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