Chapter 11 Personality Disorders
Character Disorders - the earlier term used to refer to disorders of personality
Personality disorders - "PD" (formerly character disorders) are characterized by "inflexible"
and "maladaptive" ways of perceiving, thinking about, and relating to the world.
DSM-IV - Personality disorders are coded on AXIS II (implying a long-standing nature).
Five criteria - are needed for a diagnosis. A personality disorder is rarely the
"presenting problem" with the exceptions of antisocial or borderline.
Problems with reliability and validity - Compared with other diagnostic categories, reliability
and validity are POOR when compared with the axis 1 disorders, leading to much
misdiagnosis.
High Comorbidity is also a problem, with people usually being diagnosed with more than
one personality disorder. Also, personality traits are "dimensional" in nature,
not categorical.
Three "Clusters" of disorders - the 10 personality disorders are grouped into 3 CLUSTERS.
Cluster A - (odd/eccentric) includes schizoid, schizotypal, and paranoid.
Cluster B - (erratic/dramatic) includes histrionic, narcissistic, antisocial, and borderline.
These are most likely to get into trouble and come to the attention of law enforcement
and other authorities.
Cluster C - (anxious/fearful) includes avoidant, dependent, obsessive-compulsive, and
passive-aggressive. These individuals are more likely to seek out help on their own
and make better progress in therapy.
"Provisional categories" - of "PD" currently include passive-aggressive and depressive.
Cluster A:
1. Paranoid - suspicious, blame others for problems, expect trickery, read threatening
meanings into benign comments, are unwilling to forgive, and are always on guard.
They are NOT usually psychotic, though the disorder shares some characteristics with
paranoid schizophrenia.
2. Schizoid - The primary feature is an inability and lack of desire to form relationships
with others. They are cold, distant, aloof, loners, indifferent to praise or criticism,
not emotionally reactive. They engage in solitary work and activities and may be
"hoarders." Individuals with AVOIDANT PD also have difficulties in forming
relationships with others BUT it is due to fear of rejection, NOT a lack of need or
desire.
3. Schizotypal - literally means "schizophrenic genotype. In contrast to schizoid PD,
there may be a genetic link with schizophrenia. Schizotypals share a deficit in "smooth
pursuit tracking" (following a moving object) with schizophrenics. Another similarity to
schizophrenics is an inability to stay focused on one stimulus when a second one is
presented. They have oddities in speech perception, thoughts and behavior. They may
have magical or superstitious thinking, transient psychotic episodes, peculiar thinking
and a poor grip on reality.
Cluster B:
1. Histrionic - need to be the center of attention, lively, dramatic, excessively extraverted,
theatrical, emotional, sexually provocative and seductive, speech is exaggerated and
impressionistic but lacking in meaning and detail. They are manipulative and
dependent. Women are more likely than men to receive this diagnosis.
2. Narcissistic - have an exaggerated sense of self-importance, need to be admired, lack
empathy for others, are grandiose, overestimate their talents and abilities, feel entitled
and "special," take advantage of others, and are envious of others. Their egos are, in
fact, very fragile. They are exploitive, mostly for material things (vs. the histrionic who
in more needy).
Otto Kernberg - feels that narcissism develops out of parental neglect and devaluation.
Theodore Millon - feels the opposite, narcissim develops out of parental
"overvaluation."
3. Antisocial (ASPD)- defining feature is that they violate and show a complete lack of
regard for the rights of others. They are deceitful, aggressive, impulsive, show no
remorse or loyalty, and are irresponsible. DSM requires this pattern from the age of 15
and a history of "conduct disorder" (deviant antisocial type behaviors) before age 15.
ASPD will be discussed more in a later section along with "psychopathy."
4. Borderline - hallmark is impulsivity and EXTREME INSTABILITY in self image, mood,
and interpersonal relationships. There is a serious disturbance in basic identity. They
feel "empty, bored, and lonely," drug use, gambling, binge eating, and excessive sex is
common, as are SUICIDAL gestures and attempts. A classic symptom is "self
-mutilation" particularly "cutting on oneself." Mostly female (75%), there is a link to
childhood abuse and comorbidity with dissociative identity disorder. SPLITTING (all or
none, black and white thinking) is common. Some think this very serious disorder
should be moved to the mood disorders category.
Cluster C:
1. Avoidant - the main features are fear of ridicule, rejection, and not being accepted.
It may have some biological basis. Avoidants will perceive ridicule or criticism when
none was intended. There is a problem in distinguishing it from generalized social
An important causal factor may be high levels of childhood "behavioral inhibition" (as
described by Kagan).
phobia and some see it as being a more severe manifestation of that disorder.
2. Dependent - lacks self confidence and is overly dependent on others, leaving most
major decisions to significant others. They fear expressing individuality. Their life
will center on a significant other with their own needs being subordinated in order to
keep the other person happy and involved with them. When a relationship ends, a
new one is quickly sought out. They fear having to be on their own and care for
themselves even though they are quite capable of doing so.
3. Obsesssive-Compulsive - NOT a lesser version of OCD. Features include perfectionism
inability to delegate tasks to others, preoccupation with rules and morality. Excessive
attention to trivial detail makes for poor use of time and jobs may never get done.
Overly conscientious, rigid, stingy and have difficulty parting with old or useless
belongings. They are overly dedicated to work and a hard time just relaxing and
having fun. There are no true rituals or obsessions as in OCD.
Important causal factors may be [1] high levels of "conscientiousness (one of the "Big
Five" personality traits) and [2] high levels of "Harm Avoidance." an important, highly
heritable, trait described by C. R. Cloninger (1987).
Provisional categories:
1. Passive-Aggressive - was previously a category but there was much disagreement on
what is really was. The main feature is meeting work and interpersonal demands
grudgingly and doing things badly so as to avoid future requests. I think "ambivalence"
is more what the disorder is about.
2. Depressive - If DSM adopts this one, then dysthymia may have to go! The two seem
very similar.
General Causal factors in PD:
Beck and Freeman - suggest that each disorder is characterized by sets of "traits" that
are overdeveloped and underdeveloped. For example, in obsessive-compulsive, the
traits of control and responsibility are overdeveloped whereas the traits of spontaneity
and playfulness are underdeveloped. (not in book)
Early learning - Intuitively, we think early experiences (esp. with parents) would play
a major role but the research currently does NOT support that idea. Of course,
extremes such as abuse will have a dramatic impact. (not in book)
Social Factors - changes in our society may be causing increases in PD. For example,
our obsession with immediate gratification may be associated with increased narcissism
and increased impulsivity and lack of regulation may be associated with increased
antisocial and borderline behaviors.
Treatmentof Issues in Personality Disorders:
1. In general, treatment is difficult for the personality disorders.
2. People with Cluster A and B diagnoses are generally reluctant to enter therapy and will
likely not do well because of their difficulties in forming and maintaining relationships.
3. Cluster C patients will likely do better in therapy than those from the other clusters.
4. Medications, including antidepressants, antipsychotics, and mood stabilizers are often
used in treating borderline PD
5. Borderline PD is extremely difficult to treat and the prognosis is not particularly good.
Psychopathy - or (sociopathy) Before the DSM and the ASPD diagnosis, the construct
of psychopathy was used (e.g., by Cleckley in the 1940s).
"Moral Insanity" - was a term used to describe psychopathic behavior in the 1800s.
Robert Hare - developed a 20 item "psychopathy" checklist. Two dimensions (facets)
of psychopathy are recognized: "dimension 1" relates to emotional aspects such as
lack of remorse, callousness, and exploitive use of others. "dimension 2" relates to
behavioral aspects and involves an antisocial, impulsive, and socially deviant lifestyle.
The second dimension is similar to DSM's ASPD. Prison inmates are higher on the
second dimension and are more likely to meet criteria for ASPD than for psychopathy.
Intelligence and psychopathy - the first dimension (emotional) is unrelated to intelligence
but the second dimension (antisocial behavior) is NEGATIVELY correlated with
intelligence. So it is no surprise that the second dimension is more prevalent among
prison inmates, being less intelligent, they get caught!
Ted Bundy - embodies most of the qualities of a psychopath.
Not all psychopaths or ASPDs are in prison - they may be unscrupulous businessmen,
high pressure evangelists, crooked politicians, and con men.
Causal factors in Psychopathy:
Twin and adoption studies indicate a "modest" heritable component.
There are fairly strong environmental influences as well.
Deficient Aversive Emotional Arousal and Conditioning:
1. Deficient conditioning of anxiety - David Lykken (1957) has found that psychopaths and
antisocials don't "condition," [i.e., learn to associate aversive (anxiety producing)
stimuli with punishment]. For example, they were slow to learn to stop making a
particular response in order to avoid punishment. Also, they don't show autonomic
arousal (e.g., increased heart rate or sweaty palms) when anticipating an aversive
stimulus such as shock.
2. They are unusually high on the personality trait of "sensation" (novelty) seeking.
3. Jeffrey Gray - developed a theory that suggests two basic brain systems that guide
behavior: 1. the "behavioral inhibition system" is responsible for anxiety, conditioning
of fear, and therefore socialization. 2, the "behavioral activation system" is responsible
for activating behavior in response to cues of reward (i.e., pleasure seeking such as
using alcohol or other drugs).
Fowles - (1980) suggests that psychopaths and ASPDs have an underactive behavioral
inhibition system and/or an overactive behavioral activation system (the reverse would
be true for anxiety patients).
Hans Eysenck - His theory actually predates Gray's. Excessive behavioral INHIBITION
corresponds to being neurotic (emotionally unstable) and introverted. Such persons
would likely have Cluster C disorders. Excessive behavioral ACTIVATION
corresponds to being neurotic (emotionally unstable) and extraverted. Such persons
would likely have Cluster B disorders (esp. ASPD and psychopathy). (not in book)
Successful (everyday) Psychopaths - According to Widom, these psychopaths do not have
the same deficits in autonomic responsiveness as their less successful counterparts.
As a result, their behavior does not cross the "legal line." Also, they appear to have
superior cognitive functioning (i.e., more intelligent0 so they are less likely to get caught.
Best predictor of adult psychopathy - is early onset conduct disorder which persists into
adolescence.
ADHD - An early diagnosis of attention deficit hyperactivity disorder has been shown to
be predictive of adult psychopathy in some studies.
Treatments - in general are not very effective. Prevention is the best treatment. In the
absence of prevention, the best results that can be obtained are usually with behavior
therapy in a controlled setting. (not in book)
Age changes - dimension 1 (emotional callousness) tends to be stable across the life-span
but dimension 2 (antisocial behaviors) lessens with age (they become too worn out and
tired to act out). Such older psychopaths are sometimes referred to "burned out
psychopaths."