Ch. 10 Personality Disorders

Personality Trait:

A disposition or readiness to act in a certain way

Common personality traits everyone has to some degree:

  1. Openness:

    1. Active imagination and sensitivity; opposite is practicality and routine-oriented.

  2. Conscientiousness:

    1. Self-disciplined and achievement-oriented; opposite is less goal-oriented and more laid-back.

  3. Extraversion:

    1. Socially gregarious behavior; opposite is introversion

  4. Agreeableness:

    1. Compassionate and cooperative; opposite is suspiciousness and antagonism

  5. Neuroticism:

    1. Tendency to express negative emotional states; opposite is emotional stability

Occur in about 4 to 15% of the general population. Often associated with significant social and occupational dysfunction, comorbid psychopathology, lower quality of life, and suicidality.

Personality Disorder:

Mental disorders involving dysfunctional personality traits and associated problems such as relationship disturbances and impulsive behaviors.

Continuum of Normal Personality and Personality Disorder Traits Related to Impulsivity

  1. Emotions:

    1. Normal

      1. Stable mood and low levels of impulsive urge

    2. Mild

      1. Occasional Mood swings and impulsive urges

    3. Moderate

      1. Frequent mood swings and some impulsive urges but little impairment at work or with relationships.

    4. Personality Disorder- Less Severe

      1. Intense mood swings and impulsive urges with significant impairment at work or with relationships

    5. Personality Disorder- More Severe

      1. Extreme mood swings and impulsive or aggressive urges that lead to self-harm, arrest, or violence

  2. Cognitions:

    1. Normal

      1. Occasional thoughts of spontaneity in a socially adaptive way

    2. Mild

      1. Occasional thoughts of spontaneous activity such as stealing

    3. Moderate

      1. Frequent odd thoughts or thoughts of dangerous activity such as harming self or others

    4. Personality Disorder- Less Severe

      1. Intense thoughts of suicide, paranoia, abandonment, attention from others, vengeance, or work.

    5. Personality Disorder- More Severe

      1. Extreme and constant thoughts of suicide, paranoia, abandonment, attention from others, vengeance, or work.

  3. Behaviors:

    1. Normal

      1. Acts differently in different situations depending on the social context

    2. Mild

      1. Occasionally acts inappropriately in work or social situations

    3. Moderate

      1. Problematic personality traits such as impulsivity or emotional reactivity shown in many situations

    4. Personality Disorder- Less Severe

      1. Problematic personality traits and dangerous behavior shown in most situations

    5. Personality Disorder- More Severe

      1. Problematic personality traits and dangerous behavior shown in almost all situations with intense distress and impairment

General Personality Disorder DSM-5:

  1. An enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture. This pattern is manifested in two (or more) of the following areas:

    1. Cognition (ways of perceiving and interpreting self, other people, and events).

    2. Affectivity (the range, intensity, lability, and appropriateness of emotional response).

    3. Interpersonal functioning

    4. Impulse control

  2. The enduring pattern is inflexible and pervasive across a broad range of personal and social situations.

  3. The enduring pattern leads to clinically significant distress or impairment in social, occupational, or other important areas of functioning.

  4. The pattern is stable and of long duration, and its onset can be traced back to at least adolescence or early adulthood.

  5. The enduring pattern is not better explained as a manifestation or consequence of another mental disorder.

  6. The enduring pattern is not attributable to the physiological effects of another substance or another medical condition.

Personality Disorders have 3 Main Clusters:

  1. Odd/Eccentric Group:

    1. Display features that seem bizarre to others

    2. Paranoid, schizoid, schizotypal

  2. Dramatic/Erratic/Emotional

    1. Display features that seem exaggerated to others

    2. Antisocial, borderline, histrionic, narcissistic

  3. Anxious/Fearful

    1. Display features that seem apprehensive to others

    2. Avoidant, dependent, obsessive-compulsive

4 Key Elements of Personality Functioning that could be Impaired:

  1. Identity

    1. E.g., boundaries with others and regulate one’s emotions

  2. Self-direction

    1. E.g., Pursue life goals or self-direct

  3. Empathy

    1. E.g., Understand others’ perspectives and the effects of one’s own behavior on others

  4. Intimacy

    1. E.g., Be close with other and desire to be with others

Personality Traits that can be Pathological:

  1. Negative Affectivity:

    1. E.g., Presence of many negative emotions

  2. Detachment

    1. E.g., Avoidance of others and restricted emotions

  3. Antagonism

    1. E.g., Callousness toward others or self-importance

  4. Disinhibition

    1. E.g., Impulsive behavior and immediate gratification

  5. Psychoticism

    1. E.g., Odd behaviors and thoughts

Odd/Eccentric Group

Paranoid Personality Disorder:

Personality disorder marked by general distrust and suspiciousness of others.

People with this disorder can often read harmful intentions from neutral interactions or events and assume the worst. They blame others for their misfortunes and have trouble working collaboratively or closely with others. They may be rigid, controlling, critical, blaming, and jealous.

DSM-5:

  1. A pervasive distrust and suspiciousness of others such that their motives are interpreted as malevolent, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following:

    1. Suspects, without sufficient bias, that others are exploiting, harming, or deceiving them.

    2. Is preoccupied with unjustified doubts about the loyalty or trustworthiness of friends or associates.

    3. Is reluctant to confide in others because of unwarranted fear that the information will be used maliciously against them.

    4. Reads hidden demeaning or threatening meanings into benign remarks

    5. Persistently bears grudges

    6. Perceive attacks on their character or reputation that are not apparent to others and is quick to react angrily or to counterattack.

    7. Has recurrent suspicions without justification, regarding fidelity of spouse or sexual partner.

  2. Does not occur exclusively during the course of schizophrenia, a bipolar disorder or depressive episode with psychotic features, or another psychotic and is not attributable to the physiological effects of another mental condition.

Schizoid Personality Disorder:

Personality disorder marked by social isolation and restricted emotional expression.

People with this disorder have little interest in establishing or maintaining relationships with others and show little emotional expression. They have few, if any, friends, rarely marry or have sex, and often do not express joy, sadness, warmth, or intimacy. Generally do not show the suspiciousness or paranoid ideation of those with paranoid personality disorder but often prefer to work in isolation and may find jobs that involve minimal social contact. If they do marry or become parents, they show little warmth and emotional support and appear neglectful, detached, and disinterested.

DSM-5:

  1. A pervasive pattern of detachment from social relationships and a restricted range of expression of emotions in interpersonal settings, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following:

    1. Neither desires nor enjoys close relationships, including being part of a family.

    2. Almost always chooses solitary activities

    3. Has little, if any, interest in having sexual experiences with another person.

    4. Takes pleasure in few, if any, activities.

    5. Lacks close friends or confidants other than first-degree relatives.

    6. Appears indifferent to the praise or criticism of others.

    7. Shows emotional coldness, detachment, or flattened affectivity.

  2. Does not occur exclusively during the course of schizophrenia, a bipolar disorder or depressive episode with psychotic features, or another psychotic and is not attributable to the physiological effects of another mental condition.

Schizotypal Personality Disorder:

Personality marked by social anxiety, paranoid fears, and eccentric behavior, perceptions, and thoughts

People with this disorder have extreme social anxiety and perhaps paranoia. They are odd, eccentric, or peculiar in their behavior or appearance; display inappropriate or constricted affect; and have few (if any) friends or confidants outside their immediate family. They differ from those with Paranoid personality disorder and Schizoid personality disorder since they are more odd or eccentric in their behavior and more often have perceptual and cognitive disturbances.

Most people with this disorder have unusual ideas, beliefs, and communication. They misinterpret or over-personalize events, have unusual ideas that influence their behavior (may think is possible to communicate via telepathy), and have difficulty being understood by others. May show ideas of reference where they believe everyday events somehow involve them when they actually do not. May drift toward ‘fringe’ groups that support their unusual thinking and odd beliefs. These activities provide structure for some with this disorder but also contribute to greater deterioration if psychotic-like or dissociative experiences are encouraged.

They are most likely to seek treatment for anxiety-related or depressive disorders. They may show brief or transient psychotic episodes in response to stress. These episodes are relatively short, however, lasting a few minutes to a few hours, and do not typically indicate a psychotic disorder. Only a small amount develop schizophrenia, but many develop depression.

DSM-5:

  1. A pervasive pattern of social and interpersonal deficits marked by acute discomfort with, and reduced capacity for, close relationships as well as by cognitive or perceptual distortions and eccentricities of behavior, beginning by early adulthood and present in a variety of contexts as indicated by 5 (or more) of the following:

    1. Ideas of Reference (Excluding delusions of reference).

    2. Odd beliefs or magical thinking that influences behavior and is inconsistent with subcultural norms.

    3. Unusual perceptual experiences, including bodily illusions.

    4. Odd thinking and speech

    5. Suspiciousness and paranoid ideation

    6. Inappropriate or constricted affect

    7. Behavior or appearance that is odd, eccentric, or peculiar

    8. Lack of close friends or confidants other than first-degree relatives.

    9. Excessive social anxiety that does not diminish with familiarity and tends to be associated with paranoid fears rather than negative judgements about self.

  2. Does not occur exclusively during the course of schizophrenia, a bipolar disorder or depressive disorder with psychotic features, another psychotic disorder, or autism spectrum disorder.

It is estimated that odd or eccentric personality disorders occur in 2.1% of the general population. Paranoid 1.9%. Schizoid 0.6%, and Schizotypal 0.6%. Many people with eccentric personality disorders either do not seek treatment or seek treatment for other problems. These disorders are comorbid with anxiety-related, depressive, bipolar, substance use, and psychotic disorders as well as disruptive behavior disorders like ADHD. Racial and ethnic differences are not prominent in personality disorders. Religion should not be included when diagnosing.

Dramatic/Erratic/Emotional Group

Antisocial Personality Disorder:

Personality disorder marked by extreme disregard for and violation of the rights of others and impulsive behavior

Involves deceitfulness, impulsivity, irritability/aggressiveness, criminal acts, and irresponsibility. While not all those with this disorder have criminal records, they often commit reckless acts that neglect the safety of others, and they lack remorse for the harm they inflict. They’re unlikely to maintain steady employment. May seem charming, fun, and engaging, but many of their social relationships eventually fail because of poor empathy, infidelity, and lack of responsibility as well as episodes of maltreatment, exploitation, and angry hostility.

Those with a commonly found in substance use treatment, forensic, and prison settings. Shows the strongest association with a wide range of criminal offenses compared with other personality disorders. More common in men and among those in lower socioeconomic classes and urban settings. They may migrate to urban settings and become socially or economically impoverished, or impoverishment may contribute to the development of antisocial traits. The diagnosis does not apply to someone whose antisocial behavior represents a protective survival strategy, especially in extreme poverty.

Conduct Disorder:

Involves aggression toward people and animals, property destruction, deceitfulness or theft, and serious violations of laws and rules.

This disorder is evident in the children in the form of conduct disorder. Evidence of conduct disorder before 15 is required for a diagnosis of Antisocial personality disorder.

Psychopathy:

Diagnostic construct related to antisocial personality disorder that focuses on problematic interpersonal styles such as arrogance, lack of empathy, and manipulativeness.

Involves little remorse or guilt, poor behavioral control, arrogance, superficial charm, exploitativeness, and lack of empathy. Many people with psychopathy are intensely goal-directed toward money, sex, and status.

People with psychopathy, compared to nonpsychopathic criminals, are more likely to commit violence that is predatory (e.g., stalking), callous or cold-hearted, less emotionally driven, and more premeditated. They are also associated with reactive (emotional) violence as well. Some evidence suggests that those prominent features of a type of psychopathy—consisting of a chronic antisocial and socially deviant lifestyle— appear more likely to commit crimes of passion and engage in reactive (emotionally driven) violence than their counterparts.

Antisocial DSM-5:

  1. A pervasive pattern of disregard for and violation of the rights of others, occurring since age 15 years, as indicated by 3 (or more) of the following:

    1. Failure to conform to social norms with respect to lawful behaviors, as indicated by repeatedly performing acts that are grounds for arrest.

    2. Deceitfulness, as indicated by repeated lying, use of aliases, or conning others for personal profit or pleasure.

    3. Impulsivity or failure to plan ahead.

    4. Irritability or aggressiveness as indicated by repeated physical fights or assaults.

    5. Reckless disregard for safety or self or others

    6. Consistent irresponsibility as indicated by repeated failure to sustain consistent work behavior or honor financial obligations.

    7. Lack of remorse, as indicated by being indifferent or rationalizing having hurt, mistreated, or stolen from another.

  2. The individual is at least 18 years of age.

  3. There is evidence of conduct disorder with onset before age 15 years.

  4. The occurrence of antisocial behavior is not exclusively during the course of schizophrenia or bipolar disorder.

Borderline Personality Disorder:

Personality disorder marked by impulsivity, difficulty controlling emotions, and self-mutilation or suicidal behavior.

Involves a pattern of impulsivity and unstable affect, interpersonal relationships, and self-image. The term “borderline” reflects the traditional view that the disorder was on the “borderline” of neurosis and psychosis. Those with the disorder frequently experience strong, intense negative emotions and are prone to suicidal threats, gestures, or attempts. They’re unsure of their self-image as well as their views of others. They harbor intense abandonment fears and feelings of emptiness. Stressful situations may lead to transient paranoid ideation or dissociation. Associated features include self-defeating behavior such as making a bad decision that destroys a good relationship, depressive or substance use disorder, and premature death from suicide. Approximately 10% of those with BPD commit suicide and 60-70% attempt suicide.

Most frequently diagnosed personality disorder in inpatient and outpatient settings. More women than men meet the criteria, but this is based on clinical studies. Rates of BPD in men and women appear to be similar in the general population. May be misdiagnosed among adolescents who sometimes become angry and fight with family members. Many youth eventually “grow out” of these behaviors and become responsible adults. People with true BPD show chronic and pervasive maladaptive traits into adulthood.

BPD DSM-5:

  1. A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity, beginning by early adulthood and present in a variety of contexts, as indicated by 5 (or more) of the following:

    1. Frantic efforts to avoid real or imagined abandonment.

    2. A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation.

    3. Identity disturbance: markedly and persistently unstable self-image or sense of self.

    4. Impulsivity in at least 2 areas that are potentially self-damaging.

    5. Recurrent suicidal behavior, gestures, threats, or self-mutilating behavior.

    6. Affective instability due to a marked reactivity of mood.

    7. Chronic feelings of emptiness

    8. Inappropriate, intense anger or difficulty controlling anger.

    9. Transient, stress-related paranoid ideation or severe dissociative symptoms.

Histrionic Personality Disorder:

Personality disorder marked by excessive need for attention, superficial and fleeting emotions, and impulsivity.

Hallmarks of this disorder include actions that place oneself in the center of attention, provocative or inappropriately intimate behavior, fleeting and superficial emotional expression, and suggestibility. Different from BPD since BPD involves self-destructive behavior, feelings of deep emptiness and identity disturbance, and angry disruptions in close relationships.

Those with this disorder experience difficult romantic relationships and friendships. They have trouble balancing strong needs for attention and intimacy with the reality of the situation. They have trouble delaying gratification and tend to act impulsively. They have an intense need to be loved, desired, and involved with others on an intimate basis and will use various means toward this end. They may use their physical appearance to draw attention to themselves and be melodramatically emotional or inappropriately seductive. They may perceive a relationship as being more intimate than it is because of their need for romantic fantasy.

More prevalent among women but cultural, gender, and age norms must be considered to determine whether a certain behavior indicates this disorder. The diagnostic criteria for this disorder closely resemble traits that define stereotypic femininity, so clinicians may misdiagnose this disorder in women. Cultural groups also differ with respect to emotional expression. This disorder should only be considered if the person’s emotional expression is excessive within their cultural group and causes distress or impairment. Likely to be diagnosed in some cultural groups than others.

DSM-5 Histrionic Personality Disorder:

  1. A pervasive pattern of excessive emotionality and attention seeking, beginning by early adulthood and present in a variety of contexts, as indicated by 5 (or more) of the following:

    1. Is uncomfortable in situations in which they are not the center of attention.

    2. Interactions with others is often characterized by inappropriate sexually seductive or provocative behavior.

    3. Displays rapidly shifting and shallow expressions of emotions.

    4. Consistently uses physical appearance to draw attention to self.

    5. Has a style of speech that is excessively impressionistic and lacking detail.

    6. Shows self-dramatization, theatricality, and exaggerated expression of emotion.

    7. Is suggestible.

    8. Considers relationships to be more intimate than they actually are.

Narcissistic Personality Disorder:

Personality disorder marked by grandiosity, arrogance, and a tendency to exploit others.

Display grandiosity, need for admiration, and lack of empathy for others. Have an exaggerated sense of self-importance and believe they are so unique they can only be understood by similarly ‘special’ people. These views can lead to distasteful interpersonal behaviors, such as arrogance, exploitation, and a sense of entitlement.

They have high self-confidence and self-esteem but are actually quite vulnerable to real or perceived threats to their status. They may become vengeful if challenged. They tend to have ‘serial friendships’ meaning relationships end when others no longer express admiration or envy. They cannot tolerate criticism or defeat, which may keep them from high levels of achievement.

Appears to be more prevalent among men. Controversial for a few reasons. Idealism is a characteristic of many adolescents and young adults and should not be mistaken for the traits and behaviors of narcissistic disorder. Should only be diagnosed when such beliefs are extremely unrealistic and cause significant stress or impairment. Not all mental health professionals worldwide recognize this disorder. Pathological narcissism may be a manifestation of a modern Western society that is self centered and materialistic and less centered on familial and interpersonal bounds.

DSM-5:

  1. A pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy, beginning by early adulthood and present in a variety of contexts, as indicated by 5 (or more) of the following:

    1. Has a grandiose sense of self-importance

    2. Is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love.

    3. Believes that they are “special” and unique and can only be understood by, or should associate with other special or high-status people (or institutions).

    4. Requires excessive admiration

    5. Has a sense of entitlement

    6. Is interpersonally exploitative

    7. Lacks empathy: is unwilling to recognize or identify with the feelings and needs of others.

    8. Is often envious of others or believes that others are envious of them

    9. Shows arrogant, haughty behaviors or attitudes.

Estimate of dramatic personality disorders in 5.5% of the general population. Antisocial 3.8%, Borderline 2.7%, histrionic .3%, and narcissistic 1.0%.

Anxious/Fearful Group

Obsessive-Compulsive Personality Disorder:

Personality disorder marked by rigidity, perfectionism, and a strong need for control.

Involves a preoccupation with orderliness, perfectionism, and control. Different from obsessive-compulsive disorder. They are stubborn and perfectionistic to the point that tasks never get completed. Their preoccupation with rules, details, and morality causes them trouble at work and outside of work. They are seen as inflexible and miserly and may be described by others as “control freaks”. Other features include hoarding, indecisiveness, reluctance to delegate tasks, low affection, rumination, and anger outbursts.

Many people with OCPD are successful at their career. They can be excellent workers to the point of excess, sacrificing their social and leisure activities, marriage, and family for their job. They tend to have strained relationships with their spouse and children because of their tendency to be detached and uninvolved but also authoritarian and domineering. A spouse may complain of little affection, tenderness, and warmth. Relationships with coworkers may be equally strained by excessive perfectionism, domination, indecision, worrying, and anger. Jobs that require flexibility, openness, creativity, or diplomacy may be particularly difficult for someone with OCPD.

They may be prone to various anxiety and physical disorders because of their worrying, indecision and stress. People with OCPD who are angry and hostile may be prone to cardiovascular disorders. Depression may not develop until a person recognizes the sacrifices that have been made by their devotion to work and productivity, which may not occur until middle age.

More common in women. Many people are conscientious, devoted to their work, organized, and perfectionistic, so mental health professionals must be careful not to misdiagnose. When these features produce significant distress or impairment can they be considered indicators of OCPD

DSM-5:

  1. A pervasive preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness, and efficiency, Beginning by early adulthood and present in a variety of contexts, as indicated by 4 or more of the following:

    1. Is preoccupied with details, rules, lists, order, organization, or schedules to the extent that the major point of the activity is lost.

    2. Shows perfectionism that interferes with task completion.

    3. Is excessively devoted to work and productivity to the exclusion of leisure activities and friendships (not accounted for by obvious economic necessity).

    4. Is overconscientious, scrupulous, and inflexible, about matters of morality, ethics, or values (not accounted for by cultural or religious identification).

    5. Is unable to discard worn-out or worthless objects even when they have no sentimental value.

    6. Is reluctant to delegate tasks to work with others unless they submit to his or her exact way of doing things.

    7. Adopts a miserly spending style toward both self and others; money is viewed as something to be hoarded for future catastrophes.

    8. Shows rigidity and stubbornness.

Avoidant Personality Disorder:

Personality disorder marked by anxiousness and feelings of inadequacy and social ineptness.

Often avoid jobs or situations that require significant interpersonal contact; seen as shy or loners. They avoid others because they see themselves as inept, unappealing, or inferior. They’re also afraid of being embarrassed or rejected by others. Become involved with others only in situations in which they feel certain of acceptance. They want close relationships, so it makes them different from the schizoid disorder. Other features include hypervigilance in social situations and low self-esteem.

They do well at their jobs as long as they can avoid public presentations or leadership. Social functioning and social skills development are usually greatly impaired, however. If they do develop a close relationship, they will likely cling to the person dependently. They also have anxiety-related disorders such as social phobia as well as depression.

More common in women. Religious and cultural influences may be responsible for submissive and self-effacing behaviors in some individuals. People from extremely fundamentalist religious backgrounds may appear to “avoid” socializing with others, especially at events in which alcoholic beverages are served. One must understand the “avoidant” behavior in the context of someone’s strong religious beliefs and prohibitions.

DSM-5:

A pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation, beginning by early adulthood and present in a variety of contexts, as indicated by four or more of the following:

  1. Avoids occupational activities that involve significant interpersonal contact because of fears of criticism, disapproval, or rejection.

  2. Is unwilling to get involved with people unless certain of being liked.

  3. Shows restraint within intimate relationships because of the fear of being shamed or ridiculed.

  4. Is preoccupied with being criticized or rejected in social situations

  5. Is inhibited in new interpersonal situations because of feelings of inadequacy.

  6. Views self as socially inept, personally unappealing, or inferior to others.

  7. Is usually reluctant to take personal risks or to engage in any new activities because they may prove embarrassing.

Dependent Personality Disorder:

Personality disorder marked by extreme submissiveness and a strong need to be liked and taken care of by others.

Involved excessive need to be cared for, leading to submissiveness, clinging behavior, and fears of separation. They “give their lives over” to others—they ask for advice and guidance about even the smallest of decisions, seem helpless, and readily abdicate responsibility for most areas of their lives. Their fears that other may reject or leave them is so intense, they will not express disagreements with others. They may even volunteer to do unpleasant, demeaning tasks to gain nurturance and approval. They’re prone to low self-esteem, self-doubt, self-criticism, and depression and anxiety-related disorders. Their neediness and desperation often prevents them from carefully selecting a person who will protect them and be supportive. They may choose their partners indiscriminately and become quickly attached to unreliable, uncaring, and abusive people.

More common in women. The prevalence and diagnosis of this disorder may vary across cultures, however, because many societies value dependency-related behaviors. Western societies place more emphasis and value on expressions of autonomy and self-reliance, so people in these cultures may be more prone to a diagnosis. Interpersonal connectedness and interdependency are highly valued in Japanese and Indian cultures, so dependency may be seen as pathological less often.

DSM-5:

  1. A pervasive and excessive need to be taken care of that leads to submissive and clinging behavior and fears of separation, beginning by early adulthood and present in a variety of situations, as indicated by 5 or more of the following:

    1. Has difficulty making everyday decisions without an excessive amount of advice and reassurance from others.

    2. Needs others to assume responsibility for most major areas of their life.

    3. Has difficulty expressing disagreement with others because of fear or loss of support or approval.

    4. Has difficulty initiating projects or doing things on their own (because of a lack of self-confidence in judgment or abilities rather than a lack of motivation or energy).

    5. Goes to excessive lengths to obtain nurturance and support from others, to the point of volunteering to do things that are unpleasant.

    6. Feels uncomfortable or helpless when alone because of exaggerated fears of being unable to care for themself.

    7. Is unrealistically preoccupied with fears of being left to take care of themself.

    8. Urgently seeks another relationship as a source of care and support when a close relationship ends.

Estimate that fearful/anxious personality disorders occur in 2.3% of the general population. 1.2% Avoidant, 0.3% Dependent, and 1.9% Obsessive-Compulsive.

Biological Risk Factors for Eccentric/Odd Personality Disorders:

Genetics likely play a limited role in the development of eccentric personality disorders, with inheritability estimates of just 0.29% to 0.38%. Schizotypal may share a common genetic risk factor with schizophrenia. This is consistent with the theory that schizotypal lies on the “schizophrenia spectrum,” a continuum of schizophrenia-like syndromes and symptoms. Schizotypal may represent a less severe and less dysfunctional form of schizophrenia.

Genetics may set the stage for cognitive and perceptual problems in eccentric personality disorders, especially schizotypal. This is known as the Psychobiological Theory of Personality Disorders. Many people with this disorder have trouble attending to and selecting relevant stimuli in the environment. This results in misunderstandings, suspiciousness of others, extreme social detachment, and trouble separating what is real and imagined; these problems appear to be somewhat biologically based.

Twin studies of personality traits also suggest a genetic influence on the development of eccentric personality disorders. The personality traits of restricted emotional expression, suspiciousness, and cognitive distortion appear to be influenced by genetic factors. These 3 traits are central to eccentric personality disorders. Genetics may also influence changes in the neurotransmitter dopamine that can predispose a person to eccentric behaviors.

Environmental Risk Factors for Eccentric/Odd Personality Disorders:

Parental maltreatment, neglect, and emotional withdrawal relate closely to these personality disorders as well as other mental disorders. They are clearly influenced by cognitive distortions as well. These disorders may develop when paranoid beliefs are reinforced by a cognitive set that leads a person to focus on signs of malicious intent in others.

Examples of Cognitions Associated

  1. My privacy is more important to me than closeness to people (Schizoid, Schizotypal)

  2. I shouldn’t confide in others. (Schizoid, Schizotypal)

  3. I cannot trust other people (Paranoid)

  4. Other people have hidden motives (Paranoid).

  5. It isn’t safe to confide in others (Paranoid).

Causes of Odd/Eccentric Personality Disorders:

They are likely caused by some genetic predisposition as well as stressors that emerge in a person’s life. A genetic predisposition such as a family history of schizophrenia may influence later changes that help produce an odd or eccentric personality disorder. A genetic diathesis may influence family environment—parents who are emotionally withdrawn themselves may become physically or emotionally abusive to a child. A genetic diathesis may also set the stage for dysfunction in the dopamine neurotransmitter system that leads to cognitive and perceptual deficits associated with off or eccentric personality disorders.

Neurobiology and family environment also influence each other. Some parents may become withdrawn from a child with odd cognitions or behaviors brought about by dopamine dysfunction. Neurobiological vulnerabilities also influence the development of cognitive beliefs such as mistrust and personality traits such as suspiciousness or restricted emotion that characterize these disorders. Cognitive beliefs and personality traits influence each other as well, as when a person who believes coworkers mean him harm becomes generally paranoid and suspicious.

Biological Risk Factors for Dramatic Personality Disorders:

These disorders have moderate genetic predispositions, with heritability estimates of 0.32 to 0.50. Impulsivity/Aggressive is most associated with BPD and Antisocial. People on the high impulsive/aggressive dimension have a low threshold for action and often act without deliberating. They don’t anticipate well the potential negative consequences of their actions and don’t profit from past experience or knowledge of negative consequences. Impulsive aggression is associated with reduced serotonin.

Psychopathy in adults and conduct disorder in boys are also associated with reduced brain size in areas that may be related to moral development. These areas include the amygdala. frontal and temporal cortexes, superior temporal gyrus, and hippocampus. Impulsivity in BPD may relate well to dysfunction of the orbitofrontal cortex.

Another dimension is affective instability. People high on this trait are prone to rapid, intense mood shifts when frustrated, criticized, or separated from others. The noradrenergic neurotransmitter system is most closely associated with these mood shifts. People given substances that release catecholamine, which operates on the noradrenergic system, show intense emotional reactivity. People with significant mood shifts may be hypersensitive to fluctuations in the noradrenergic neurotransmitter system. Affective instability in BPD may relate to poor functioning in the frontal cortex and other areas important for emotion.

Antisocial behavior and affective instability, which are large parts of the dramatic personality disorders, also appear to have significant genetic predispositions. Antisocial behavior in particular demonstrates a strong family history. Genetic predispositions exist for many other behaviors associated with these conditions as well. Including anxiety, anhedonia (severe depression), disinhibition, and oppositionality.

Environmental Risk Factors for Dramatic Personality Disorders:

Child maltreatment relates closely to these disorders. Antisocial may develop because of traumatic childhood experiences, such as physical or sexual maltreatment, aggressive parents, divorce, and inconsistent discipline. BPD relates to childhood sexual maltreatment and poor parental bonding with a child due to perceived abandonment or actual separation.

Various parent-child relationships likely influence histrionic, including one in which parental love and attention depends on a child’s attractiveness and sexual provocativeness. One result might be that a daughter’s self-worth depends primarily on how her father relates to her, and this pattern may repeat itself into adulthood with other men. Psychosocial theories of Narcissistic primarily focus on underlying feelings of inadequacy that drive one to seek recognition from others.

Several cognitive beliefs also underlie symptoms of these disorders. Some believe lying, deception, cheating, and seductiveness are acceptable ways of securing one’s needs. These beliefs can lead to aggressive or provocative interpersonal styles and problems that characterize antisocial and other dramatic personality disorders.

Examples of Cognitions Associated with Dramatic Personality Disorders:

  1. I should be the center of attention (Histrionic).

  2. I can’t tolerate boredom (Histrionic).

  3. Other people should satisfy my needs (Narcissistic).

  4. Lying and cheating are okay as long as you don’t get caught (Antisocial).

  5. If I want something, I should do whatever is necessary to get it (Antisocial).

Causes of Dramatic Personality Disorders:

Likely caused by genetic predispositions and family-based stressors. A family history of depressive, bipolar, substance use, or antisocial personality disorder likely serves as a genetic diathesis. This genetic diathesis directly influences family environmental (child maltreatment or poor parental bonding) and neurobiological (Impulsive aggression, affective instability) factors related to dramatic personality disorders. Family environmental factors influence, and are influenced by, cognitive beliefs and personality traits such as emotional dysregulation that comprise dramatic personality disorders. Neurobiological factors such as noradrenergic dysfunction also influence these cognitive beliefs and personality traits.

Biological Risk Factors for Anxious/Fearful Personality Disorders

Genetics play a modest role in these disorders, with heritability estimates of 0.34 to 0.47. Other dimensions of these disorders may have some genetic basis include behavioral inhibition, tendency to anticipate harm or future negative events, excessive sensitivity to negative events, heightened arousal, and a tendency to read threat or potential harm into benign events.

People with these disorders may inherit neurobiological vulnerabilities as well, especially those involving noradrenergic and gamma-aminobutyric acid (GABA) neurotransmitter systems. These vulnerabilities lead to heightened fearfulness and sensitivity to potential threats. Inherited personality traits may also contribute to the development of these disorders. Inhibition (Avoidant), compulsivity (OCPD), anxiousness, insecure attachment, social avoidance, and submissiveness are central traits to these disorders. Twin studies suggest a strong genetic component for these traits.

Environmental Risk Factors for Anxious/Fearful Personality Disorders

Avoidant personality disorder may result when an anxious, introverted, and unconfident person experiences repeated episodes of embarrassment, rejection, or humiliation in childhood. Adolescence may be a particularly difficult time for these individuals because of the importance of attractiveness, popularity, and dating. The interaction of these temperamental traits and negative experiences may lead to cognitive schemas such as excessive self-consciousness or feelings of inadequacy or inferiority that comprise avoidant personality disorder.

Dependent personality disorder may result from an interaction between an anxious/fearful temperament and an insecure attachment to parents. Those with this disorder rely on others for reassurance, help, and a sense of security because they see themselves as weak and ineffectual. They are also preoccupied with threats of abandonment, and they feel helpless. These cognitive schemas set the stage for those with dependent personality disorder to become depressed when faced with interpersonal loss or conflict.

Less is known about family or environmental influences regarding OCPD. Children who ultimately develop OCPD may have been well behaved and conscientious but perhaps overly serious and rigid. Cognitive schemas associated with OCPD include hyper-responsibility for oneself and others, perfectionism, excessive attention to detail, and catastrophic thinking when faced with perceived failure or setback.

Examples of Cognitions Associated with Anxious/Fearful Personality Disorders:

  1. I am weak and needy (Dependent).

  2. I am helpless when left on my own (Dependent).

  3. I am socially inept and socially undesirable in work or social situations (Avoidant).

  4. It is important to do a perfect job on everything (OCPD)

  5. Any flaw or defect of performance may lead to catastrophe (OCPD).

Causes of Anxious/Fearful Personality Disorders

They are likely caused by genetic predispositions and family environment problems. A family history of anxiety-related disorder serves as the genetic diathesis for anxious/fearful personality disorders and influences the development of family environment, neurobiological, cognitive, and personality risk factors. Insecure attachment to parents or rejection from parents relate to the underlying neurobiological vulnerabilities of anxiety or inhibition. Family environment and neurobiological factors influence the development of cognitive beliefs such as those related to low self-esteem or catastrophizing events. These factors also influence personality traits such as anxiousness or inhibition that underlie anxious/fearful personality disorders.

Prevention of Personality Disorders

Prevention efforts for personality disorders are rare. Researchers have focused, however, on 3 major risk factors of personality disorders that may be the focus of future prevention efforts in this area. One of these risk factors is child maltreatment. Efforts to prevent child maltreatment may help influence the development of personality disorders. Successful prevention of child maltreatment often involves frequent home visits, reducing maternal stress, increasing social support, and parent training.

Skills Taught in the Prevention of Child Maltreatment:

  1. Basic Problem Solving

    1. Parents are taught to recognize and define typical life problems, list a goal, develop options and plans, and evaluate the outcome.

  2. Positive Parenting: Enjoying the Child

    1. Parents are taught about normative development and how to enjoy the child’s unfolding abilities. In addition, parents learn to engage in child-led play and to the the world through the child’s eyes.

  3. Parenting Skills

    1. Parents are taught how to recognize developmentally appropriate goals for the child, how to make requests in a way that ensures compliance, how to decrease unwanted behaviors from the child, and how to increase desired behaviors through reward and praise.

  4. Extending Parenting

    1. Parents are taught about child safety. Instructions includes material on discipline and maltreatment, selecting safe caregivers, and childproofing to prevent injury, and supervising children.

  5. Anger Management

    1. This module teaches parents to see themselves through the eyes of their child, to recognize and control anger, to relax, and to build in options that can be used if they feel anger is coming on (distracting oneself, taking deep breaths, removing oneself from the situation).

Another main risk factor for personality disorders is poor interpersonal skills. Many people with personality disorders experience great difficulty in interpersonal contexts such as family relationships, friendships, and work situations. Many are socially withdrawn, aggressive, impulsive, insecure, dependent, and highly attention-seeking. Efforts to enhance a person’s social skills may help prevent troublesome interpersonal styles that characterize personality disorder.

Interpersonal skills training is especially relevant to deficits seen in avoidant personality disorder such as extreme shyness and difficulty initiating relationships. Social skills that are taught can include listening and attending, empathy, appropriate self-disclosure, and respectful assertiveness. Training in each of these skills involves educating a client about the skills, modeling appropriate social interactions, and asking the client to practice the skills.

A 3rd major risk factor for personality disorders is emotional dysregulation. Problems in emotional responsiveness such as restricted affect or affective instability characterize many personality disorders. Prevention efforts help people identify, cope with, change, and control negative emotional states. Treatment procedures for BPD might be modified for prevention efforts. People can learn to describe emotional states, identify events or interpretations that prompt these emotions, understand how an emotion is experienced or expressed, and attend to the aftereffects of an emotion.

Emotional Regulation Training: Anger

  1. Prompting events for feeling anger-examples

    1. Losing power or respect

    2. Being insulted

    3. Not having things turn out the way you expected

    4. Experiencing physical or emotional pain

    5. Being threatened with physical or emotional pain by someone.

  2. Interpretations that prompt feelings of anger- examples

    1. Expecting pain

    2. Feelings that you have been treated unfairly

    3. Believing that things should be different

    4. Rigidly thinking “I’m right”

    5. Judging that the situation is illegitimate, wrong, or unfair

  3. Experiencing the emotion of anger-examples

    1. Feeling out of control or extremely emotional

    2. Feeling tightness in your body

    3. Feeling your face flush or get hot

    4. Teeth clamping together, mouth tightening

    5. Crying; being unable to stop the tears

    6. Wanting to hit, bang the wall, throw something, blow up.

  4. Expressing and acting on anger-examples

    1. Gritting or showing your teeth in an unfriendly manner

    2. A red or flushed face

    3. Verbally or physically attacking the cause of your anger; criticizing

    4. Using obscenities or yelling, screaming, or shouting

    5. Clenching your hands or fists

    6. Making aggressive or threatening gestures

    7. Pounding on something, throwing things, breaking things

    8. Brooding or withdrawing from contact with others

  5. Aftereffects of anger- examples

    1. Narrowing of attention

    2. Attending only to the situation making you angry and not being able to think of anything else

    3. Remembering and ruminating about other situations that have made you angry in the past

    4. Depersonalization, dissociative experience, numbness.

Assessment of Personality Disorders

Self-report questionnaire

Easy to administer and economical with respect to time and effort. Generally used as screening instruments and not as diagnostic measures because they do not assess the level of impairment or distress. Do not typically assess whether symptoms have been evident since young adulthood.

Millon Clinical Multiaxial Inventory—IV:

The measure consists of 24 scales related to all personality disorders and other problems such as depression and excessive substance use. Child and adolescent versions are also available.

Minnesota Personality Inventory—2:

A well-used self-report measure that can suggest diagnoses but also indicates various problematic behaviors and personality styles.

Interviews

Many clinicians use unstructured clinical interviews to assess personality disorders, although researchers prefer the structured interview. Unstructured interviews allow a mental health professional to ask any question about personality disorder symptoms. Unstructured interviews are often less reliable and more susceptible to interviewer bias than structured interviews, however. Mental health professionals who use unstructured clinical interviews or case review also routinely fail to assess specific personality disorder diagnostic criteria or they express cultural bias.

Structured interviews take more time but are systematic, comprehensive, replicable, and objective. Structured interviews for personality disorders provide a mental health professional with useful suggestions for inquiries about various symptoms. Structured Interviews may focus more on diagnostic than dimensional aspects of personality disorders, however, and so could be supplemented by other instruments that measure personality traits.

Structured Clinical Interview for DSM-5 Personality Disorders

Informant Reports

Assessment methodology in which individuals who know a person well complete ratings of his or her personality traits and behavior.

Informants such as family members or close friends can provide an important historical perspective on a person’s traits, especially if the informants themselves have no mental disorder. There are some downsides to informant reports. They often conflict with self-reports, and so a clinician may be unsure which perspective is most truthful. Relatives and close friends will not know everything about a person that would be necessary to provide a valid description, they may be biased, and they may have false assumptions about or expectations of a person. However, informant reports of personality disorder features remains a promising assessment method.

Advantages and Disadvantages

  1. Questionnaire

    1. Advantages

      1. Quick, not time-consuming

      2. Useful as a screening measure

    2. Disadvantages

      1. Overdiagnoses

      2. Potentially subject to self-portrayal bias

  2. Unstructured Clinical Interview

    1. Advantages

      1. Easily integrated into standard clinical practice

      2. Natural “flow”

    2. Disadvantages

      1. Not directly tied to diagnostic

      2. Subject to clinician bias or error

  3. Structured Clinical Interview

    1. Advantages

      1. Tied to diagnostic criteria

      2. Most empirically supported

    2. Disadvantages

      1. Potentially long and tedious

      2. May seem awkward to introduce into a typical clinical session

  4. Informant Ratings

    1. Advantages

      1. Not subject to self-portrayal “bias”

      2. Can provide a historical perspective

    2. Disadvantages

      1. Often fails to agree with self-report

      2. Dependent on the extent of the informant’s knowledge of the target.

Biological Treatments of Personality Disorders

Medication use has been primarily targeted by primarily toward those with BPD. Medications for this population include antidepressant, anti-anxiety, and antipsychotic drugs. The beneficial effects of these drugs are limited to one area of functioning such as impulsivity or affective instability. Not all studies indicate positive results, however, and many people drop out of medication treatment. Some even argue that patients with personality disorder might be better off not taking any medications, given current empirical evidence.

Medication may be more effective for specific groups of symptoms and not an overall personality disorder. 3 main symptom groups that may respond to medication include cognitive-perceptual, affect, and impulsive aggression. Cognitive-perceptual symptoms of odd/eccentric personality disorders may be treated with antipsychotic drugs such as perphenazine, trifluoperazine, or haloperidol. Affective (emotional) symptoms of dramatic personality disorder may be treated with selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine or mood stabilizers such as topiramate or lamotrigine. Impulsive aggressive problems of people with dramatic personality disorders may be treated with SSRIs, mood stabilizers, or antipsychotic drugs.

Psychological Treatments of Personality Disorders

Some people with personality disorders, particularly those with BPD, seek many forms of treatment such as individual, group, and family/couple therapy; day treatment; hospitalization; halfway houses; and medication. People with BPD also pursue lengthy treatments. Many treatment studies in personality disorder thus focus on BPD; common therapies used include short-term psychodynamic, cognitive behavioral, and dialectical behavior therapies.

Short-Term Psychodynamic Therapy

Involves frequent meetings with a therapist to develop a close alliance and help clients transfer negative emotions. Focuses on conflicts or themes that impede a person’s life, such as abandonment, emptiness, jealousy, or aggression. A psychodynamic therapist will explore historical events in a person’s life that may have led to problematic personality traits. Issues of child maltreatment or other trauma may also be discussed to help a client develop insight into their symptoms. Interpersonal conflict resolution, appropriate emotional experience, and less self-destructive behavior are key aspects of short-term psychodynamic therapy as well.

Cognitive-Behavioral Therapy

Focuses on easing symptoms of anxiety and depression. Clinicians may use cognitive therapy to modify irrational thoughts, social skills training to improve interpersonal relationships, relaxation training to ease high levels of physical arousal, and behavioral activation to increase social contact Marital and family therapy may be used as well to improve communication and problem-solving skills.

Dialectical Behavior Therapy

Cognitive-behavioral treatment for suicidal behavior and related features of BPD. Addresses symptoms commonly associated with BPD, including suicidal gestures/attempts, self-injury, and self-mutilation. Clients learn various skills to change behavioral, emotional, and thinking patterns that cause problems and extreme distress. Clinicians often conduct dialectical behavior therapy in a group format, and clients often remain in treatment for several months to a year. The therapy is effective for reducing suicidal behaviors, excessive substance use, number of days in psychiatric hospitalization, and treatment dropout. May also improve depression and hopelessness in some clients.

Treatment Strategies

  1. Interpersonal Effectiveness Skill Training

    1. Clients learn to manage interpersonal conflict, appropriately meet their desires or needs, and say no to unwanted demands from others.

  2. Emotional Regulation Skills Training

    1. Clients learn to identify different emotional states, understand how emotions affect them and others, engage in behavior likely to increase positive emotions, and counteract negative emotional states.

  3. Distress Tolerance Skills Training

    1. Clients learn to tolerate or “get through” stressful situations using distraction exercises (to ultimately gain a better perspective), self-soothing strategies such as listening to beautiful music, and techniques to improve their experience of the current moment such as imagery or relaxation.

  4. Mindfulness Skills Training

    1. Clients learn to self-observe their attention and thoughts without being judgmental.