10 personality disorders

learning objectives 10

·  10.1 What are some of the general features of personality disorders?

·  10.2 What are some of the difficulties of doing research on personality disorders?

·  10.3 What characteristics do the Cluster A personality disorders have in common?

·  10.4 What characteristics do the Cluster B personality disorders have in common?

·  10.5 What characteristics do the Cluster C personality disorders have in common?

·  10.6 What are the clinical features of borderline personality disorder and how is this disorder treated?

·  10.7 What are the features of antisocial personality disorder and psychopathy?

A person’s broadly characteristic traits, coping styles, and ways of interacting in the social environment emerge during childhood and normally crystallize into established patterns by the end of adolescence or early adulthood. These patterns constitute the individual’s personality—the set of unique traits and behaviors that characterize the individual. Today there is reasonably broad agreement among personality researchers that about five basic personality trait dimensions can be used to characterize normal personality. This five-factor model of personality traits includes the following five trait dimensions: neuroticism, extraversion/introversion, openness to experience, agreeableness/antagonism, and conscientiousness (e.g., Goldberg,  1990 ; John & Naumann,  2008 ; McCrae & Costa,  2008 ).

Clinical Features of Personality Disorders

For most of us, our adult personality is attuned to the demands of society. In other words, we readily comply with most societal expectations. In contrast, there are certain people who, although they do not necessarily display obvious symptoms of most of the disorders discussed in this book, nevertheless have certain traits that are so inflexible and maladaptive that they are unable to perform adequately at least some of the varied roles expected of them by their society, in which case we may say that they have a  personality disorder  (formerly known as a character disorder). Two of the general features that characterize most personality disorders are chronic interpersonal difficulties and problems with one’s identity or sense of self (Livesley,  2001 ).

In the case below, many of the varied characteristics of someone with a personality disorder are illustrated.

Narcissistic Personality Disorder Bob, age 21, comes to the psychiatrist’s office accompanied by his parents. He begins the interview by announcing he has no problems…. The psychiatrist was able to obtain the following story from Bob and his parents. Bob had apparently spread malicious and false rumors about several of the teachers who had given him poor grades, implying that they were having homosexual affairs with students. This, as well as increasingly erratic attendance at his classes over the past term, following the loss of a girlfriend, prompted the school counselor to suggest to Bob and his parents that help was urgently needed. Bob claimed that his academic problems were exaggerated, his success in theatrical productions was being overlooked, and he was in full control of the situation. He did not deny that he spread the false rumors but showed no remorse or apprehension about possible repercussions for himself.

Bob is a tall, stylishly dressed young man. His manner is distant but charming …. However, he assumes a condescending, cynical, and bemused manner toward the psychiatrist and the evaluation process. He conveys a sense of superiority and control over the evaluation…. His mother … described Bob as having been a beautiful, joyful baby who was gifted and brilliant. The father … noted that Bob had become progressively more resentful with the births of his two siblings. The father laughingly commented that Bob “would have liked to have been the only child.” … In his early school years, Bob seemed to play and interact less with other children than most others do. In fifth grade, after a change in teachers, he became arrogant and withdrawn and refused to participate in class. Nevertheless, he maintained excellent grades…. It became clear that Bob had never been “one of the boys.” … When asked, he professed to take pride in “being different” from his peers…. Though he was well known to classmates, the relationships he had with them were generally under circumstances in which he was looked up to for his intellectual or dramatic talents. Bob conceded that others viewed him as cold or insensitive … but he dismissed this as unimportant. This represented strength to him. He went on to note that when others complained about these qualities in him, it was largely because of their own weakness. In his view, they envied him and longed to have him care about them. He believed they sought to gain by having an association with him.

Source: Adapted with permission from DSM-IV-TR Casebook: A Learning Companion to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (pp. 239–41) (Copyright © 2002), Washington, DC. American Psychiatric Association.

According to general DSM-5 criteria for diagnosing a personality disorder, the person’s enduring pattern of behavior must be pervasive and inflexible, as well as stable and of long duration. It must also cause either clinically significant distress or impairment in functioning and be manifested in at least two of the following areas: cognition, affectivity, interpersonal functioning, or impulse control. From a clinical standpoint, people with personality disorders often cause at least as much difficulty in the lives of others as they do in their own lives. Other people tend to find the behavior of individuals with personality disorders confusing, exasperating, unpredictable, and, to varying degrees, unacceptable. Whatever the particular trait patterns affected individuals have developed (obstinacy, covert hostility, suspiciousness, or fear of rejection, for example), these patterns color their reactions to each new situation and lead to a repetition of the same maladaptive behaviors because they do not learn from previous mistakes or troubles. For example, a dependent person may wear out a relationship with someone such as a spouse by incessant and extraordinary demands such as never being left alone. After that partner leaves, the person may go almost immediately into another equally dependent relationship without choosing the new partner carefully.

Personality disorders typically do not stem from debilitating reactions to stress in the recent past, as do posttraumatic stress disorder (PTSD) or many cases of major depression. Rather, these disorders stem largely from the gradual development of inflexible and distorted personality and behavioral patterns that result in persistently maladaptive ways of perceiving, thinking about, and relating to the world. In many cases, major stressful life events early in life help set the stage for the development of these inflexible and distorted personality patterns.

The category of personality disorders is broad, encompassing behavioral problems that differ greatly in form and severity. In the milder cases we find people who generally function adequately but who would be described by their relatives, friends, or associates as troublesome, eccentric, or hard to get to know. Like Bob, they may have difficulties developing close relationships with others or getting along with those with whom they do have close relationships. One severe form of personality disorder (antisocial personality disorder) results in extreme and often unethical “acting out” against society. Many such individuals are incarcerated in prisons, although some are able to manipulate others and keep from getting caught.

The DSM-5 personality disorders are grouped into three clusters. These were derived on the basis of what were originally thought to be important similarities of features among the disorders within a given cluster.  Table 10.1  on page 333 provides a summary.

·  • Cluster A: Includes paranoid, schizoid, and schizotypal personality disorders.  People with these disorders often seem odd or eccentric, with unusual behavior ranging from distrust and suspiciousness to social detachment.

·  • Cluster B: Includes histrionic, narcissistic, antisocial, and borderline personality disorders. Individuals with these disorders share a tendency to be dramatic, emotional, and erratic.

·  • Cluster C: Includes avoidant, dependent, and obsessive-compulsive personality disorders.  In contrast to the other two clusters, people with these disorders often show anxiety and fearfulness.

Personality disorders first appeared in the DSM in 1980 (in DSM– III). Although the use of clusters has continued since then, research has raised many questions about their validity. As will be discussed later in this chapter (see “Unresolved Issues”), there are substantial limitations to the category and cluster designations. Indeed, several proposals carefully considered by the DSM-5 task force were to remove four personality disorders entirely and abandon the cluster organization. One of the primary issues is that there are simply too many overlapping features across both categories and clusters (Krueger & Eaton,  2010 ; Sheets & Craighead,  2007 ; Widiger & Mullins-Sweatt,  2005 ). Nevertheless, because much of the research literature to date has used these clusters as an organizing rubric in one way or another, we still mention them here.

research CLOSE-UP: Epidemiological Study

Epidemiological studies are designed to establish the prevalence (number of cases) of a particular disorder in a very large sample (usually many thousands) of people living in the community.

There is not as much evidence for the prevalence of personality disorders as there is for most of the other disorders discussed in this book, in part because there has never been a really large  epidemiological study comprehensively examining all the personality disorders the way the two National Comorbidity Surveys examined the other disorders we have discussed (Kessler et al.,  1994 ; Kessler, Berglund, Demler et al.,  2005b ). Nevertheless, a handful of epidemiological studies in recent years have assessed the prevalence of the personality disorders, albeit with differing conclusions (Lenzenweger,  2008 ; Paris,  2010 ). However, prevalence estimates for one or more personality disorders have ranged from 4.4 to 14.8 percent (Grant et al.,  2005 ; Lenzenweger,  2008 ; Paris,  2010 ). Such discrepancies are likely due to problematic diagnostic criteria, which will be discussed later in this chapter. One review averaging across six relatively small epidemiological studies estimated that about 13 percent of the population meets criteria for at least one personality disorder at some point in their lives (Mattia & Zimmerman,  2001 ; see also Weissman,  1993 ). Several studies from Sweden yielded very similar estimates (Ekselius et al.,  2001 ; Torgersen et al.,  2001 ,  2012 ). In addition, a very large subset of people in the NCS-Replication received a modified personality disorders interview that allowed assessment of the prevalence of Cluster A, B, and C personality disorders but only two specific personality disorders (Lenzenweger et al.,  2007 ). This study estimated that about 10 percent of the population exhibits at least one personality disorder, with 5.7 percent in Cluster A, 1.5 percent in Cluster B, and 6 percent in Cluster C. Due to the high comorbidity between clusters, some individuals meet criteria for personality disorders in more than one cluster, so the percent of people in each cluster adds up to more than 10 percent.

Since their entry into the DSM in 1980, the personality disorders have been coded on a separate axis, Axis II. This was because they were regarded as different enough from the standard psychiatric syndromes (which were coded on Axis I) to warrant separate classification. However, in DSM-5, the multiaxial system was abandoned. Personality disorders are now included with the rest of the disorders we discuss in this textbook. Personality disorders are often associated with (or comorbid with) anxiety disorders ( Chapters 5 and  6 ), mood disorders ( Chapter 7 ), substance use problems ( Chapter 11 ), and sexual deviations ( Chapter 12 ). (See, for example, L. A. Clark,  2005 ,  2007 ; Grant, Hasin et al.,  2005 ; Grant, Stinson et al.,  2005 ; Links et al.,  2012 ; Mattia & Zimmerman,  2001 ) One summary of evidence estimated that about three-quarters of people diagnosed with a personality disorder also have another disorder as well (Dolan-Sewell et al.,  2001 ).

in review

·  ● What is the definition of a personality disorder?

·  ● What are the general DSM criteria for diagnosing personality disorders?

Difficulties Doing Research On Personality Disorders

Before we discuss the clinical features and causes of personality disorders, we should note that several important aspects of doing research in this area have hindered progress relative to what is known about many other disorders. Two major categories of difficulties are briefly described.

Difficulties in Diagnosing Personality Disorders

A special caution is in order regarding the diagnosis of personality disorders because more misdiagnoses probably occur here than in any other category of disorder. There are a number of reasons for this. One problem is that diagnostic criteria for personality disorders are not as sharply defined as they are for most other diagnostic categories, so they are often not very precise or easy to follow in practice. For example, it may be difficult to diagnose reliably whether someone meets a given criterion for dependent personality disorder such as “goes to excessive lengths to obtain nurturance and support from others” or “has difficulty making everyday decisions without an excessive amount of advice and reassurance from others.” Because the criteria for personality disorders are defined by inferred traits or consistent patterns of behavior rather than by more objective behavioral standards (such as having a panic attack or a prolonged and persistent depressed mood), the clinician must exercise more judgment in making the diagnosis than is the case for many other disorders.

With the development of semistructured interviews and self-report inventories for the diagnosis of personality disorders, certain aspects of diagnostic reliability increased substantially. However, because the agreement between the diagnoses made on the basis of different structured interviews or self-report inventories is often rather low, there are still substantial problems with the reliability and validity of these diagnoses (Clark & Harrison,  2001 ; Livesley,  2003 ; Trull & Durrett,  2005 ). This means, for example, that three different researchers using three different assessment instruments may identify groups of individuals with substantially different characteristics as having a particular diagnosis such as borderline or narcissistic personality disorder. Of course, this virtually ensures that few obtained research results will be replicated by other researchers even though the groups studied by the different researchers have the same diagnostic label (e.g., Clark & Harrison,  2001 ).

Given problems with the unreliability of diagnoses (e.g., Clark,  2007 ; Livesley,  2003 ; Trull & Durrett,  2005 ), a great deal of work over the past 20 years has been directed toward developing a more reliable and accurate way of assessing personality disorders. Several theorists have attempted to deal with the problems inherent in categorizing personality disorders by developing dimensional systems of assessment for the symptoms and traits involved in personality disorders (e.g., Clark,  2007 ; Krueger & Eaton,  2010 ; Trull & Durrett,  2005 ; Widiger et al.,  2009 ). However, a unified dimensional classification of personality disorders has been slow to emerge, and a number of researchers have been trying to develop an approach that will integrate the many different existing approaches (e.g., Markon et al.,  2005 ; Krueger, Eaton, Clark et al.,  2011a ; Widiger et al.,  2009 ,  2012 ).

The model that has perhaps been most influential is the five-factor model. This builds on the five-factor model of normal personality mentioned earlier to help researchers understand the commonalities and distinctions among the different personality disorders by assessing how these individuals score on the five basic personality traits (e.g., Clark,  2007 ; Widiger & Trull,  2007 ; Widiger et al.,  2009 ,  2012 ). To fully account for the myriad ways in which people differ, each of these five basic personality traits also has subcomponents or facets. For example, the trait of neuroticism is comprised of the following six facets: anxiety, angry-hostility, depression, self-consciousness, impulsiveness, and vulnerability. Different individuals who all have high levels of neuroticism may vary widely in which facets are most prominent—for example, some might show more prominent anxious and depressive thoughts, others might show more self-consciousness and vulnerability, and yet others might show more angry-hostility and impulsivity. And the trait of extraversion is composed of the following six facets: warmth, gregariousness, assertiveness, activity, excitement seeking, and positive emotions. (All the facets of each of the five basic trait dimensions and how they differ across people with different personality disorders are explained in  Table 10.2  on p. 335.) By assessing whether a person scores low, high, or somewhere in between on each of these 30 facets, it is easy to see how this system can account for an enormous range of different personality patterns—far more than the 10 personality disorders currently classified in the DSM.

Within a dimensional approach, normal personality trait dimensions can be recast into corresponding domains that represent more pathological extremes of these dimensions: negative affectivity (neuroticism); detachment (extreme introversion); antagonism (extremely low agreeableness); and disinhibition (extremely low conscientiousness). A fifth dimension, psychoticism, does not appear to be a pathological extreme of the final dimension of normal personality (openness)—rather, as we will discuss later in the chapter in the section on schizotypal personality disorder, it reflects traits similar to the symptoms of psychotic disorders (e.g., schizophrenia) (Watson et al.,  2008 ).

With these cautions and caveats in mind, we will look at the elusive and often exasperating clinical features of the personality disorders. It is important to bear in mind, however, that what we are describing is merely the prototype for each personality disorder. In reality, as would be expected from the standpoint of the five-factor model of personality disorders, it is rare for any individual to fit these “ideal” descriptions. And, as the Thinking Critically About DSM-5 box below illustrates, this situation will not change in DSM-5.

DSM-5 THINKING CRITICALLY about DSM-5: Why Were No Changes Made to the Way Personality Disorders Are Diagnosed?

Many new and innovative proposals were offered for inclusion in the personality disorders section of DSM-5. Indeed, the proposed revisions were among the most radical for any of the disorders covered in this book. The details were hotly debated, although the general goal was to incorporate a more dimensional approach to the assessment and diagnosis of personality pathology (Livesley,  2011 ; Skodol et al.,  2011 ; Widiger et al.,  2009 ).

In the end, the DSM-5 task force proposed revisions that reflected a hybrid dimensional–categoricalmodel. This consisted of both categorical components and dimensional components. This model includes a set of general criteria for all personality disorders, an overall dimensional measure of the severity of personality dysfunction, a limited set of personality disorder types, and a set of pathological personality traits that could be specified in the absence of one of the personality disorder types. The proposed categorical component also retained 6 of the original 10 specific personality disorder types (antisocial, avoidant, borderline, narcissistic, obsessive-compulsive, and schizotypal).

The greatest change to the status quo came from the incorporation of dimensional components. The new personality domain was intended to describe personality characteristics of all patients, even those without a specific personality disorder. The proposals would have allowed clinicians to rate the level of impairment in personality functioning, reflecting aspects of both identity (having a stable and coherent sense of self and the ability to pursue meaningful life goals) and interpersonal functioning (the capacity for empathy and intimacy). In addition, diagnosticians could indicate the degree to which the patient showed substantial abnormality on five trait domains (negative affectivity, detachment, antagonism, disinhibition, and psychoticism), which are based primarily on the five-factor trait model discussed in this chapter.

In the end, however, the Board of Trustees of the American Psychiatric Association vetoed all of the proposed changes and decided to retain the old categories of personality disorders. In other words, personality disorders in DSM-5 are the same as they were in DSM-IV. Why were no changes accepted? We cannot be sure. But, as you may have gathered from our description above, the new system was very complicated. Although it may have led to a better classification system, the fact that it was not very intuitive or user-friendly may have been a problem. The primary audience for the DSM is clinicians who diagnose and treat people with mental disorders. We suspect that the new proposed system was rejected because it was quite cumbersome and judged too time-consuming for overworked clinicians to learn and use. Moreover clinicians probably would not have found the proposed system to be user-friendly in part because the idea of rating people on dimensions is foreign to the way clinicians have been taught to think. The new proposals were not dismissed entirely, however. They now appear in Section III of DSM-5, which describes disorders in need of further study. This may have been a wise course of action. Perhaps with more time and more research, it will become apparent whether or not the new approach provides enough benefits to make people willing to accept the challenges learning to use it will require.

One of the problems with the diagnostic categories of personality disorders is that the exact same observable behaviors may be associated with different personality disorders and yet have different meanings with each disorder. For example, this woman’s behavior and expression could suggest the suspiciousness and avoidance of blame seen in paranoid personality disorder. Or they could indicate the social withdrawal and absence of friends that characterize schizoid personality disorder. Or they could indicate the social anxiety about interacting with others because of fear of being rejected or negatively evaluated that is seen in avoidant personality disorder.

Difficulties in Studying the Causes of Personality Disorders

Relatively little is known about the causal factors involved in the development of most personality disorders. One reason for this is that personality disorders only began to receive consistent attention from researchers after they entered the DSM in 1980. Another problem stems from the high level of comorbidity among them. For example, in an early review of four studies, Widiger and colleagues found that 85 percent of patients who qualified for one personality disorder diagnosis also qualified for at least one more, and many qualified for several more (Widiger & Rogers,  1989 ; Widiger et al.,  1991 ). A study of nearly 900 psychiatric outpatients reported that 45 percent qualified for at least one personality disorder diagnosis and, among those with one, 60 percent had more than one and 25 percent had two or more (Zimmerman et al.,  2005 ). Even in a nonpatient sample, Zimmerman and Coryell ( 1989 ) found that of those with one personality disorder, almost 25 percent had at least one more (see also Mattia & Zimmerman,  2001 ; Trull et al.,  2012 ). This substantial comorbidity adds to the difficulty of untangling which causal factors are associated with which personality disorder.

Another problem in drawing conclusions about causes occurs because researchers have more confidence in prospective studies, in which groups of people are observed before a disorder appears and are followed over a period of time to see which individuals develop problems and what causal factors have been present. Although this has begun to change, to date, relatively little prospective research has been conducted with most of the personality disorders. Instead, the vast majority of research has been conducted on people who already have the disorders; some of it relies on retrospective recall of prior events, and some of it relies on observing current biological, cognitive, emotional, and interpersonal functioning. Thus, any conclusions about causes that are suggested must be considered very tentative.

Of possible biological factors, it has been suggested that infants’ temperament (an inborn disposition to react affectively to environmental stimuli; see  Chapter 3 ) may predispose them to the development of particular personality traits and disorders (e.g., L. A. Clark,  2005 ; Mervielde et al.,  2005 ; Paris,  2012 ). Some of the most important dimensions of temperament are negative emotionality, sociability versus social inhibition or shyness, and activity level. One way of thinking about temperament is that it lays the early foundation for the development of the adult personality, but it is not the sole determinant of adult personality. Given that most temperamental and personality traits have been found to be moderately heritable (e.g., Bouchard & Loehlin,  2001 ; Livesley,  2005 ), it is not surprising that there is increasing evidence for genetic contributions to certain personality disorders (e.g., Kendler et al.,  2008 ,  2011 ; Livesley,  2005 ,  2008 ; Livesley & Jang,  2008 ; South et al.,  2012 ; Torgersen et al.,  2000 ). However, for at least most disorders, the genetic contribution appears to be mediated by the genetic contributions to the primary trait dimensions most implicated in each disorder rather than to the disorders themselves (Livesley,  2005 ; Kendler et al.,  2008 ). In addition, some progress is being made in understanding the psychobiological substrate of at least some of the traits prominently involved in the personality disorders (e.g., Depue,  2009 ; Depue & Lenzenweger,  2001 ,  2006 ; Livesley,  2008 ; Paris,  2005 ,  2007 ; Roussos & Siever,  2012 ).

Genetic propensities and temperament may be important predisposing factors for the development of particular personality traits and disorders. Parental influences, including emotional, physical, and sexual abuse, may also play a big role in the development of personality disorders.

Among psychological factors, psychodynamic theorists originally attributed great importance in the development of character disorders to an infant’s getting excessive versus insufficient gratification of his or her impulses in the first few years of life (Fonaghy & Luyten, 2012). More recently, learning-based habit patterns and maladaptive cognitive styles have received more attention as possible causal factors (e.g., Beck et al.,  1990 ,  2004 ; Lobbestad & Arntz,  2012 ). Many of these maladaptive habits and cognitive styles that have been hypothesized to play important roles for certain disorders may originate in disturbed parent–child attachment relationships rather than derive simply from differences in temperament (e.g., Benjamin,  2005 ; Fraley & Shaver,  2008 ; Meyer & Pilkonis,  2005 ; Shiner,  2009 ). Parental psychopathology and ineffective parenting practices have also been implicated in certain disorders (e.g., Farrington,  2006 ; Paris,  2001 ,  2007 ). Many studies have also suggested that early emotional, physical, and sexual abuse may be important factors in a subset of cases for several different personality disorders (Battle et al.,  2004 ; Grover et al.,  2007 ).

Various kinds of social stressors, societal changes, and cultural values have also been implicated as sociocultural causal factors (Paris,  2001 ). Ultimately, of course, the goal is to achieve a biopsychosocial perspective on the origins of each personality disorder, but today we are far from reaching that goal.

in review

·  ● What are three reasons for the high frequency of misdiagnoses of personality disorders?

·  ● What are two reasons why it is difficult to conduct research on personality disorders?

Cluster a Personality Disorders

People with Cluster A personality disorders display unusual behaviors such as distrust, suspiciousness, and social detachment and often come across as odd or eccentric. In the following section, we will look at paranoid, schizoid, and schizotypal personality disorders.

Paranoid Personality Disorder

TABLE 10.1 Summary of Personality Disorders

Personality Disorder	Characteristics	Prevalence	Gender Ratio Estimate
Cluster A
Paranoid	Suspiciousness and mistrust of others; tendency to see self as blameless; on guard for perceived attacks by others	0.5–2.5%	males > females
Schizoid	Impaired social relationships; inability and lack of desire to form attachments to others	<1%	males > females
Schizotypal	Peculiar thought patterns; oddities of perception and speech that interfere with communication and social interaction	3%	males > females
Cluster B
Histrionic	Self-dramatization; over concern with attractiveness; tendency to irritability and temper outbursts if attention seeking is frustrated	2–3%	males = females
Narcissistic	Grandiosity; preoccupation with receiving attention; self-promoting; lack of empathy	<1%	males > females
Antisocial	Lack of moral or ethical development; inability to follow approved models of behavior; deceitfulness; shameless manipulation of others; history of conduct problems as a child	1% females, 3% males	males > females
Borderline	Impulsiveness; inappropriate anger; drastic mood shifts; chronic feelings of boredom; attempts at self-mutilation or suicide	2%	females = males
Cluster C
Avoidant	Hypersensitivity to rejection or social derogation; shyness; insecurity in social interaction and initiating relationships	0.5–1%	males = females
Dependent	Difficulty in separating in relationships; discomfort at being alone; subordination of needs in order to keep others involved in a relationship; indecisiveness	2%	males = females
Obsessive-Compulsive	Excessive concern with order, rules, and trivial details; perfectionistic; lack of expressiveness and warmth; difficulty in relaxing and having fun	1%	males > females (by 2:1)

Source: APA ( 2013 ); Weissman ( 1993 ); Zimmerman & Coryell ( 1990 ).

Individuals with  paranoid personality disorder  have a pervasive suspiciousness and distrust of others, leading to numerous interpersonal difficulties. They tend to see themselves as blameless, instead blaming others for their own mistakes and failures—even to the point of ascribing evil motives to others. Such people are chronically tense and “on guard,” constantly expecting trickery and looking for clues to validate their expectations while disregarding all evidence to the contrary. They are often preoccupied with doubts about the loyalty of friends and hence are reluctant to confide in others. They commonly bear grudges, refuse to forgive perceived insults and slights, and are quick to react with anger and sometimes violent behavior (Bernstein & Useda,  2007 ; Oltmanns & Okada, 2006). Recent research has suggested that paranoid personality disorder may consist of elements of both suspiciousness and hostility (Edens et al.,  2009 ; Falkum et al.,  2009 ).

DSM-5 criteria for: Paranoid Personality Disorder

·  A. A pervasive distrust and suspiciousness of others such that their motives are interpreted as malevolent, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following:

·  1. Suspects, without sufficient basis, that others are exploiting, harming, or deceiving him or her.

·  2. Is preoccupied with unjustified doubts about the loyalty or trustworthiness of friends or associates.

·  3. Is reluctant to confide in others because of unwarranted fear that the information will be used maliciously against him or her.

·  4. Reads hidden demeaning or threatening meanings into benign remarks or events.

·  5. Persistently bears grudges (i.e., is unforgiving of insults, injuries, or slights).

·  6. Perceives attacks on his or her character or reputation that are not apparent to others and is quick to react angrily or to counterattack.

·  7. Has recurrent suspicions, without justification, regarding fidelity of spouse or sexual partner.

·  B. Does not occur exclusively during the course of schizophrenia, a bipolar disorder or depressive disorder with psychotic features, or another psychotic disorder and is not attributable to the physiological effects of another medical condition.

Note: If criteria are met prior to the onset of schizophrenia, add “premorbid,” i.e., “paranoid personality disorder (premorbid).”

Source: Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (Copyright © 2013). American Psychiatric Association.

It is important to keep in mind that people with paranoid personalities are not usually psychotic; that is, most of the time they are in clear contact with reality, although they may experience transient psychotic symptoms during periods of stress (M. B. Miller, Useda et al.,  2001 ). People with paranoid schizophrenia share some symptoms found in paranoid personality, but they have many additional problems including more persistent loss of contact with reality, delusions, and hallucinations. Nevertheless, individuals with paranoid personality disorder do appear to be at elevated liability for schizophrenia (Lenzenweger,  2009 ).

Paranoid Construction Worker A 40-year-old construction worker believes that his coworkers do not like him and fears that someone might let his scaffolding slip in order to cause him injury on the job. This concern followed a recent disagreement on the lunch line when the patient felt that a coworker was sneaking ahead and complained to him. He began noticing his new “enemy” laughing with the other men and often wondered if he were the butt of their mockery….

The patient offers little spontaneous information, sits tensely in the chair, is wide-eyed, and carefully tracks all movements in the room. He reads between the lines of the interviewer’s questions, feels criticized, and imagines that the interviewer is siding with his coworkers….

He was a loner as a boy and felt that other children would form cliques and be mean to him. He did poorly in school but blamed his teachers—he claimed that they preferred girls or boys who were “sissies.” He dropped out of school and has since been a hard and effective worker, but he feels he never gets the breaks. He believes that he has been discriminated against because of his Catholicism but can offer little convincing evidence. He gets on poorly with bosses and coworkers, is unable to appreciate joking around, and does best in situations where he can work and have lunch alone. He has switched jobs many times because he felt he was being mistreated.

The patient is distant and demanding with his family. His children call him “Sir” and know that it is wise to be “seen but not heard” when he is around…. He prefers not to have people visit his house and becomes restless when his wife is away visiting others.

Source: Adapted with permission from the DSM III Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Case Book(Copyright © 1981). American Psychiatric Association.

CAUSAL FACTORS

Little is known about important causal factors for paranoid personality disorder (Falkum et al.,  2009 ). Some have argued for partial genetic transmission that may link the disorder to schizophrenia, but results examining this issue are inconsistent, and if there is a significant relationship it is not a strong one (Kendler et al.,  2006 ; M. B. Miller, Useda et al.,  2001 ). There is a modest genetic liability to paranoid personality disorder itself that may occur through the heritability of high levels of antagonism (low agreeableness) and neuroticism (angry-hostility), which are among the primary traits in paranoid personality disorder (Widiger, Trull et al.,  2002 ; see also Falkum et al.,  2009 ; Hopwood & Thomas,  2012 ; Kendler et al.,  2006 ). (See  Table 10.2  below.) Psychosocial causal factors that are suspected to play a role include parental neglect or abuse and exposure to violent adults, although any links between early adverse experiences and adult paranoid personality disorder are clearly not specific to this one personality disorder and may play a role in other disorders as well (Battle et al.,  2004 ; Grover et al.,  2007 ; Natsuaki et al.,  2009 ).

Schizoid Personality Disorder

TABLE 10.2 DSM-IV Personality Disorders and the Five-Factor Model

NEO-PI-R Domains and Facets	PAR	SZD	SZT	ATS	BDL	HST	NAR	AVD	DEP	OBC
Neuroticism
Anxiety			H		H			H	H
Angry-hostility	H			H	H		H
Depression					H	H		H
Self-consciousness			H			H	H	H	H
Impulsiveness					H
Vulnerability					H			H	H
Extraversion
Warmth		L	L			H			H
Gregarious		L	L			H		L
Assertiveness								L	L	H
Activity
Excitement seeking				H		H		L
Positive emotions		L	L			H
Openness to Experience
Fantasy		H			H	H
Aesthetics
Feelings		L				H
Actions			H
Ideas			H
Values										L
Agreeableness
Trust	L		L		L	H			H
Straightforwardness	L			L
Altruism				L			L		H
Compliance	L			L	L				H	L
Modesty							L		H
Tender mindedness				L			L
Conscientiousness
Competence					L					H
Order										H
Dutifulness				L						H
Achievement striving							H			H
Self-discipline				L
Deliberation				L

Note: NEO-PI-R = Revised NEO Personality Inventory. H, L = high, low, respectively, based on the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; American Psychiatric Association,  1994 ) diagnostic criteria. Personality disorders: PAR = paranoid; SZD = schizoid; SZT = schizotypal; ATS = antisocial; BDL = borderline; HST = histrionic; NAR = narcissistic; AVD = avoidant; DEP = dependent; OBC = obsessive-compulsive.

Source: Adapted from Widiger, Trull et al. ( 2002 ). A description of the DSM-IV personality disorders with the five-factor model of personality. In P. T. Costa & T. A. Widiger (Eds.), Personality Disorders and the Five-Factor Model of Personality (2nd ed.) (p. 90). Washington, DC: APA Books.

Individuals with  schizoid personality disorder  are usually unable to form social relationships and usually lack much interest in doing so. Consequently, they tend not to have good friends, with the possible exception of a close relative. Such people are unable to express their feelings and are seen by others as cold and distant. They often lack social skills and can be classified as loners or introverts, with solitary interests and occupations, although not all loners or introverts have schizoid personality disorder (Bernstein et al.,  2009 ; M. B. Miller, Useda et al.,  2001 ). People with this disorder tend not to take pleasure in many activities, including sexual activity, and rarely marry. More generally, they are not very emotionally reactive, rarely experiencing strong positive or negative emotions, but rather show a generally apathetic mood. These deficits contribute to their appearing cold and aloof (M. B. Miller, Useda et al.,  2001 ; Mittal et al.,  2007 ). In terms of the five-factor model, they show extremely high levels of introversion (especially low on warmth, gregariousness, and positive emotions). They are also low on openness to feelings (one facet of openness to experience) (Widiger, Trull et al.,  2002 ) and on achievement striving (e.g., Hopwood & Thomas,  2012 ).

DSM-5 criteria for: Schizoid Personality Disorder

·  A. A pervasive pattern of detachment from social relationships and a restricted range of expression of emotions in interpersonal settings, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following:

·  1. Neither desires nor enjoys close relationships, including being part of a family.

·  2. Almost always chooses solitary activities.

·  3. Has little, if any, interest in having sexual experiences with another person.

·  4. Takes pleasure in few, if any, activities.

·  5. Lacks close friends or confidants other than first-degree relatives.

·  6. Appears indifferent to the praise or criticism of others.

·  7. Shows emotional coldness, detachment, or flattened affectivity.

·  B. Does not occur exclusively during the course of schizophrenia, a bipolar disorder or depressive disorder with psychotic features, another psychotic disorder, or autism spectrum disorder and is not attributable to the physiological effects of another medical condition.

Note: If criteria are met prior to the onset of schizophrenia, add “premorbid,” i.e., “schizoid personality disorder (premorbid).”

Source: Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (Copyright © 2013). American Psychiatric Association.

CAUSAL FACTORS

Like paranoid personality disorder, schizoid personality disorder has not been the focus of much research attention. This is hardly surprising since people with schizoid personality disorder are not exactly the people we might expect to volunteer for a research study. Early theorists considered a schizoid personality to be a likely precursor to the development of schizophrenia, but this viewpoint has been challenged, and any genetic link that may exist is very modest (Kalus et al.,  1995 ; Kendler et al.,  2006 ; Lenzenweger,  2010 ; M. B. Miller, Useda et al.,  2001 ). Schizoid personality traits have also been shown to have only a modest heritability (Kendler et al.,  2006 ).

Some theorists have suggested that the severe disruption in sociability seen in schizoid personality disorder may be due to severe impairment in an underlying affiliative system (Depue & Lenzenweger,  2005 ,  2006 ). Cognitive theorists propose that individuals with schizoid personality disorder exhibit cool and aloof behavior because of maladaptive underlying schemas that lead them to view themselves as self-sufficient loners and to view others as intrusive. Their core dysfunctional belief might be, “I am basically alone” (Beck et al.,  1990 , p. 51) or “Relationships are messy [and] undesirable” (Pretzer & Beck,  1996 , p. 60; see also Beck et al.,  2004 ). Unfortunately, we do not know why or how some people might develop such dysfunctional beliefs.

Schizotypal Personality Disorder

Individuals with  schizotypal personality disorder  are also excessively introverted and have pervasive social and interpersonal deficits (like those that occur in schizoid personality disorder), but in addition they have cognitive and perceptual distortions, as well as oddities and eccentricities in their communication and behavior (Kwapil & Barrantes-Vidal,  2012 ; Raine,  2006 ). Although contact with reality is usually maintained, highly personalized and superstitious thinking is characteristic of people with schizotypal personality, and under extreme stress they may experience transient psychotic symptoms (APA,  2013 ; Widiger & Frances,  1994 ). Indeed, they often believe that they have magical powers and may engage in magical rituals. Other cognitive–perceptual problems include ideas of reference (the belief that conversations or gestures of others have special meaning or personal significance), odd speech, and paranoid beliefs.

The Introverted Computer Analyst Bill, a highly intelligent but quite introverted and withdrawn 33-year-old computer analyst, was referred for psychological evaluation by his physician, who was concerned that Bill might be depressed and unhappy. Bill had virtually no contact with other people. He lived alone in his apartment, worked in a small office by himself, and usually saw no one at work except his supervisor, who occasionally visited to give him new work and pick up completed projects. He ate lunch by himself, and about once a week, on nice days, went to the zoo for his lunch break.

Bill was a lifelong loner; as a child he had had few friends and had always preferred solitary activities over family outings (he was the oldest of five children). In high school he had never dated and in college had gone out with a woman only once—and that was with a group of students after a game. He had been active in sports, however, and had played varsity football in both high school and college. In college he had spent a lot of time with one relatively close friend—mostly drinking. However, this friend now lived in another city.

Bill reported rather matter-of-factly that he had a hard time making friends; he never knew what to say in a conversation. On a number of occasions he had thought of becoming friends with other people but simply couldn’t think of the right words, so “the conversation just died.” He reported that he had given some thought lately to changing his life in an attempt to be more “positive,” but it had never seemed worth the trouble. It was easier for him not to make the effort because he became embarrassed when someone tried to talk with him. He was happiest when he was alone.

Oddities in thinking, speech, and other behaviors are the most stable characteristics of schizotypal personality disorder (McGlashan et al.,  2005 ) and are similar to those often seen in patients with schizophrenia. In fact, many researchers conceptualize schizotypal personality disorder as an attenuated form of schizophrenia (Lenzenweger,  2010 ; Raine,  2006 ). Interestingly, although some aspects of schizotypy appear related to the five-factor model of normal personality (specifically facets of intro-version and neuroticism), the other aspects related to cognitive and perceptual distortions are notadequately explained by the five-factor model of normal personality (Watson et al.,  2008 ). Indeed, these core symptoms of schizotypy form the basis of the only proposed trait that does not map neatly unto the five factors of normal personality. This final pathological trait is psychoticism, which consists of three facets: unusual beliefs and experiences, eccentricity, and cognitive and perceptual dysregulation (Krueger, Eaton, Derringer et al.,  2011b ).

CAUSAL FACTORS

Unlike schizoid and paranoid personality disorders, there has been a significant amount of research on schizotypal personality disorder (Esterberg et al.,  2010 ). In fact, in the original proposal for the DSM-5, schizotypal personality was the only categorical disorder retained from Cluster A. Estimates of the prevalence of this disorder in the general population have varied somewhat, but one good review of such studies has estimated that the prevalence is about 2 to 3 percent in the general population (Raine,  2006 ). The heritability of schizotypal personality disorder is moderate (Kwapil & Barrantes-Vidal,  2012 ; Raine,  2006 ; Lin et al.,  2006 ,  2007 ).

DSM-5 criteria for: Schizotypal Personality Disorder

·  A. A pervasive pattern of social and interpersonal deficits marked by acute discomfort with, and reduced capacity for, close relationships as well as by cognitive or perceptual distortions and eccentricities of behavior, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

·  1. Ideas of reference (excluding delusions of reference).

·  2. Odd beliefs or magical thinking that influences behavior and is inconsistent with subcultural norms (e.g., superstitiousness, belief in clairvoyance, telepathy, or “sixth sense”; in children and adolescents, bizarre fantasies or preoccupations).

·  3. Unusual perceptual experiences, including bodily illusions.

·  4. Odd thinking and speech (e.g., vague, circumstantial, metaphorical, overelaborate, or stereotyped).

·  5. Suspiciousness or paranoid ideation.

·  6. Inappropriate or constricted affect.

·  7. Behavior or appearance that is odd, eccentric, or peculiar.

·  8. Lack of close friends or confidants other than first-degree relatives.

·  9. Excessive social anxiety that does not diminish with familiarity and tends to be associated with paranoid fears rather than negative judgments about self.

·  B. Does not occur exclusively during the course of schizophrenia, a bipolar disorder or depressive disorder with psychotic features, another psychotic disorder, or autism spectrum disorder.

Note: If criteria are met prior to the onset of schizophrenia, add “premorbid,” e.g., “schizotypal personality disorder (premorbid).”

Source: Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (Copyright © 2013). American Psychiatric Association.

The biological associations of schizotypal personality disorder with schizophrenia are remarkable (Cannon et al.,  2008 ; Jang et al.,  2005 ; Siever & Davis,  2004 ; Yung et al.,  2004 ). A number of studies on patients, as well as on college students, with schizotypal personality disorder (e.g., Raine,  2006 ; Siever et al.,  1995 ) have shown the same deficit in the ability to track a moving target visually that is found in schizophrenia (Coccaro,  2001 ; see also  Chapter 13 ). They also show numerous other mild impairments in cognitive functioning (Voglmaier et al.,  2005 ), including deficits in their ability to sustain attention (Lees-Roitman et al.,  1997 ; Raine,  2006 ) and deficits in working memory (e.g., being able to remember a span of digits), both of which are common in schizophrenia (Farmer et al.,  2000 ; Squires-Wheeler et al.,  1997 ). In addition, individuals with schizotypal personality disorder, like patients with schizophrenia, show deficits in their ability to inhibit attention to a second stimulus that rapidly follows presentation of a first stimulus. For example, normal individuals presented with a weak auditory stimulus about 0.1 second before a loud sound that elicits a startle response show a smaller startle response than those not presented the weak auditory stimulus first (Cadenhead, Light et al.,  2000a ; Cadenhead, Swerdlow et al.,  2000b ). This normal inhibitory effect is reduced in people with schizotypal personality disorder and with schizophrenia, a phenomenon that may be related to their high levels of distractibility and difficulty staying focused (see also Hazlett et al.,  2003 ; Raine,  2006 ). Finally, they also show language abnormalities that may be related to abnormalities in their auditory processing (Dickey et al.,  2008 ).

A genetic relationship to schizophrenia has also long been suspected. In fact, this disorder appears to be part of a spectrum of liability for schizophrenia that often occurs in some of the first-degree relatives of people with schizophrenia (Kendler & Gardner,  1997 ; Kwapil & Barrantes-Vidal,  2012 ; Raine,  2006 ; Tienari et al.,  2003 ). Moreover, teenagers who have schizotypal personality disorder have been shown to be at increased risk for developing schizophrenia and schizophrenia-spectrum disorders in adulthood (Asarnow,  2005 ; Cannon et al.,  2008 ; Raine,  2006 ; Tyrka et al.,  1995 ). Nevertheless, it has also been proposed that there is a second subtype of schizotypal personality disorder that is not genetically linked to schizophrenia. This subtype is characterized by cognitive and perceptual deficits and is instead linked to a history of childhood abuse and early trauma (Berenbaum et al.,  2008 ; Raine,  2006 ). Schizotypal personality disorder in adolescence has been associated with elevated exposure to stressful life events (Anglin et al.,  2008 ; Tessner et al.,  2011 ) and low family socioeconomic status (Cohen et al.,  2008 ).

Cluster B Personality Disorders

In the following section, we look closely at histrionic, narcissistic, antisocial, and borderline personality disorders. Remember that people with Cluster B personality disorders share a tendency to be dramatic, emotional, and erratic.

Histrionic Personality Disorder

Excessive attention-seeking behavior and emotionality are the key characteristics of individuals with  histrionic personality disorder . As you can see from the table of DSM-5 criteria, these individuals tend to feel unappreciated if they are not the center of attention; their lively, dramatic, and excessively extraverted styles often ensure that they can charm others into attending to them. But these qualities do not lead to stable and satisfying relationships because others tire of providing this level of attention. In craving stimulation and attention, their appearance and behavior are often quite theatrical and emotional as well as sexually provocative and seductive (Freeman et al.,  2005 ). They may attempt to control their partners through seductive behavior and emotional manipulation, but they also show a good deal of dependence (e.g., Blagov et al.,  2007 ; Bornstein & Malka,  2009 ; P. R. Rasmussen,  2005 ). Their speech is often vague and impressionistic, and they are usually considered self-centered, vain, and excessively concerned about the approval of others, who see them as overly reactive, shallow, and insincere.

This woman could be just “clowning around” one night in a bar with friends. But if she frequently seeks opportunities to engage in seductive and attention-seeking behavior, she could have histrionic personality disorder.

The prevalence of histrionic personality disorder in the general population is estimated at 2 to 3 percent, although the prevalence of this disorder may be decreasing (Blashfield et al.,  2012 ). Some (but not all) studies suggest that this disorder occurs more often in women than in men (Lynam & Widiger,  2007 ; Widiger & Bornstein,  2001 ). Reasons for the possible sex difference have been very controversial. One review of these controversies suggested that this sex difference is not surprising, given the number of traits that occur more often in females that are involved in the diagnostic criteria. For example, many of the criteria for histrionic personality disorder (as well as for several other personality disorders such as dependent) involve maladaptive variants of female-related traits (e.g., Widiger & Bornstein,  2001 ) such as overdramatization, vanity, seductiveness, and overconcern with physical appearance. However, other personality traits prominent in histrionic personality disorder are actually more common in men than in women (e.g., high excitement seeking and low self-consciousness). A recent careful analysis of the issue suggests that the higher prevalence of histrionic personality in women actually would not be predicted based on known sex differences in the personality traits prominent in the disorder. This does indeed suggest the influence of some form of sex bias in the diagnosis of this disorder (Lynam & Widiger,  2007 ).

CAUSAL FACTORS