial explanation: BPD results from a combination of internal and external forces
        * Internal forces: Difficulty identifying and controlling one’s emotions, social skill deficits, abnormal neurotransmitter activity
        * External forces: An environment in which a child’s emotions are punished, ignored, trivialized, or disregarded
        * Received some, but not consistent, research support
      * Developmental Psychopathology Explanation: Believe that internal and external factors intersect over the course of a person’s life to help produce this disorder
        * Early parent-child relationships are particularly influential in the development of BPD
        * Children who experience early trauma and abuse and whose parents are markedly inattentive, uncaring, confusing, threatening, and dismissive, are likely to develop a disorganized attachment style
        * Central psychological deficit is the person’s inability to mentalize
        * Mentalization: People’s capacity to understand their own mental states and those of other people
        * People subjected to early dysfunctional attachment relationships emerge from their childhood with a weakened ability to mentalize and a poor ability to control their emotions, attention, thinking, and behavior
        * Cannot accurately understand either their own or other people’s underlying mental states
• Treatments
    * Psychotherapy can eventually lead to some degree of improvement
    * Wildly fluctuating interpersonal attitudes of clients with the disorder can make it difficult for therapists to establish collaborative working relationships with them
    * Clients with BPD may violate the boundaries of the client-therapist relationship
    * Traditional psychoanalytic therapy has not been effective
    * Contemporary psychodynamic approaches have been more effective than traditional psychoanalytic approaches
    * Dialectical Behavior Therapy: A comprehensive treatment approach, applied particularly in cases of borderline personality disorder and/or suicidal intent; includes both individual therapy sessions and group sessions
      * Cognitive-behavioral interventions
      * Social skill-building and support
      * Received considerable research support
      * Now considered the treatment of choice for people with bpd
    * Antidepressant, antibipolar, antianxiety, and antipsychotic drugs
      * Help calm the emotional and aggressive storms of some ppl with bpd
      * Use of drugs on an outpatient basis is unwise
      * Should be used largely as an adjunct to psychotherapy approaches

Histrionic Personality Disorder

• People are emotionally charged and continually seek to be the center of attention
• Keep changing themselves to attract and impress an audience
• Speech is scanty in detail and substance
• Lack a sense of who they really are
• Overreact to any minor event that gets in the way of their quest for attention
• Some make suicide attempts, often to manipulate others
• May draw attention to themselves by exaggerating their physical illnesses or fatigue
• Exaggerate the depth of their relationships
• Once believed to be more common in women than in men
• Males and females are equally affected
• Theories
    * Psychodynamic perspective
      * Parents were cold and controlling and left their children feeling unloved and afraid of abandonment
      * Children learned to behave dramatically so their parents would pay attention to them
      * Omg guys this reminds me of buck from 911, though i wouldn’t say he has histrionic personality disorder
    * Cognitive-Behavioral Perspective
      * People are less and less interested in knowing the world at large because they’re so self-focused and emotional
      * Hold a general assumption that they’re helpless to care for themselves
      * Constantly seek out others who will meet their needs
      * Wow this one reminds me of harry styles in ‘confessions of a gay disney prince’ though, again, i don’t think that character has histrionic personality disorder
    * Sociocultural perspective
      * Produced in part by cultural norms and expectations
      * Vain, dramatic, and selfish behavior may actually be an exaggeration of femininity as our culture once defined it
      * Diagnosed less in cultures that discourage overt sexualization
• Treatments
    * More likely to seek out treatment on their own
    * Working with them can be very difficult because of their demands
    * May pretend to have important insights or to change during treatment merely to please the therapist
    * Therapists must remain objective and maintain strict professional boundaries
    * Cognitive-behavioral therapists - change their belief that they’re helpless and develop better, more deliberate ways of thinking and solving problems
    * Psychodynamic therapy
    * Group therapy
    * Ultimate goal: Help their clients recognize their excessive dependency, find inner satisfaction, and become more self-reliant
    * Drug therapy is less successful

Narcissistic Personality Disorder

• People are generally grandiose, need much admiration, and feel no empathy with others
• Expect constant attention and admiration from those around them
• Exaggerate their achievements and talents
• Expect others to recognize them as superior
• Often appear arrogant
• Often make favorable first impressions but can rarely maintain long-term relationships
• Seldom interested in the feelings of others
• Theories
    * Psychodynamic theories
      * Cold, rejecting parents
      * People with narcissistic personality disorder spend their lives defending against feeling rejected and wary of the world
      * Repeatedly tell themselves that they’re actually perfect and desirable
      * Seek admiration from others
    * Object Relations Theorists: Grandiose self-image is a way for these people to convince themselves that they’re totally self-sufficient and without need of warm relationships with their parents or anyone else
    * Children who are neglected, abused, and/or lose their parents are at particular risk for the later development of narcissistic personality disorder
    * Cognitive-behavioral theories
      * Narcissistic personality disorder develops when people are treated too positively in early life
      * Admiring or doting parents teach them to overvalue their self-worth
      * Repeatedly rewarded for minor or no accomplishments
    * Sociocultural theories: Link between narcissistic personality disorder and eras of narcissism
      * Family values and social ideals in certain societies periodically break down
      * Produces generations of young people who are self-centered and materialistic
      * Western cultures are considered likely to produce generations of narcissism
• Treatments
    * One of the most difficult to treat
      * Clients are unable to acknowledge weakness
      * Clients are unable to appreciate the effect of their behavior on others
      * Clients are unable to incorporate feedback from others
    * Clients may try to manipulate the therapist
    * Psychodynamic therapists help them recognize and work through their basic insecurities and defenses
    * Cognitive-behavioral therapists try to redirect the clients’ focus onto the opinions of others and increase their ability to emphasize
    * No approaches have had clear success

“Anxious” Personality Disorders

• Typically display anxious and fearful behavior
• Research support for explanations is very limited
• Treatments are considerably more helpful than that for other personality disorders

Avoidant Personality Disorder

• People are very uncomfortable and inhibited in social situations, overwhelmed by feelings of inadequacy, and extremely sensitive to negative evaluation
• So fearful of being rejected that they give no one an opportunity to reject them
• Actively avoid occasions for social contact
• Believe themselves to be unappealing or inferior to others
• Few or no close friends
• Similar to social anxiety disorder
    * High comorbidity rate
    * People with social anxiety disorder primarily fear social circumstances
    * People with avoidant personality disorder primarily fear social relationships
• 2.4% of adults have avoidant personality disorder
• Theories
    * Often assumed to have the same causes as anxiety disorders
    * Psychodynamic Theories
      * Shame and insecurity tied to childhood experiences
      * If parents repeatedly punish/ridicule their child, the child may develop a negative-self image
      * Leads to the child feeling unlovable and distrusting the love of others
    * Cognitive-Behavioral Theories
      * Harsh criticism and rejection in early childhood may lead certain people to assume that others in their environment will always judge them negatively
      * Come to expect rejection
      * Fail to develop effective social skills
• Treatments
    * Often distrust the therapist’s sincerity and start to fear their rejection
    * Treated similarly to people with social anxiety disorder and other anxiety disorders

Dependent Personality Disorder

• People have a pervasive, excessive need to be taken care of
• Clinging and obedient
• Fear separation from people with whom they’re in a close relationship
• Rely on others so much that they can’t make decisions for themselves
• Constantly need assistance with everything and have extreme feelings of inadequacy and helplessness
• Theories
    * Psychodynamic Theories:
      * Unresolved conflicts during the oral stage can give rise to a lifelong need for nurturance
      * Early parental loss or rejection may prevent normal experiences of attachment and separation
      * Many parents of people with this disorder were over involved and overprotective, increasing their children’s dependency and separation anxiety
        * Buster Bluth
    * Cognitive-Behavioral Theories:
      * Behavior
        * Parents unintentionally rewarded their children’s clinging and loyal behavior
        * Parents punished acts of independence
        * Some parents’ dependent behaviors may have served as models
      * Cognitive
        * Maladaptive attitudes
          * I am inadequate and helpless
          * I must find a person to provide protection
          * Jerry - Rick and Morty
        * Dichotomous thinking
• Treatments
    * Help patients accept responsibility for themselves
    * Couple or family therapy
    * Psychodynamic therapy focuses on the same issues as therapy for depressed people
    * Cognitive-Behavioral Therapists
      * Combine behavioral and cognitive interventions to help the clients take control of their lives
      * Assertiveness training
      * Challenge and change their assumptions of incompetence and helplessness
    * Antidepressant drug therapy
    * Group therapy format

Obsessive-Compulsive Personality Disorder

• People are so preoccupied with order, perfection, and control that they lose all flexibility, openness, and efficiency
• 7.9% of the population
• Men are twice as likely
• May became so focused on organization and details that they fail to grasp the point of the activity
• Set unreasonably high standards for themselves and others
• Rigid and stubborn
• Theories
    * Freud
      * People with OCPD are anal retentive
      * Fixated at the anal stage
      * Become filled with anger
      * Persistently resist both their anger and their instincts to have bowel movements
      * Become extremely orderly and restrained
      * Any early struggles with parents over control and independence may ignite the aggression
    * Cognitive-Behavioral Theories
      * Illogical thinking processes help keep OCPD going
      * Dichotomous thinking may produce rigidity and perfectionism
      * People with OCPD tend to misread or exaggerate the potential outcomes of mistakes or errors
• Treatments
    * Ppl with OCPD don’t think there’s anything wrong with them
    * Often respond well to psychodynamic or cognitive-behavioral therapy
    * SSRIs

Multicultural Factors: Research Neglect

• Lack of multicultural research
• Gender and other cultural differences may be particularly important in both the development and diagnosis of borderline personality disorder
    * 75% of all people who have a diagnosis of bpd are female
    * Could be that the traumas women experience as children are prereqs for the development of bpd
      * Should be viewed and treated as a special form of ptsd
    * Could be a reaction to persistent feelings of marginality, powerlessness, and social failure
      * Disorder may be more attributable to social inequalities than to psychological factors

Are There Better Ways to Classify Personality Disorders?

• Personality disorders differ more in degree than in type of dysfunction
• Should be classified by dimensions rather than by categories

The “Big Five” Theory of Personality and Personality Disorders

• Neuroticism, extroversion, openness to experiences, agreeableness, conscientiousness
• Everyone’s personality can be summarized by a combination of the five traits
• Would be best to describe all people with personality disorders as being high, low, or in between on the five supertraits
    * Drop the use of personality disorders altogether

DSM-5’s Proposed Dimensional Approach

• Personality Disorder-Trait Specified (PDTS): A personality disorder currently undergoing study for possible inclusion in a future revision of DSM-5. People would receive this diagnosis if they had significant impairment in their functioning as a result of one or more very problematic traits
• Negative Affectivity: People experience negative emotions frequently and intensely
    * Emotional Lability: Unstable emotions
    * Anxiousness
    * Separation insecurity
    * Preservation: Repetition of certain behaviors despite repeated failures
    * Submissiveness
    * Hostility
    * Depressivity
    * Suspiciousness
    * Strong emotional reactions (overreactions to emotionally arousing situations)
• Detachment: People tend to withdraw from other people and social interactions
    * Restricted Emotional Reactivity: Little reaction to emotionally arousing situations
    * Depressivity
    * Suspiciousness
    * Withdrawal
    * Anhedonia: Inability to feel pleasure or take interest in things
    * Intimacy avoidance
• Antagonism: People behave in ways that put them at odds with other people
    * Manipulativeness
    * Deceitfulness
    * Attention seeking
    * Hostility
• Disinhibition: People behave impulsively, without reflecting on potential future consequences
    * Irresponsibility
    * Distractibility
    * Risk taking
• Psychoticism: People have unusual and bizarre experiences
    * Unusual beliefs and experiences
    * Eccentricity
    * Cognitive and perceptual dysregulation: Odd thought processes and sensory experiences