personality disorders

Chapter 10: Personality Disorders

Learning Objectives

  • 10.1 Describe the general features of personality disorders.

  • 10.2 Summarize the challenges of doing research on personality disorders.

  • 10.3 List the three Cluster A personality disorders and describe the key clinical features of each.

  • 10.4 Describe the four Cluster B personality disorders and explain what common features they share.

  • 10.5 List the three Cluster C personality disorders and describe the clinical features that are central to each.

  • 10.6 Explain the role that sociocultural factors might play in the prevalence of personality disorders.

  • 10.7 Discuss the challenges associated with treating personality disorders and summarize the approaches that are used.

  • 10.8 Describe the clinical features of psychopathy and explain how it is similar to and different from antisocial personality disorder.

Clinical Features of Personality Disorders

  • 1. Chronic Interpersonal Difficulties

    • Individuals with personality disorders often create confusion and frustration in interpersonal relations.

    • Others may struggle with how to interact or resolve conflicts with them, leading to feelings of offense or need for accommodation.

  • 2. Problems with Identity or Sense of Self

    • There is often a lack or inflation in their sense of self; individuals may have an unstable or distorted self-image.

  • 3. Inability to Adequately Function in Society

    • Individuals may struggle to conform to societal norms and expectations, leading to consistent violations of social rules in various settings such as work, relationships, or school.

Research Challenges in Personality Disorders

Diagnosing Personality Disorders

  • Defining Diagnostic Criteria

    • There is a struggle between maintaining categorical vs. dimensional classifications of personality disorders.

  • Studying Causes

    • High levels of comorbidity across personality disorders complicate research efforts, with estimates ranging from 25-85% for various studies.

    • Few prospective studies are available on the subject.

    • Research identifies biological factors, including infant temperament and low to moderate heritability estimates; likely, the disorder itself is not inherited, but its features might be (e.g., neuroticism may elevate risk for co-occurring disorders).

Cluster A Personality Disorders (Odd & Eccentric)

Overview of Cluster A Disorders

  • 1. Paranoid Personality Disorder

    • Characteristics: Suspiciousness and mistrust of others, sees self as blameless, holds grudges, sensitive to criticism.

    • Point Prevalence: 3.2% (Males = Females)

  • 2. Schizoid Personality Disorder

    • Characteristics: Fundamental lack of desire to form attachments, flat affect, generally apathetic towards others.

    • Point Prevalence: 1.3% (Males > Females)

  • 3. Schizotypal Personality Disorder

    • Characteristics: Peculiar thought patterns, odd perceptions, speech, and behaviors that interfere with social interactions. Likely on the milder end of the schizophrenia spectrum.

    • Point Prevalence: 0.6% (Males > Females)

    • Note: Figures are means based on 11 different epidemiological studies.

Cluster B Personality Disorders (Dramatic, Emotional, & Erratic)

Overview of Cluster B Disorders

  • 1. Histrionic Personality Disorder

    • Characteristics: Self-dramatization, overconcern with attractiveness, irritability and temper outbursts when seeking attention is frustrated.

    • Point Prevalence: 0.9% (Females > Males)

  • 2. Narcissistic Personality Disorder

    • Characteristics: Grandiosity, preoccupation with admiration, self-promoting, lack of empathy, and envious of others.

    • Point Prevalence: 1.61% (Males > Females)

  • 3. Antisocial Personality Disorder

    • Characteristics: Lack of moral or ethical development, inability to adhere to socially approved behavior models, deceitfulness, and manipulative behavior; often with conduct problems since childhood.

    • Point Prevalence: 3.6% (Males > Females)

  • 4. Borderline Personality Disorder

    • Characteristics: Impulsivity, extreme emotional dysregulation, feelings of boredom, tendencies towards non-suicidal self-injury (NSSI) or suicide, unstable self-image, and fear of abandonment.

    • Point Prevalence: 2.7% (Females = Males)

Cluster C Personality Disorders (Anxious & Fearful)

Overview of Cluster C Disorders

  • 1. Avoidant Personality Disorder

    • Characteristics: Hypersensitivity to rejection, timidity, insecurity in social situations and initiating relationships, avoidance of new situations; possibly severe social anxiety disorder (SAD).

    • Point Prevalence: 2.1% (Females > Males)

  • 2. Dependent Personality Disorder

    • Characteristics: Enmeshment, discomfort being alone, subordination of self needs to maintain relationships, marked indecisiveness, and feelings of helplessness.

    • Point Prevalence: 0.4% (Females > Males)

  • 3. Obsessive-Compulsive Personality Disorder

    • Characteristics: Rigidity regarding order, rules, and trivial details; excessive perfectionism, reluctance to delegate tasks, lack of warmth, difficulty relaxing; often miserly.

    • Point Prevalence: 4.7% (Males > Females)

Case Study: Avoidant Personality Disorder

  • Subject: “Bob”, a 30-year-old male referred by his wife due to discomfort in public settings.

  • Observations: Limited speech, restricted affect, and poor eye contact; expressively, unable to state personal goals or desires for change.

  • Diagnosis: Social Anxiety Disorder mentioned, with a suggested treatment plan of weekly Cognitive Behavioral Therapy (CBT).

  • Therapeutic Interaction: Bob often engaged in neutral topics; any attempt to discuss personal matters led to prolonged silence and disengagement. Therapy was challenged by Bob's unwillingness to express personal needs or undertake CBT assignments.

Additional Notes on Obsessive-Compulsive Personality Disorder

  • Clarification: OCPD is distinct from Obsessive-Compulsive Disorder (OCD); individuals with OCPD experience no true obsessions or compulsions.

  • Symptom Distinction: OCPD tends to be ego-syntonic, whereas OCD symptoms are ego-dystonic.

  • Prevalence: About 20% of individuals with OCD may also present with OCPD; additionally, 20-60% of individuals with Anorexia Nervosa have been noted to possess traits of OCPD.

Psychopathy vs. Antisocial Personality Disorder

  • Psychopathy: Not classified as a formal DSM-5 diagnosis; considered a stable trend in personality rather than a disorder per se.

  • Overlap with ASPD: Though there is significant overlap between ASPD and psychopathy, distinctions exist, particularly in terms of emotional capacities and behavioral tendencies.

  • Causal Factors in Psychopathy:

    • Genetic influences are estimated at 43-56%.

    • Associated with lower levels of fear, impaired fear conditioning, and deficits in the amygdala functioning.

    • Individuals typically present with a blunted fear response and more general emotional deficiencies. Early parental loss, rejection or inconsistency may also be significant factors.

Treatments and Outcomes for Personality Disorders

General Difficulty in Treatment

  • The Ego-syntonic nature of personality disorders can complicate treatment, contrasting with the Ego-dystonic nature identified in other psychological disorders,

  • Therapeutic Resistance: Clients may express reluctance or lack perceivable need for change, potentially influenced by who initiated the referral for treatment.

  • Relationship Issues: Difficulties in forming therapeutic relationships may emerge from the patient’s interpersonal characteristics.

Specific Treatments

  • Borderline Personality Disorder

    • Common treatment includes Dialectical Behavior Therapy (DBT), which encompasses group therapy focused on interpersonal effectiveness, distress tolerance, emotion regulation, and mindfulness practices.

    • Types of DBT: Includes individual therapy sessions and phone coaching.

    • Medications: Use of antidepressants (e.g., SSRIs) noted, although evidence for efficacy in treating BPD is limited.

  • Other Disorders

    • Treatments such as antipsychotic or antidepressant medications are under consideration for disorders like Schizotypal PD.

    • For Avoidant PD, similarities in treatment regimens to Social Anxiety Disorder may be noted.

    • Antisocial Personality Disorder poses particular challenges due to individuals rarely seeking treatment of their own accord, often requiring incarceration as a form of management instead.

Ethical and Practical Implications

  • The treatment and understanding of personality disorders must navigate ethical considerations regarding client autonomy, engagement with treatment, and the socio-cultural factors influencing both the prevalence and perception of these disorders.