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Personality Disorders

Personality disorders (PD) are the most common cause of visits to psychological clinics. Each PD is a syndrome, a col­lection of traits or symptoms forming a type, as discussed in Chapter 11.

PDs are what used to be called neuro­ses in the first half of the 20th Century. In behavioral terms, neuroses are persist­ent, maladaptive patterns of personality.

What did the word "neurosis" mean, in behavioral terms?

People with PDs fit the same descrip­tion. They tend to be inflexible in the sense that they seem unable to change, even if they want to. In some cases they do not want to: they are brought into therapy only because relatives or marriage partners insist on it.

Personality disorders are maladaptive in the sense that they have bad conse­quences for a person, making it harder to live a normal and productive life. Hoermann, Zupanick, and Dombeck (2015) say before a diagnosis of PD is made, a person must demonstrate "significant and enduring difficulties in at least two of these areas":

  1. Distorted thinking patterns
  2. Problematic emotional responses
  3. Over- or under-regulated impulse control
  4. Interpersonal difficulties

Hoermann, Zupanick, and Dombeck (2015) point out that the ten classic personality disorders (PDs) can be grouped into three clusters. The PDs in each cluster have overlapping features, and if a person is diagnosed with more than one PD, the multiple diagnoses are likely to come from the same cluster.

Cluster A (the "odd, eccentric" cluster): Paranoid, Schizoid, and Schizotypal PDs

Cluster B (the "dramatic, emotional, erratic" cluster): Borderline, Narcissistic, Histrionic, and Antisocial PDs

Cluster C (the "anxious, fearful" cluster): Avoidant, Dependent, and Obsessive-Compulsive PDs

Personality disorders are among the least reliable diagnoses. Specialists often disagree about their diagnoses, and because there is such overlap between different types, sometimes it is not clear where a patient fits.

The DSM-5 revision of diagnostic categories was a multi-year process that re-awakened many controversies about personality disorders. Critics recommended "a break from past practices of 'tinkering' with categorical criteria" (Skodol, Morey, Bender, and Oldham, 2013).

What alternative to the "type" approach was recommended by critics?

Critics of the old approach recommend­ed movement toward a dimensional model. This would involve rating person­alities on a variety of dimensions or traits, rather than diagnosing all-or-none categories.

Some progress was made toward that goal in DSM-5, but a plan to move to dimensional models and eliminate the old list of ten PDs was blocked. For now, the ten types of personality dis­order still exist as diagnostic cate­gories.

In describing the PD types, we will follow the cluster model suggested above. First is Cluster A (the "odd, eccentric" cluster): Paranoid, Schizoid, and Schizotypal personality disorders.

The paranoid personality is suspicious of others, irritable, and often jealous. Unlike paranoid schizophrenics, people with paranoid personality disorder do not hear voices or believe in wild conspiracy theories.

They are just suspicious and hostile all the time. They also tend to be litigious, bringing lawsuits against imagined enemies.

What is the paranoid personality disorder?

The schizoid PD is characterized primarily by voluntary social aloneness. The schizoid person is "a loner by choice" with few if any friends. He or she does not care about the advice or praise of others.

A schizoid person usually lives alone and seems self-absorbed or absent-minded. Unlike the schizotypal personality, the schizoid does not make exotic interpret­ations of events or have rambling speech. People with a schizoid person­ality may do well in a skilled job if they can work independently and avoid interacting much with other people.

What is the schizoid personality?

A schizotypal personality is an "odd individual" who has trouble coping with social relationships. This type tends to interpret events of the world in peculiar ways unique to that person. Such a person may seem halfway to the delusions of schizophrenia, but the schizotypal personality is still coping.

The schizotypal person may deteriorate under stress and may occasionally express delusional ideas. A schizotypal personality tends to use unusual words and catch phrases that have a special private meaning. The person's speech rambles but is not incoherent like the speech of some schizophrenics.

What is the schizotypal personality?

Cluster B (of the three clusters of PDs identified by Hoermann, Zupanick, and Dombeck, 2015) consists of "dramatic, emotional, erratic" types. These include borderline, narcissistic, histrionic, and antisocial personality disorders.

A borderline personality tends to have intense, erratic relationships. The borderline type can be hostile and demanding, intelligent and challenging. They tend to have strong emotional responses.

Borderline patients are often unique, complicated, and hard-to-please. They are also unpredictable and inconsistent, being calm and controlled one week, going on a binge another week.

Borderlines sometimes make dramatic improvements in therapy. However, suicide is also more common among this group than others.

DSM-5 focuses on instability in all facets of behavior as diagnostic of the borderline personality, making it rather hard to diagnose. Independent clinicians often disagree on the diagnosis.

What is the "borderline" type?

The narcissistic personality disorder is characterized by a grandiose self-image and sense of self-worth. This is combined with a lack of interest in the interests or feelings of others.

Narcissistic types care mostly about themselves. Most of their behavior is designed to impress others or boost their image.

They typically do not think they have any personality problems. If they come to the attention of a therapist, it is usually because they are trying to save a relationship.

What is the narcissistic type?

The histrionic personality is prone to emotional displays. Bootzin and Acocella (1984) write:.

Histrionic personalities will "faint" at the sight of blood, will dominate an entire dinner party with the tale of their recent faith healing, will be so "overcome" with emotion during a sad movie that they have to be taken home immediately (thus spoiling their companion's evening), will threaten suicide if a lover's interest cools, and so forth. To themselves, they seem very sensitive; to others, they often seem shallow and insincere.

What is the histrionic type?

The remaining PD from cluster B is the antisocial personality type. We will consider that separately on the next page. It is an important type commonly found in criminals and, ironically, also in those occupying positions of power.

Cluster C is the "anxious, fearful" cluster. It consists of three personality disorders: the avoidant, dependent, and obsessive-compulsive PDs.

Avoidant personalities are anxious to avoid the risks of social contact. Millon (1981) describes the avoidant person­ality as hypersensitive to rejection, humiliation, or shame.

This type of person wants to be loved but expects not to be. They may therefore seek reassurance constantly, over-reacting to any hint of disapproval.

Avoidant personalities have low self-esteem and are typically angry with themselves over social failures. The schizoid personality enjoys aloneness; the avoidant personality does not.

What are characteristics of the avoidant personality disorder?

Dependent personalities, as the name suggests, show extreme dependence on other people. They may panic if left alone. If they remain in the company of others, they may function well.

Dependent personalities tend to cling to, or imitate, somebody else. This is their source of strength but also their weak­ness.

If "dropped" they are devastated. Often their imitative tendency is so great that they adopt the mannerisms and speech habits of another person.

How does the dependent personality react to relationships?

Finally, the obsessive-compulsive personality is a "workaholic without warmth" (Meyer and Salmon, 1984). They tend to be preoccupied with details until it hampers their productivity.

Such people are said to be overly con­trolled emotionally and unable to express tender emotions such as caring. They make lists, sort things into neat piles, and may be fanatically detailed in planning.

People with this PD have trouble having fun in social situations. They tend to have a poor sense of humor and are usually not very creative, preferring dependability and routine.

What is the obsessive-compulsive personality disorder and how is it distinguished from OCD?

The obsessive-compulsive personality disorder is distinguished from OCD, the obsessive-compulsive disorder. People with the personality disorder do not show "true obsessions and compul­sions" like people with OCD. They do not engage in repeated checking. They do not suffer from intrusive, obsessive thoughts.

However, a person who stacks up old news­papers until they create a fire hazard might be considered for a diagnosis of hoarding. DSM-5 put that under the category of OCD or obsessive-compul­sive disorders because hoarding is a compulsive behavior.

Samuel, Carroll, Rounsaville, and Ball (2013) argue against treating personality disorders like all-or-none "categorical entities." They favor a view in which personality disorders are "extreme versions of the same traits that describe normal personality."

How do Samuel et al. put PDs in the category of spectrum disorders?

Samuel, Carroll, Rounsaville, and Ball (2013) would put personality disorders into the category of spectrum disorders. If PDs come on a spectrum, that would explain why almost everybody can recognize mild versions of PDs among friends and acquaintances.

In case you have not noticed, everything in DSM-5 is turning into a spectrum disorder. Autism is one. Depression is another.

Schizophrenics do not have to be all-the-way schizophrenics; they can be "schizotypal." In general, abnormal psychology syndromes come on a spectrum of intensity from mild to severe.

About 10-15% of adolescents could be diagnosed with a personality disorder, according to clinicians. Only about half that many actually receive a PD diag­nosis from a therapist, because clini­cians are reluctant to saddle young people with a psychiatric diagnosis.

We devote the next page to one particular personality disorder, the antisocial personality disorder (also known as the sociopath or psychopath). This is an especially interesting and dangerous type.

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References:

Hoermann, S., Zupanick, C. E., & Dombeck, M. (2015, November 17) Intro to personality disorders. MentalHelp.net. Retrieved from: https://www.mentalhelp.net/articles/dsm-5-the-ten-personality-disorders-cluster-a/ .

Meyer, R.G. & Salmon, P. (1984) Abnormal Psychology. Boston: Allyn and Bacon.

Millon, T (1983). The DSM-III: An insider's perspective. American Psychologist, 38, 804-814.

Samuel, D. B., Carroll, K. M., Rounsaville, J., Ball, S. A. (2013) Personality disorders as maladaptive, extreme variants of normal personality. Journal of Personality Disorders, 27, 625-635. doi:10.1521/pedi.2013.27.5.625

Skodol, A. E., Morey, L. C., Bender, D. S., & Oldham, J. M. (2013) When is it time to move on? Rejoinder for 'The ironic fate of the personality disorders in DSM-5'. Personality Disorders: Theory, Research, and Treatment, 4, 354. http://dx.doi.org/10.1037/per0000054


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