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