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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