Clinical psychology
Chapter 15
Personality disorders

The personality disorders are a heterogeneous group of disorders defined by problems in forming a stably positive sense of self and with sustaining close and constructive relationships.
People with personality disorders experience difficulties with their identity and their relationship in multiple domains of life, and these problems are sustained for years.
Their personality problems are evident in cognition, emotion, relationships, and impulsive control. The symptoms of personality disorders are pervasive and persistent.

Classifying personality disorders

The DSM-5 approach to classification

In the DSM-5, the 10 different personality disorders are classified in three clusters, reflecting the idea that these disorders are characterized by:

• Odd or eccentric behavior
• Dramatic, emotional or erratic behavior
• Anxious or fearful behavior

Many people with psychological disorder will also experience a personality disorder.
Comorbid personality disorder are associated with more severe symptoms, poorer social functioning, and worse treatment outcomes for may conditions.

Diagnostic reliability

• One issue in assessing personality disorders is whether people can accurately describe their own personalities.
• Many of the personality disorders may not be as enduring as the DSM asserts.

Using structured interviews and multiple informants can improve reliability.

Comorbidity

Personality disorders tend to be comorbid with each other.

Alternative DSM-5 model for personality disorders

Reducing the number of personality disorders, incorporating personality trait dimensions, and diagnosing personality disorders on the basis of extreme scores on personality trait dimensions.

Two types of dimensional scores

• 5 personality trait domains
• 25 more specific personality trait facets.

Key strengths:

• Richer sense of detail than do the personality disorder diagnoses
• Personality traits tend to be more stable over time than are personality disorder diagnoses
• Including personality traits help link the DSM with a broad research literature of personality

Alternative DSM-5 criteria for Personality disorder

• Significant impairments in self and interpersonal functioning
• At least one pathological personality trait domain or facet
• Personality impairments are persistent and pervasive
• Personality impairments are not explained by developmental stage, sociocultural environment, substance abuse, another psychological condition, or a medical condition.

Odd/eccentric cluster

Odd/eccentric cluster includes:

• Paranoid personality disorder
• Schizoid personality disorder
• Schizotypal personality disorder

Paranoid personality disorder

DSM-5 criteria for Paranoid personality disorder

• Presence of four or more of the following signs of distrust and suspiciousness, beginning by early adulthood and shown in many contexts
  • Unjustified suspiciousness of being harmed, deceived, or exploited
  • Unwarranted doubts about the loyalty or trustworthiness of friends or associates
  • Reluctance to confide in others because of suspiciousness
  • The tendency to read hidden meanings into the benign actions of others
  • Bears grudges for perceived wrongs
  • Angry reactions to perceived attacks on character or reputation
  • Unwarranted suspiciousness of the fidelity of partner.

People with paranoid personality disorder are suspicious of others.
Suspicion influences relationships.
They expect to be mistreated or exploited and thus are secretive and continually on the lookout for signs of trickery and abuse. They are often hostile and react angrily to perceived insults.

Other symptoms of schizophrenia are not present and there is less impairment in social and occupational functioning.
Full-blown delusions are not present.

Co-occurs most often with schizotypical, bordeline, and avoidant personality disorders.

Schizoid personality disorder

DSM-5 criteria for Schizoid personality disorder

• Presence of four or more of the following signs of interpersonal detachment and restricted emotion are present from early adulthood across many contexts
  • Lack of desire for or enjoyment of close relationships
  • Almost always prefers solitude to companionship
  • Little interest in sex
  • Few or no pleasurable activities
  • Lack of friends
  • Indifference to praise or criticism
  • Flat affect, emotional detachment

People with schizoid personality disorder do not desire or enjoy social relationships and usually have no close friends.
They rarely experience strong emotions.

Comorbidity is highest for schizotypical, avoidant, and paranoid disorders.

Schizotypal personality disorder

DSM-5 criteria for Schizotypal personality disorder

• Presence of five or more of the following in many contexts beginning in early adulthood.
  • Ideas of reference
  • Odd beliefs or magical thinking, e.g., belief in extrasensory perception
  • Unusual perceptions, e.g., distorted feelings about one’s body
  • Odd patterns of thought and speech
  • Suspiciousness or paranoia
  • Inappropriate or restricted affect
  • Odd or eccentric behavior or appearance
  • Lack of close friends
  • Anxiety around other people, which does not diminish with familiarity

Schizotypal personality disorder is defined by unusual and eccentric thoughts and behavior, interpersonal detachment, and suspiciousness.

Some people diagnosed with schizotypal personality disorder develop more severe psychotic symptoms over time, and a small portion do develop schizophrenia over time.

Etiology of the personality disorders in the Odd/eccentric cluster

Highly heritable.

The genetic vulnerability of schizotypal personality disorder appears to overlap with the genetic vulnerability for schizophrenia.
They also have deficits in cognitive and neuropsychological functioning that are similar but milder than those seen in schizophrenia.
They also have enlarged ventricles and less temporal lobe gray matter.
Among people with schizotypal personality disorder who do not have a family history of schizophrenia, early trauma and adversity are commonly reported.

Dramatic/erratic cluster

The disorders in the dramatic/erratic cluster are:

• Antisocial personality disorder
• Borderline personality disorder
• Histrionic personality disorder
• Narcissistic personality disorder

They are characterized by symptoms that range from highly inconsistent behavior to inflated self-esteem, exaggerated emotional displays, and rule-breaking behavior.

Antisocial personality disorder and psychopathy

Antisocial personality disorder: Clinical description

Antisocial personality disorder (APD) involves a pervasive pattern of disregard for the rights of others.
The person with APD is distinguished by aggressive, impulsive, and callous traits.
People with APD show irresponsible behavior. They show little regard for truth and little remorse for their misdeeds.

APD is observed much more frequently among men than women.
Higher among younger than among older adults.

DSM-5 criteria for Antisocial personality disorder

• Age at least 18
• Evidence of conduct disorder before age 15
• Pervasive pattern of disregard of the rights of others since the age of 15 as shown by at least three of the following:
  • Repeated lawbreaking
  • Deceitfulness, lying
  • Impulsivity
  • Irritability and aggressiveness
  • Reckless disregard for own safety and that of others
  • Irresponsibility as seen in unreliable employment or financial history
  • Lack of remorse

Psychopathy: Clinical description

One of the key characteristics is poverty of emotions.

Etiology of antisocial personality disorder and psychopathy

Genetic factors

Genetic risk for APD, psychopathy, conduct disorder, and substance use appear to be related.
A person might inherit a general vulnerability for these types of symptoms, and then environmental factors might shape which of the symptoms evolve.

Social factors: Family environment and poverty

High negativity, low warmth, and parental inconsistency predict antisocial behavior.
The family environment might be particularly important when a child has an inherent tendency toward antisocial behavior.
Social factors, including poverty and exposure to violence, predict antisocial behavior in children, even when the children are not genetically at risk for APD.

Fearlessness

An inability of people with psychopathy to profit from experience or even from punishment. People with psychopathy fail to learn from punishment because they are fearless.
People with psychopathy fail to show classical conditioning to aversive stimuli at a very basic level.

Impulsivity

People with psychopathy may be unresponsive to threats when they are pursuing rewards. Part of this deficit might be overcome by slowing the person down so that he or she attend to the signals of treat.
People with psychopathy have less gray matter in the prefrontal cortex.

Deficits in empathy driving unresponsiveness to other’s victimization

Some features of psychopathy arise from a lack of empathy.

Borderline personality disorder

BPD is very common in clinical settings, is very hard to treat, and associated with suicidality.

Clinical descriptions of borderline personality disorder

DSM-5 criteria for Borderline personality disorder

• Presence of five or more of the following in many context beginning by early adulthood
  • Frantic efforts to avoid abandonment
  • Unstable interpersonal relationships in which others are either idealized or devalued
  • Unstable sense of self
  • Self-damaging, impulsive behaviors in at least two areas, such as spending sex, substance abuse, recklessness driving, and binge eating
  • Recurrent suicidal behavior, gestures, or self-injurious behavior
  • Marked mood reactivity
  • Chronic feelings of emptiness
  • Recurring bouts of intense or poorly controlled anger
  • During stress, a tendency to experience transient paranoid thoughts and dissociative symptoms.

The core features of borderline personality disorder are impulsivity and instability in relationships and mood.
Suicidal behavior is a particular concern in BPD. People with BPD are also particularly likely to engage in non-suicidal self-injury.

Over a 10 to 15 year period, about three-quarters of people with BPD stabilize and so no longer meet diagnostic criteria.
People with BPD are highly likely to have comorbid posttraumatic stress disorder or mood disorders.
They are also at risk for comorbid substance-related disorders and eating disorders, as well as schizotypal personality disorder.

Etiology of borderline personality disorder

Neurobiological factors

Biological factors seem to be quite important in the development of BPD.
Genetic factors .
Lower serotonin function.
Other vulnerabilities may contribute to the components of emotion dysregulaton or impulsivity, rather than to the disorder as a whole.
Increased activation of the amygdala.
Low levels of activity and structural changes in the prefrontal cortex and the anterior cingulate cortex. Connectivity between the prefrontal cortex and the amygdala seems to be disrupted.

Social factors: childhood abuse

People with BPD are much more likely to report a history of parental separation, verbal abuse, and emotional abuse during childhood than are people diagnosed with other personality disorders.
Dissociation is caused by extreme stress of childhood abuse.

Linehan’s diathesis-stress theory

BPD might develop when people who have difficulty controlling their emotions because of a biological diathesis are raised in a family environment that is invalidating.
In a invalidation environment, the person’s feelings are discounted and disrespected. An extreme form of invalidation is child abuse.
Emotion dysregulation and invalidation interact with each other in a dynamic fashion.

Histrionic personality disorder

DSM-5 criteria for Histrionic personality disorder

• Presence of five or more of the following signs of excessive emotionality and attention seeking shown in many context by early adulthood
  • Strong need to be the center of attention
  • Inappropriate sexual seductive behavior
  • Rapidly shifting expression of emotions
  • Use of physical appearance to draw attention to self
  • Speech that is excessively impressionistic and lacking in detail
  • Exaggerated, theatrical emotional expression
  • Overly suggestible
  • Misreads relationships as more intimate than they are

The key feature of histrionic personality disorder is overly dramatic and attention-seeking behavior.
Self-centered, overly concerned with their physical attractiveness, and uncomfortable when not the center of attention.
They can be inappropriately sexual provocative and seductive and are easily influenced by others.
They speech is often impressionistic and lacking in detail.

Highly comorbid with depression, borderline personality disorder, and medical problems.

Etiology of Histrionic personality disorder

The emotional display and seductiveness are encouraged by parental seductiveness.

Narcissistic personality disorder

DSM-5 criteria for Narcissistic personality disorder

• Presence of five or more of the following shown by early adulthood in many context
  • Grandiose view of one’s importance
  • Preoccupation with one’s success, brilliance, beauty
  • Belief that one is special and can be understood only by other high-status people
  • Extreme need for admiration
  • Strong sense of entitlement
  • Tendency to exploit others
  • Lack of empathy
  • Envious of others
  • Arrogant behavior or attitudes

People with narcissistic personality disorder have a grandiose view of their abilities and are preoccupied with fantasies of great success.
They require almost constant attention and excessive admiration.
Interpersonal relationships are disturbed by their lack of empathy, arrogance to other coupled with feelings of envy, their habit of taking advantage of others and feelings of entitlement.

Etiology of narcissistic personality disorder

Self-psychology model

The characteristics of narcissistic personality disorder may mask a very fragile self-esteem.
Two parenting dimensions would increase the risk of narcissism: emotional coldness and an overemphasis of the child’s achievements.

Social-cognitive model
Built around two basic ideas

• People with this disorder have fragile self-esteem, in part because they are trying to maintain the belief that they are special
• Interpersonal interactions are important to them for bolstering self-esteem, rather than for gaining closeness and warmth.

Anxious/fearful cluster

Includes:

• Avoidant personality disorder
• Dependent personality disorder
• Obsessive-compulsive personality disorder

People with these disorders are prone to worry and distress

Avoidant personality disorder

DSM-5 criteria for Avoidant personality disorder

• A pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to criticism as shown by four or more of the following starting by early adulthood in many contexts:
  • Avoidance of occupational activities that involve significant interpersonal contact, because of fears of criticism or disapproval
  • Unwilling to get involved with people unless certain of being liked
  • Restrained in intimate relationships because of the fear of being shamed or ridiculed
  • Preoccupation with being criticized or rejected
  • Inhibited in new interpersonal situations because of feelings of inadequacy
  • Views self as socially inept or inferior
  • Unusually reluctant to try new activities because they may prove embarrassing

People with avoidant personality disorder are so fearful of criticism, rejection, and disapproval that they will avoid jobs or relationships to protect themselves from negative feedback.

Avoidant personality disorder often co-occurs with social anxiety disorder, and major depression. Also borderline personality disorder, schizotypal personality disorder, and alcohol abuse.

Heritable (a bit)
The genetic vulnerability to social anxiety disorder overlap with vulnerability to avoidant personality disorder.

And early childhood experiences.

Dependent personality disorder

DSM-5 criteria for Dependent personality disorder

• An excessive need to be taken care of, as shown by the presence of at least five of the following beginning by early adulthood and shown in many context:
  • Difficulty making decisions without excessive advice and reassurance from others
  • Need for others to take responsibility for most major areas of life
  • Difficulty disagreeing with others for fear of losing their support
  • Difficulty doing things on own or starting projects because of lack of self-confidence
  • Doing unpleasant things as a way to obtain the approval and support of others
  • Feelings of helplessness when alone because of fears of being unable to care for self
  • Urgently seeking new relationship when one ends
  • Preoccupation with fears of having to take care of self

The core features of dependent personality disorder are an overreliance on others and a lack of self-confidence.

Dependent personality disorder often co-occurs with borderline, schizoid, histrionic, schizotypal, and avoidant personality disorders, as well as mood disorders, anxiety disorders, and bulimia.

Dependent personality disorder may result from an overprotective and authoritarian parenting style that prevents the development of feelings of self-efficacy.

Obsessive-compulsive personality disorder

DSM-5 criteria for Obsessive-compulsive personality disorder

• Intense need for order, perfection, and control, as shown by the presence of at least four of the following beginning by early adulthood and evidenced in many contexts:
  • Preoccupation with rules, details, and organization to the extent that the point of an activity is lost
  • Extreme perfectionism interferes with task completion
  • Excessive devotion to work to the exclusion of leisure and friendships
  • Inflexibility about morals and values
  • Difficulty discarding worthless items
  • Reluctance to delegate unless others conform to one’s standards
  • Miserliness
  • Rigidity and stubbornness

The person with obsessive-compulsive personality disorder is a perfectionist, preoccupied with details, rules, and schedules. They often pay so much attention to detail that they fail to finish projects.
They are more oriented toward work than pleasure.

Often co-occurs with obsessive-compulsive disorder and avoidant personality disorder.

Treatment of personality disorders

Many people with personality disorders enter treatment for a condition other than their personality disorder.
Personality disorders predict slower improvement in psychotherapy.

General approaches to the treatment of personality disorders

Psychodynamic therapist aim to alter the patient’s present-day views of the childhood problems assumed to underlie the personality disorder.

In cognitive therapy of personality disorders, they apply the same kind of analysis used in the treatment of depression. Each disorder is analyzed in terms of negative cognitive beliefs that could help explain the pattern of symptoms.

Treatment of schizotypal personality disorder, avoidant personality disorder, and psychopathy

Treatments for schizotypal personality disorder draw on the connections of this disorder with schizophrenia.
Antipsychotic drugs have shown effectiveness with schizotypal personality disorder.

Avoidant personality disorder appears to respond to the same treatments that are effective for those with social anxiety disorder.
Antidepressant medication as well as cognitive behavioral treatment can be helpful.
Group versions of cognitive behavioral treatment have been found to be helpful and may offer chances to practice constructive social interactions in a safe environment.

Psychoanalytic psychotherapy with psychopathy was found to be helpful in domains such as improving interpersonal relationships, increasing the capacity for feeling remorse and empathy, reducing the amount of lying, being released from probation, and holding down a job.
Similar for cognitive behavioral therapy.
To be at all effective, treatment had to be quite intensive.

Treatment of borderline personality disorder

Dialectical behavior therapy of borderline personality disorder

Dialectical behavior therapy (DBT), combines client-centered empathy and acceptance with cognitive behavioral problems solving, emotion-regulation techniques, and social skills training.

• Therapists help the patient accepting them as they are and yet helping them to change
• The patient’s realization that splitting the world in good and band is not necessary

The cognitive behavioral aspect of DBT involves four stages

• Dangerously impulsive behaviors are addressed, with the goal of promoting greater control
• Learning to tolerate the extreme emotionality
• Improving relationships and self-esteem
• Promote connectedness and happiness

Mentalization-based therapy of borderline personality disorder

Mentalization-based therapy is a form of psychodynamic treatment developed for BPD.
Foster a more active, thoughtful approach to relationships and feelings.

Schema-focused cognitive therapy of borderline personality disorder

Enriches traditional cognitive therapy with a broader focus on how early childhood antecedents and parenting shape current cognitive patterns.
The therapists and the patient work to identify the maladaptive assumptions that a client holds about relationships from his or her early experiences.