Personality Disorders Lecture

What Is Personality?

• Stable, consistent, distinctive style of thinking, feeling, acting, relating
• Organised by trait models
  • Five-Factor Model (OCEAN)
    • Openness
    • Conscientiousness
    • Extraversion
    • Agreeableness
    • Neuroticism
  • HEXACO Model
    • Honesty–Humility
    • Emotionality
    • eXtraversion
    • Agreeableness (vs. Anger)
    • Conscientiousness
    • Openness to Experience
• Personality Traits — 3 scientific criteria
  1. Cross-situational consistency
  2. Relative stability over time
  3. Individual differences

From Normal to Disordered

• Livesley: Personality serves three life-tasks
  1. Stable, integrated representation of self & others
  2. Capacity for intimacy
  3. Pro-social, cooperative behaviour
     ➔ Failure = Personality Disorder (PD)
• Millon: Disordered traits show
  • Rigidity & inflexibility
  • Self-defeating vicious cycles
  • Structural fragility ("cracking" under stress)

DSM-5-TR General Personality Disorder Criteria

A. Enduring pattern that deviates from cultural expectations in ≥2 of
• Cognition
• Affectivity
• Interpersonal functioning
• Impulse control
B. Inflexible & pervasive
C. Causes clinically significant distress/impairment
D. Stable, onset by adolescence/early adulthood
E. Not better explained by another mental disorder
F. Not due to substance/medical condition

Assessment Tools

• Clinical interview (problem: many PDs are ego-syntonic ⇒ poor insight)
• MCMI-IV
  • 15 "clinical" scales (schizoid, avoidant, etc.)
  • 3 "severe" scales (schizotypal, borderline, paranoid)
• MMPI-2 PSY-5 Scales
  • \text{AGGR} – Aggressiveness
  • \text{PSYC} – Psychoticism
  • \text{DISC} – Disconstraint
  • \text{NEGE} – Negative Emotionality
  • \text{INTR} – Introversion / Low Positive Emotionality

DSM-5-TR Cluster Organization

• Cluster A (Odd/Eccentric)
  Paranoid, Schizoid, Schizotypal
• Cluster B (Dramatic/Emotional/Erratic)
  Antisocial, Histrionic, Narcissistic, Borderline
• Cluster C (Anxious/Fearful)
  Avoidant, Dependent, Obsessive-Compulsive

Cluster A – Odd / Eccentric

Shared Presentation

• Social awkwardness, withdrawal, suspicion, eccentricity

Paranoid Personality Disorder (PPD)

• Core: pervasive distrust & suspiciousness — others seen as intentionally harmful without evidence
• DSM highlights + ≥4 symptoms
  • Suspects exploitation/harm
  • Doubts loyalty
  • Reluctant to confide
  • Reads hidden threats
  • Bears grudges
  • Quick to counter-attack
  • Recurrent partner-infidelity suspicions
• Differential: must exclude schizophrenia & mood-psychosis
• Etiology: unknown; presumed bio-psycho-social

Schizoid Personality Disorder (SPD)

• Pervasive detachment + restricted affect (≥4)
  • No desire/enjoyment of close relationships
  • Solitary activities
  • Low sexual interest
  • Few pleasures
  • No close friends
  • Indifferent to praise/criticism
  • Emotional coldness / flattened affect
• Heritability ≈ 30\% (twin studies)

Schizotypal Personality Disorder (STPD)

• Social/interpersonal deficits + cognitive/perceptual distortions & eccentricity (≥5)
  • Ideas of reference
  • Magical thinking
  • Unusual perceptual experiences
  • Odd speech
  • Suspicion/paranoia
  • Inappropriate/constricted affect
  • Odd behaviour/appearance
  • No close friends
  • Excessive social anxiety linked to paranoia
• Not confined to schizophrenia or autism spectrum
• Etiology
  • Childhood maltreatment/PTSD history
  • Genetic link to schizophrenia spectrum

Comparative Snapshot

• Schizotypal = "Distorted reality" (odd ideas, eccentric)
• Paranoid = "Delusional/paranoid" (grudges, distrust)
• Schizoid = "Social withdrawal" (aloof, indifferent)

Etiology Summary for Cluster A

• PPD: Multifactorial (bio + psych + social)
• SPD: Genetic component (~30\%); developmental solitude
• STPD: PTSD/abuse + strong genetic tie to schizophrenia

Cluster B – Dramatic / Emotional / Erratic

Shared Presentation

• Impulse-control difficulties, affective instability, interpersonal chaos

Antisocial Personality Disorder (ASPD)

• Pattern of disregard/violation of others’ rights since age 15
  • Need ≥3 of: unlawful acts, deceitfulness, impulsivity, aggressiveness, reckless disregard, irresponsibility, lack of remorse
  • Individual is ≥18 yrs with evidence of Conduct Disorder before 15
• Prevalence 1\%-4\%, higher in people assigned male at birth (AMAB)
• High comorbidity: substance-use
• Genetic evidence: higher concordance in MZ twins; adoption studies; unknown specific genes
• Environmental: low warmth, high conflict parenting
• Biological correlates
  • Low resting skin conductance, blunted fear conditioning
  • Temporal lobe slow waves, reduced amygdala/hippocampus & prefrontal activity

Psychopathy (Not DSM term)

• Subset of ASPD focusing on affect/cognition
  • Lack of remorse, superficial charm, manipulativeness, thrill seeking
• Hare Psychopathy Checklist-Revised (PCL-R) — 20 items scored 0-2; high scorers are psychopaths
  Example items: glibness, grandiosity, pathological lying, callousness, impulsivity, varied criminality
• Relationship
  • All psychopaths meet ASPD; only ~20\% of ASPD score high on PCL-R
  • Among felons: 75\%{-}80\% = ASPD, 15\%{-}25\% = psychopathy

Histrionic Personality Disorder (HPD)

• Core: excessive emotionality & attention seeking (≥5)
  • Uncomfortable if not centre of attention
  • Inappropriate sexually seductive behaviour
  • Rapidly shifting, shallow affect
  • Uses appearance to draw attention
  • Impressionistic speech
  • Theatricality / exaggeration
  • Suggestible
  • Overestimates intimacy
• Prevalence 2\%-3\%, more common AFAB, onset teens-20s
• Etiology: familial trend; childhood trauma; inconsistent/over-indulgent parenting

Narcissistic Personality Disorder (NPD)

• ≥5 of 9 traits (grandiosity, fantasies of limitless success, special/unique, excessive admiration, entitlement, exploitative, low empathy, envy, arrogance)
• Prevalence <1\%; 50\%-75\% AMAB
• Etiology
  • Unknown; mix of genetic, social, environmental
  • Kohut: immature grandiosity + idealizing others when self-esteem development fails
  • Possibly reinforced by cultural values

Borderline Personality Disorder (BPD)

• Instability of relationships, self-image, affect + impulsivity (≥5)
  • Abandonment avoidance, identity disturbance, unstable relationships (idealize⇄devalue), impulsive self-damage, affective swings, chronic emptiness, intense anger, transient paranoia/dissociation
• Prevalence 1\%-2\%; ~3× more common AFAB
• Comorbid: mood disorders, SUD, PTSD, eating disorders, Cluster A PDs
• Etiology
  • Object-relations: inconsistent parental love ⇒ insecure ego
  • Childhood abuse/trauma (≈70\% report abuse)
  • Biological: familial aggregation; dorsolateral prefrontal & limbic dysfunction (Schulze et al., 2016)

Cluster C – Anxious / Fearful

Shared Presentation

• Social inhibition, fears of separation, perfectionistic rigidity; overlap with anxiety & depression presentations

Avoidant Personality Disorder (AvPD)

• Social inhibition, feelings of inadequacy, hypersensitive to negative evaluation (≥4)
  • Avoids jobs with interpersonal contact, unwilling to get involved unless certain of being liked, restraint in intimacy, preoccupied with criticism, inhibited in new relations, self-view as inept/inferior, risk-avoidant
• Prevalence 1.5\%-2.5\%; onset late teens
• Comorbid: depression, social anxiety, OCD
• Etiology
  • Genetics ≈64\% (temperament)
  • Fearful attachment
  • Childhood rejection/maltreatment

Dependent Personality Disorder (DPD)

• Excessive need to be cared for → submissive/clinging & fear of separation (≥5)
  • Difficulty deciding, needs others to assume responsibility, fears disagreement, trouble initiating, excessive nurturing seeking, helpless alone, quickly seeks new caretaking relationship, fears self-care
• Prevalence 0.5\%-1\%; more AFAB; onset early adulthood
• Etiology: unknown; genetic influence + abuse/trauma

Obsessive-Compulsive Personality Disorder (OCPD)

• Preoccupation with order, perfectionism, control at expense of flexibility (≥4)
  • Details/lists preoccupation, perfectionism interferes, work devotion, inflexible morals, hoards worthless objects, reluctant to delegate, miserly, rigidity/stubbornness
• Prevalence 2.1\%-7.9\%; ~2× AMAB
• Comorbid: OCD (20%), panic, depression, AvPD
• Etiology
  • Parent-child attachment issues
  • Possible gene malfunction
• Distinction vs OCD: OCPD = ego-syntonic perfectionism without true obsessions/compulsions (see Zencare video)

Treatment Approaches

General Schema-Focused Therapy (for PDs)

• CBT-based; identifies maladaptive schemas, logical errors, dysfunctional attitudes

Evidence-Based Therapies for BPD

1. Object-Relations Therapy
   • Strengthen weak ego
   • Reduce splitting (idealize ⇄ devalue)
   • Blend client-centred acceptance + CBT focus
2. Dialectical Behaviour Therapy (DBT)
   • Developed by Marsha Linehan
   • Combines mindfulness, distress tolerance, emotion regulation, interpersonal effectiveness
   • Challenges dichotomous thinking, teaches assertiveness & regulation
   • Empirical support for reducing self-harm, hospitalization, improving social/occupational function

Treatment Challenges

• Ego-syntonic nature → low insight & motivation
• Transference issues (idealize then vilify therapist, esp. BPD)
• Comorbidity (e.g., SUD + ASPD) complicates course

Numerical & Statistical References

• Heritability of Schizoid ≈ 30\%
• AvPD genetic contribution ≈ 64\%
• ASPD prevalence 1\%-4\% (general population)
• BPD prevalence 1\%-2\%, HPD 2\%-3\%, NPD <1\%, OCPD 2.1\%-7.9\%
• Psychopathy among ASPD ≈ 20\%; ASPD among convicted felons 75\%-80\%, psychopathy 15\%-25\%

Ethical, Philosophical & Practical Implications

• Labelling PDs impacts stigma, treatment access; cultural expectations built into DSM criterion A
• Debate: Are traits like narcissism "products of our times" shaped by social media & value systems?
• Criminal justice vs mental health: psychopathy links to recidivism influence sentencing & rehabilitation policy
• Egosyntonic disorders raise questions of autonomy—when (if ever) is involuntary treatment justified?

Biopsychosocial Integration

• Biological: genes, brain structure/function (prefrontal, limbic, temporal abnormalities)
• Psychological: temperament, attachment, cognitive schemas, response modulation deficits
• Social: parenting style, abuse/neglect, cultural values, peer rejection, socioeconomic factors

Quick Disorder–Trait Matrix (Mnemonic)

• Paranoid → Suspicion
• Schizoid → Social detachment
• Schizotypal → Cognitive/perceptual eccentricity
• Antisocial → Norm-violating, callous
• Histrionic → Dramatic, approval-seeking
• Narcissistic → Grandiosity, entitlement
• Borderline → Instability, impulsivity
• Avoidant → Inhibition, inadequacy
• Dependent → Submissive, clingy
• OCPD → Perfectionistic, rigid

These notes consolidate diagnostic criteria, prevalence figures, etiological theories, assessment tools, and therapeutic approaches to serve as a comprehensive study resource on Personality Disorders.