Which personality disorders exist? - Chapter 8 (Abnormal Psychology)

Personality is the collection of characteristics that the person has or shows and that distinguishes him or her from others. It is the way we behave, think, believe and feel. These characteristics make us unique.

A personality trait is a complex pattern of behavior, thoughts and emotions that remain constant over a longer period of time, and in different situations.

The 'big five' theory states that there are five different factors of personality traits. Everyone satisfies every factor to a certain extent, and how strongly that per factor is the case determines our personality.

The big five:

1. Negative emotionality
2. Extraversion
3. Openness to new experiences
4. Compliance
5. Persistence

Definition and diagnosis of personality disorder

A personality disorder is a long-term pattern of unadopted behavior, thoughts and feelings. Personality disorders usually begin in adolescence, or in early adulthood, and sustain a large part of life. To diagnose a personality disorder in a person under the age of eighteen, the personality pattern must be present for at least a year.

In the DSM-IV, personality disorders are on the second axis. This means that these disorders are seen differently from acute disorders. The disorders on the second axis are chronic and penetrating. The DSM-V has rejected this distinction between disorders on As-I and As-II. Personality disorders are therefore no longer on the second axis in the DSM-V. The DSM-V has divided ten personality disorders into three clusters, based on their similarities. The DSM-V admits that this system is limited, not well validated and does not explain the fact that people often have multiple personality disorders from different clusters. The three clusters of the DSM-V are as follows:

1. Cluster A is called odd or eccentric behaviours and thinking. In this cluster are the paranoid personality disorder, the schizoid personality disorder and the schizotypal personality disorder. These personality disorders have characteristics of schizophrenia, but patients do not live outside of reality.
2. Cluster B is called dramatic, erratic and emotional behavior and interpersonal relationships. In this cluster are antisocial personality disorder, borderline personality disorder, histrionic personality disorder and narcissistic personality disorder. People with one of these disorders are manipulative, volatile, unconcerned in social relationships and prone to impulsive behavior.
3. Cluster C has the description anxious and fearful emotions and chronic self-doubt. This includes dependent personality disorder, avoidant personality disorder and obsessive-compulsive personality disorder. These people have low self-esteem and difficulty with social relationships.

Odd-eccentric personality disorders

People with an odd-eccentric personality disorder (from cluster A) behave in ways that strongly suggest schizophrenia. Many scientists therefore believe that this disorder is a weakened version of schizophrenia, or that people with this disorder have a very high chance of developing schizophrenia. Some scientists believe that this disorder should fall under schizophrenia than under the personality disorders, precisely because it appears to be a mild version of schizophrenia.

Paranoid personality disorder

People with paranoid personality disorder are very suspicious of others. The main characteristic of this disorder is a penetrating and unjustified distrust of others. They believe that other people want to exploit them and are constantly worried about the loyalty and trustworthiness of others. They are very sensitive to evidence that confirms their views, but ignore the evidence that goes against their views. Some paranoid people withdraw to protect themselves, but others become very aggressive towards the outside world. Between 0.7 and 5.1 percent of people are diagnosed with paranoid personality disorder in their lifetime. Studies show that this disorder is more common in people with a family member with schizophrenia. Twins studies show that the genetic contribution of this disorder is approximately 50%.

Cognitive psychologists believe that this disorder stems from the idea that other people are hostile, in combination with a weak self-confidence.

People with paranoid personality disorder often only come to the therapist when they are in crisis. They also seek help for symptoms of depression or anxiety. It almost does not happen that people seek help because of the paranoia itself. In therapy, cognitive psychologists try to reduce the fear and hostility of the patient. Psychoanalysts try to give the patient insight into their condition, but that must be done in a very cautious manner. The therapist must be calm and respectful and explain everything in a simple way, in order to gain the trust of a patient. He can never directly point out to a patient that it is paranoid, the therapist must do so by asking questions. In this way, he lets the patient see that he is interpreting these things in a certain, negative way.

Cognitive therapy focuses on making these people feel that they can do things themselves in difficult situations. They also learn to reduce the fear of others.

Schizoid personality disorder

People with schizoid personality disorder have no desire to enter into relationships with other people. They see these relationships as useless, and do not express any emotion when they talk to someone else. Other people see someone with schizoid personality disorder as aloof, withdrawn, slow, uninterested and humourless.

Schizoid people can generally function in society, in places where little social interaction is needed. This fairly rare disorder mainly occurs in men.

Gemini studies suggest that some personality traits responsible for a schizoid personality disorder are hereditary.

Cognitive psychologists describe schizoid individuals as people who can not show emotions. These people are not interested in life and other people. Treatments for schizoid individuals are intended to make patients feel more emotions and to teach them social skills. Sometimes group therapy is also given.

Schizotypal personality disorder

The schizotypal personality disorder is quite similar to schizoid personality. These disorders have the same symptoms, with the difference that people with schizotypal personality disorder also suffer from strange ways of thinking. The symptoms of schizotypal personality disorder are very similar to the symptoms of schizophrenia, but then they are less serious.

There are four categories for the characteristics of this personality disorder:

1. Paranoia or suspiciousness: they see others as deceitful and hostile.
2. Ideas of reference: they believe that random events are related to them.
3. Strange beliefs and magical thinking: for example, they can believe that others can read their thoughts
4. Illusions: a kind of hallucinations

People with this disorder often jump from the heel to the branch, and speak far too extensively. When others say something, they can show socially unwanted emotions or even have no emotional reaction at all.

The behavior of these people is often strange.

Neuropsychological research has shown that people with this disorder have a smaller working memory. As a result, they are less able to pay attention to cognitive tasks and have a less good memory.

The biological background is largely the same as in people with schizophrenia. Another similarity with schizophrenia is that schizotypal people exhibit the same deviations in attention. Schizotypal personality disorders are often treated with the same drugs as schizophrenia.

Psychotherapy is sometimes used as a therapeutic treatment. What matters is that people get good social skills. With cognitive therapy an attempt is made to adapt the way of thinking of schizotypal people.

'Dramatic-emotional' personality

disorders People with disorders from cluster B have in common that they often exhibit dramatic or impulsive behavior. They often do not pay attention to the safety of themselves or others.

Borderline personality disorder

The characteristics of a borderline personality disorder are instability of mood, of self-image and of interpersonal relationships. For example, someone can suddenly become very insecure or anxious. People with borderline personality disorder may be isolated at one moment and suddenly change the behaviour to a more hateful one or even, in rare circumstances, a happier type of mood.. These people are almost always paranoid to be abandoned and when they are abandoned, they  tend to respond with extreme measures.

Often people describe an emptiness they want to fill with keeping new acquaintances close. They 'stick' to people. This disorder is more common in women than in men.

Borderline personality disorder is a very complex disorder. As a result, many people with borderline have many similarities in symptoms with other personality disorders. People with borderline generally also have a different mental disorder, for example depression, anxiety disorder, substance abuse or somatization disorder. They often exhibit impulsive and self-damaging behavior.

75% of people with borderline do a suicide attempt, 10% succeed. The risk of suicide is greatest in the first two years after the diagnosis is made.

It is not clear whether there is a genetic background for borderline. People with borderline are usually impulsive and have low serotonin levels.

It is thought that in people with borderline personality disorder there is an error in emotion regulation. This would then be a physiological error. This gives people extreme emotions, which provide impulsive behaviours. These emotions are often criticized by others, but that does not help the regulation. This often makes the problem worse.

People with this disorder need help from others in difficult situations, but often do not dare to ask for this help. In difficult situations they often have more stress than other people.

Psychoanalysts think that people with borderline personality disorder have an underdeveloped image of themselves and others. If parents demand dependence on the child, a child becomes very receptive to what others think about him and will not develop a good self-image. If these people think that they are rejected by others, they reject themselves by doing self-harm. People with borderline tend to see people as very good or very bad, so in extremes. This is called splitting .

A therapy has been developed, dialectical behavior therapy, using techniques from cognitive behavioral therapy and interpersonal and psychodynamic techniques. The focus is on helping to develop a more realistic and positive self-image and skills to solve problems and to regulate emotions and correct black-and-white thinking. People are presented with a possible stressful situation and learn to find a solution. This ensures that they become less impulsive in such a stressful situation because they know what they can do. The therapy seems to be effective.

Psychodynamic treatments are about making patients understand that their disorder is due to the way they were raised. Transference-focused therapy uses the relationship between the patient and the therapist to help the patient achieve a more realistic and better understanding of himself and his or her interpersonal relationships. Mentalization-based therapy is based on the theory that people with borderline personality disorder have problems with understanding the mental states of themselves and others through traumatic experiences in childhood and poor attachment to their caregiver.

Cognitive therapies focus on giving their clients a better self-image. These therapies also try to eliminate splitting.

Medicines focus on reducing anxiety and depressive symptoms. People who are psychotic also use antipsychotic drugs. The results can be called doubtful.

Histrionic personality disorder

The characteristics of the histrionic personality disorder are similar to those of borderline, only people with this disorder mainly want to be at the centre of attention. They do so, for example, by being very dramatic or seductive. They also like to show the positive qualities of their body. Often in the family of these people someone with a different mental disorder.

The diagnosis is most common among women who no longer have a partner.

People with this disorder greatly exaggerate problems, and on average they have more doctor visits per year than an average other person. If they seek psychic help, it is usually not for their personality disorder, but for anxiety or depression.

Psychoanalysts provide insight into the problems and cognitive psychologists try to change the assumptions of the patients. They are taught to express their emotions in a socially desirable way.

Narcissistic personality disorder

The narcissistic personality disorder is very similar to the histrionic personality disorder, only people with the last disorder look to others for confirmation, whereas narcissists only look at themselves. They see dependence as something bad and dangerous and see themselves as grand and powerful. In Western society these people can often become very successful. However, if the disorder is very serious, they may get problems because they make wrong choices.

People with this disorder behave in a dramatic way, look for the attention of others and show few emotions. They see others as weak and themselves as important. They think that they themselves are better than the rest of the world.

In relationships they expect things from people that others cannot live up to. They themselves ignore other people's wishes. Often these people are arrogant and want power.

Sigmund Freud thought that narcissism was a phase that every child has to go through. The problem with narcissistic personalities is, according to him, that they are stuck in that phase. That could be because they found the stage too fine, or too annoying. Other theorists said that narcissism comes from loneliness, because one is rejected. Supporters of social learning theory think that parents of narcissistic people rate the child too high. The child cannot live up to expectations but continues to feel superior to others. People with narcissistic personality disorder often have a history of physical abuse and neglect, and often had a parent who was abused or who had a mental health problem.

People with this disorder generally do not seek help. If they seek help, it is usually for another disorder. They see problems as weakness and as problems of others. These people are very difficult to deal with because they can hardly endure the criticism they get. Cognitive therapy lets them form a realistic picture of what they can do. They also learn to deal more sensitively with others.

'Anxious-fearful' personality

Disorders from cluster C have the characteristic that people who suffer from them all have a chronic anxiety and show behavior to avoid the things they fear.

Avoiding personality disorder

People with an avoidant personality disorder are very afraid of being criticized. That is why they avoid people as much as possible. People with this disorder feel that they can not do anything. The difference between this disorder and a social phobia is that people with a social phobia are usually afraid of specific situations, while people with an avoidant personality disorder are afraid of people in general. The difference with a schizoid personality disorder is that schizoid people do not see themselves as incompetent.

It could be that people inherit a temperament from their parents, giving them a greater chance of this disorder. If parents often react to their children with frustration and anger, children can become very sensitive to criticism, especially if they already have a biological background to this. Often people do not dare to believe positive feedback, because they are afraid that the other person just says it to do nice.

Treatments for this disorder are usually aimed at learning social skills, and changing negative thoughts about the patient and others. Sometimes SSRIs are used to reduce social anxiety.

Dependent personality disorder

People with a dependent personality disorder are also anxious in interpersonal relationships, but this fear is caused by being afraid to be abandoned. The fear comes from the need to be cared for by others and a desire to be loved. These people always want someone around them who can take care of them. They are afraid of bumping others to the chest and want to please someone else at any cost, whatever the requirement may be.

These people can make difficult decisions for themselves, they only do things to please someone else.

This disorder is more common in certain families than in others, but it is not clear whether this is due to genes or the environment.

Children who are afraid of a chronic illness or to be abandoned by their parents can develop this disorder. The cognitive theory states that negative thoughts, in which people undermine themselves, are the reason for this disorder.

In contrast to other personality disorders, people with this disorder often seek help. Psychodynamic therapy allows the patient to see what his experiences with caregivers were that led to their dependent behavior.

Cognitive behavioral therapy makes people more assertive and reduces anxiety. It allows patients to see that they are not as dependent on others as they think. Techniques are also taught to relax in an anxious situation and they learn to make decisions for themselves.

Obsessive-compulsive personality disorder

People with obsessive-compulsive personality disorder are very rigid and dogmatic, and can not express their emotions. They have extreme self-control, attention to detail and often miss spontaneity. They often work a lot and do not take time for fun activities. Others see these people as stubborn, stingy, possessive and moralistic.

People with this disorder are very focused on efficiency, but due to their perfectionism they often do not do much. They often think that they should not make mistakes. .

This disorder is more common in men. People with this disorder are more likely to have depression, an eating disorder or an anxiety disorder.

The difference with obsessive-compulsive disorder is that the personality disorder is more general, whereas OCD is more specific. Strangely enough, families have found no connection between having both disorders.

People often seek therapy because they are in crisis. This crisis must first be overcome before actual therapy can be started. In this they learn to reduce obsessive behavior and to change or confuse their daily schedules. The patient learns to relax and has to write down his automatic, negative thoughts to gain insight into this.

An alternative model for personality disorders in the DSM-V

The definition of the personality disorder and the criteria used to diagnose personality disorders have not changed in the DSM-V compared to the DSM-IV-TR. The DSM-V does, however, make use of a dimensional, or continuum, perspective. However, this perspective is not used in clinical practice. The categorical approach to personality disorders has had a lot of criticism. The most important limitation was that the personality disorders have a lot of overlap in their diagnostic criteria. There was little agreement between clinicians. Research has shown that individuals with a personality disorder differ over time in how severe the symptoms are and which symptoms they show exactly. The alternative DSM-V model characterizes personality disorders in terms of defects in personality functioning and pathological personality traits. The first step in diagnosing a personality disorder is to determine the level of the sense of identity or the relationships with others on a scale. The second step is to determine whether the individual has pathological personality traits. This can be done on five different dimensions: negative affectivity, detachment, antagonism, disinhibition, and psychoticism. The third step is to determine whether the individual meets the criteria of one of the six following disorders: antisocial, avoiding, borderline, narcissistic, obsessive-compulsive, and schizotypal. If an individual does not meet the criteria for one of these disorders, but has significant problems with the self-image and relationships together with pathological personality traits, the diagnosis personality disorder - trait specified is given. The clinician then specifies which pathological personality traits the person has. The DSM-V approach is thus a hybrid model: it combines a dimensional model with a categorical approach.