Chapter 12

Personality Disorders
 Outline

 An Overview of Personality Disorders

 Cluster A Personality Disorders
 Paranoid, schizoid, schizotypal
 Cluster B Personality Disorders
 Antisocial, borderline, histrionic, narcissistic
 Cluster C Personality Disorders
 Avoidant, dependent, obsessive-compulsive
 Focus Questions

o What are the essential features of personality

disorders?
o What are the features of odd or eccentric
personality disorders?
o What are the features of dramatic, emotional and
erratic personality disorders?
o What are the features of anxious or fearful
personality disorders?
 What are Personality Disorders?

 A persistent pattern of emotions, cognitions and

behaviour that results in enduring emotional
distress for the person affected and/or for others
and may cause difficulties with work and
relationships
 Personality Disorders: An Overview

 Enduring, inflexible predispositions

 Maladaptive, causing distress and/or impairment
 High comorbidity with other disorders
 Generally poor prognosis
 Ego-syntonic: Unlike other disorders, often feel
consistent with one’s identity; patients don’t feel
that treatment is necessary
 Ten specific personality disorders organised into
three clusters
 Categorical and Dimensional Models

 ‘Kind' vs 'Degree'
 Personality disorders have traditionally been
assigned as all-or-nothing categories
 DSM-5 retained categorical diagnoses but also
introduced additional dimensional model of
personality disorders
 Dimensional model: Individuals are rated on the
degree to which they exhibit various personality
traits
 Categorical and Dimensional Models

 Cross-cultural research establishes the universal

nature of the five dimensions
 Five factor model of personality ('Big Five')
 Openness to experience
 Conscientiousness
 Extraversion
 Agreeableness
 Neuroticism
 DSM-5 Personality Disorders

 Cluster A = Odd or Eccentric

 Paranoid, schizoid and schizotypal personality
disorders
 Cluster B = Dramatic or Erratic
 Antisocial, borderline, histrionic and narcissistic
personality disorders
 Cluster C = Anxious or Fearful
 Avoidant, dependent and obsessive-compulsive
personality disorders
DSM-5 Personality Disorders
 Personality Disorders: Statistics

 Prevalence of personality disorders

 Affects about 6% of the general population
 Origins and course of personality disorders
 Thought to begin in childhood
 Tend to run a chronic course if untreated
 May transition into a different personality
disorder
 Personality Disorders: Statistics

 Gender distribution and gender bias in diagnosis

 Men more often show traits such as aggression
and detachment; women more often show
submission and insecurity
 Antisocial – more often male
 Histrionic – more often female
 Comorbidity is the rule, not the exception
 Often have two or more personality disorders
or an additional mood or anxiety disorder
Gender bias in diagnosing personality
disorders
 Cluster A: Paranoid Personality Disorder

 Overview and clinical features

 Pervasive and unjustified mistrust and suspicion
 Few meaningful relationships, sensitive to
criticism
 Poor quality of life
 Cluster A: Paranoid Personality Disorder

 Causes
 Not well understood
 May involve early learning that people and the
world are dangerous or deceptive
 Cultural factors: More often found in people with
experiences that lead to mistrust of others, e.g.
 Prisoners
 Refugees
 People with hearing impairments
 Older adults
 Cluster A: Paranoid Personality Disorder

 Treatment options
 Few seek professional help on their own
 Treatment focuses on development of trust
 Cognitive therapy to counter negativistic
thinking
 Lack of good outcome studies
 Cluster A: Schizoid Personality Disorder

 Overview and clinical features

 Pervasive pattern of detachment from social
relationships
 Very limited range of emotions in interpersonal
situations
 The causes
 Aetiology is unclear
 Childhood shyness
 Preference for social isolation resembles autism
 Cluster A: Schizoid Personality Disorder

 Causes
 Aetiology is unclear due to scarcity of research
 Childhood shyness is usually present
 Some individuals experienced abuse or neglect
in childhood
 Preference for social isolation resembles autism
 Cluster A: Schizoid Personality Disorder

 Treatment options
 Few seek professional help on their own
 Focus on the value of interpersonal
relationships
 Building empathy and social skills
 Lack of good outcome studies
 Cluster A: Schizotypal Personality Disorder

 Overview and clinical features

 Behaviour and dress is odd and unusual
 Socially isolated and highly suspicious
 Magical thinking, ideas of reference and
illusions
 Many meet criteria for major depression
 Some conceptualise this as resembling a milder
form of schizophrenia
 Cluster A: Schizotypal Personality Disorder

 Causes
 Mild expression of schizophrenia genes?
 May be more likely to develop after childhood
maltreatment or trauma, especially in men
 More generalised brain deficits may be present
(e.g. problems with learning or memory
 Cluster A: Schizotypal Personality Disorder

 Treatment options
 Address comorbid depression
 30–50% meet criteria for major depressive
disorder
 Main focus is on developing social skills
 Medical treatment is similar to that used for
schizophrenia
 Treatment prognosis is generally poor
Grouping Cluster A Disorders
 Cluster B: Antisocial Personality Disorder

 Overview and clinical features

 Failure to comply with social norms
 Violation of the rights of others
 Irresponsible, impulsive and deceitful
 Lack of a conscience, empathy and remorse
 'Sociopathy‘, 'psychopathy' typically refer to this
disorder or very similar traits
 May be very charming, interpersonally
manipulative
Criminality in Antisocial Psychopaths
 Cluster B: Antisocial Personality Disorder

 Often show early histories of behavioural

problems, including conduct disorder
 'Callous-unemotional' type of conduct disorder
more likely to evolve into antisocial PD
 Families with inconsistent parental discipline and
support
 Families often have histories of criminal and
violent behaviour
 Neurobiological Contributions
to Antisocial Personality Disorder

 Prevailing neurobiological theories

 Underarousal hypothesis – cortical arousal is
too low
 Cortical immaturity hypothesis – cerebral cortex
is not fully developed
 Fearlessness hypothesis – fail to respond to
danger cues
 Gray’s model: Inhibition signals are outweighed
by reward signals
 Development of Antisocial Personality
Disorder
 Genetic influences
 More likely to develop antisocial behaviour if
parents have a history of antisocial behaviour
or criminality
 Developmental influences
 High-conflict childhood increases likelihood of
APD in at-risk children
 Impaired fear conditioning
 Children who develop APD may not adequately
learn to fear aversive consequences of negative
actions (e.g. punishment for setting fires)
 Development of Antisocial Personality
Disorder
 Arousal theory
 People with APD are chronically under-aroused
and seek stimulation from the types of activities
that would be too fearful or aversive for most
 Psychological and social influences
 In research studies, psychopaths are less likely
to give up when goal becomes unattainable –
may explain why they persist with behaviour
(e.g. crime) that is punished
 Development of Antisocial Personality
Disorder
 APD is the result of multiple interacting factors
 Mutual biological-environmental influence
 Early antisocial behaviour alienates peers who
would otherwise serve as corrective role
models
 Antisocial behaviour and family stress mutually
increase one another
 Treatment of Antisocial Personality
Disorder
 Few seek treatment on their own
 Antisocial behaviour is predictive of poor
prognosis
 Emphasis is placed on prevention and
rehabilitation
 Often incarceration is the only viable alternative
 May need to focus on practical (or selfish)
consequences (e.g. if you assault someone you’ll
go to prison)
 Cluster B: Borderline Personality Disorder

 Overview and clinical features

 Unstable moods and relationships
 Impulsivity, fear of abandonment, very poor
self-image
 Self-mutilation and suicidal gestures
 Comorbidity rates are high with other mental
disorders, particularly mood disorders
 Cluster B: Borderline Personality Disorder

 Comorbid disorders
 1 in 5 borderline patients is also depressed
 10% of suicide attempts are successful
 40% meet criteria for bipolar disorder
 67% engage in substance abuse
 Eating disorders
 25% of bulimia patients have borderline
personality disorder
 Cluster B: Borderline Personality Disorder

 Causes
 Strong genetic component
 Also linked to depression genetically
 High emotional reactivity may be inherited
 May have impaired functioning of limbic system
 Early trauma/abuse increases risk
 Many BPD patients have high levels of shame
and low self-esteem
 Cluster B: Borderline Personality Disorder

 'Triple vulnerability' model of anxiety applies to

borderline personality too
 Results from the combination of:
 generalised biological vulnerability (reactivity)
 generalised psychological vulnerability (lash out
when threatened)
 specific psychological vulnerability (stressors
that elicit borderline behaviour)
 Cluster B: Borderline Personality Disorder

 Treatment options – few good outcome studies

 Antidepressant medications provide some
short-term relief
 Dialectical behaviour therapy is most promising
treatment
 Focus on dual reality of acceptance of
difficulties and need for change
 Focus on interpersonal effectiveness
 Focus on distress tolerance to decrease
reckless/self-harming behaviour
 Cluster B: Histrionic Personality Disorder

 Overview and clinical features

 Overly dramatic and sensational
 May be sexually provocative
 Often impulsive and need to be the centre of
attention
 Thinking and emotions are perceived as shallow
 More commonly diagnosed in females
 Cluster B: Histrionic Personality Disorder

 Causes
 Aetiology unknown due to lack of research
 Often co-occurs with antisocial PD
 Feminine variant of antisocial traits?
 Treatment options
 Focus on attention-seeking and long-term
negative consequences
 Targets may also include problematic
interpersonal behaviours
 Little evidence that treatment is effective
 Cluster B: Narcissistic Personality Disorder

 Overview and clinical features

 Exaggerated and unreasonable sense of self-
importance
 Preoccupation with receiving attention
 Lack sensitivity and compassion for other
people
 Highly sensitive to criticism, envious, arrogant
 Cluster B: Narcissistic Personality Disorder

 Causes are largely unknown

 Failure to learn empathy as a child
 Sociological view – product of the 'me'
generation
 Treatment options
 Focus on grandiosity, lack of empathy,
unrealistic thinking
 Emphasise realistic goals and coping skills for
dealing with criticism
 Little evidence that treatment is effective
 Cluster C: Avoidant Personality Disorder

 Overview and clinical features

 Extreme sensitivity to the opinions of others
 Highly avoidant of most interpersonal
relationships
 Interpersonally anxious and fearful of rejection
 Low self-esteem
 Cluster C: Avoidant Personality Disorder

 Causes
 May be linked to schizophrenia; occurs more
often in relatives of people with schizophrenia
 Experiences of early rejection
 Treatment
 Similar to treatment for social phobia
 Focus on social skills, entering anxiety-
provoking situations
 Good relationship with therapist is important
 Cluster C: Dependent Personality Disorder

 Overview and clinical features

 Reliance on others to make major and minor
life decisions
 Unreasonable fear of abandonment
 Clingy and submissive in interpersonal
relationships
 Cluster C: Dependent Personality Disorder

 Causes
 Not well understood due to lack of research
 Linked to early disruptions in learning
independence
 Treatment options
 Research on treatment efficacy is lacking
 Therapy typically progresses gradually due to
lack of independence
 Treatment targets include skills that foster
confidence and independence
 Cluster C: Obsessive-Compulsive
Personality Disorder

 Overview and clinical features

 Excessive and rigid fixation on doing things the
‘right’ way
 Highly perfectionistic, orderly and emotionally
shallow
 Unwilling to delegate tasks because others will
do them wrong
 Difficulty with spontaneity
 Often have interpersonal problems
 Obsessions and compulsions are rare
 Cluster C: Obsessive-Compulsive
Personality Disorder

 Causes are not well known

 Weak genetic contribution
 Treatment
 Little data on treatment
 Address fears related to the need for
orderliness
 Target rumination, procrastination and feelings
of inadequacy
 Summary of Personality Disorders

 Long-standing patterns of behaviour

 Begin early in development and run a chronic
course
 Disagreement exists over how to categorise
personality disorders
 Categorical vs dimensional, or some
combination of both
 For most, little is known about causes or
treatment