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· Personality Disorders

Personality disorders are a persistent pattern of emotions, cognitions, and behavior that results in enduring emotional distress for the person affected (APA, 2013). A personality disorder may also cause problems with work and relationships. DSM-5 divides the personality disorders into 3 categories or clusters.

· Cluster A Personality Disorders

Cluster A is comprised of those personality disorders for which the central feature is substantial difficulties with interpersonal functioning. These disorders include paranoid personality disorder, schizoid personality disorder, and schizotypal personality disorder.

Paranoid Personality Disorder

· The central features of paranoid personality disorder include pervasive feelings of mistrust and suspiciousness that significantly interfere with functioning and act to undermine the important relationships in a person's life (Barlow & Durand, 2018; APA, 2013). An important qualifier for these symptoms is that the suspicions are unfounded and not grounded in reality (in other words, the person does not have a real reason to feel paranoid). A clinician diagnosing this disorder must also make sure that the paranoid symptoms are not better understood as being due to paranoid schizophrenia (APA, 2013).

· Another important factor to keep in mind in the context of paranoid personality disorder is the cultural relevance of paranoid feelings. For example, Ridley (1984) points out that feelings of suspiciousness on the part of African Americans toward white clinicians can often be a normal and healthy response to experiences of racism. Ridley refers to this as "cultural paranoia," and warns that psychologists working with African American clients should not confuse cultural paranoia with the more traditional concept of pathological paranoia.

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Schizoid Personality Disorder

· The essential features of schizoid personality disorder are a pervasive pattern of social withdrawal and detachment from others. People who possess this difficulty do not appear to be particularly interested in fostering meaningful connections with others and usually gravitate toward professions and/or activities that entail solitude and limited social contact. These people are likely to be described by others as "loners." They appear to be completely disinterested in forming meaningful attachments and interpersonal connections.

· The interpersonal deficits that characterize schizoid personality disorder can be very similar to those found in cases of high-functioning autism; in fact, autism spectrum is frequently a rule-out diagnosis when considering schizoid personality disorder. It is possible to conceptualize schizoid personality disorder as being at the higher-functioning end of the autistic spectrum. A central difference between schizoid personality disorder and autism is that schizoid personality disorder does not involve cognitive deficits and the interpersonal difficulties seem to be due to a lack of interest rather than any type of organic or developmental impairment (APA, 2013).

Schizotypal Personality Disorder

· The central characteristics of schizotypal personality disorder include a pervasive difficulty maintaining close, satisfying interpersonal relationships that is brought about by significantly eccentric, odd behaviors and cognitive distortions. Here the term, "cognitive distortions," refers to a highly peculiar, semi-delusional outlook on the world. Such distortions can include magical thinking, ideas of reference, and unusual perceptions.

· Magical thinking often involves bizarre, unrealistic ideas about cause and effect. For example, a person may truly believe that, if he wears a blue shirt every Wednesday it will mean that he will not miss his bus. Ideas of reference are similar to "delusions of reference" (as described in the lecture reviewing the psychotic disorders). Ideas of reference usually involve a belief that environmental stimuli are personality directed toward the self. For example, a person experiencing an idea of reference may believe that a television personality is speaking specifically to him, or may feel that his favorite sports team lost a big game as a way of punishing him for something he had done. Unusual perceptions, meanwhile, involves illusion-based perceptions that, while strange, are not significant enough to qualify as a delusion or hallucination. Ideas about clairvoyance or having a "sixth sense" are more common examples of unusual perceptions.

· Additional criteria for the diagnosis of schizotypal personality disorder include an inappropriate or flattened affect, unusual mannerisms or style of dress, suspicious/paranoid feelings, and a lack of close friends and confidants (other than first-degree relatives; APA, 2013). The most important diagnostic determinant in schizotypal personality disorder is that the symptoms do not occur within the context of schizophrenia or another psychotic disorder (APA, 2013). A psychotic disorder is the primary rule-out diagnosis for schizotypal personality disorder. In fact, a significant number of people who are initially diagnosed with schizotypal personality disorder will eventually be identified as suffering from schizophrenia or one of the other psychotic disorders (Green, 2004).

· Epidemiological research on schizotypal personality disorder has found that people identified with this disorder possess a higher-than-average likelihood of having a relative who has been diagnosed with schizophrenia or another psychotic spectrum disorder (Camisa et al., 2005; Bergman et al., 2000). These findings suggest that there is likely a strong genetic loading or determinant to schizotypal personality disorder (Green, 2004; Bergman et al., 2000).

· Cluster B Personality Disorders

The Cluster B personality disorders are comprised of personality syndromes that are based in significant deficits in emotional functioning (Gabbard, 1994). This can range from severe difficulties with emotional regulation (such as in borderline personality disorder) to extreme deficits in the ability to relate to and feel empathy toward others (such as in antisocial personality disorder). The disorders that comprise Cluster B include narcissistic personality disorder, histrionic personality disorder, antisocial personality disorder, and borderline personality disorder.

Narcissistic Personality Disorder

· Narcissus is a character from Greek mythology that fell in love with his own reflection. The psychological term, narcissism, is derived from this myth and refers to seeing the self in a grandiose and overly-positive fashion that is not completely in-tune with reality. As noted earlier, a certain degree of narcissism is often healthy and a necessary component to self-confidence and a positive sense of self-esteem. It is only when narcissistic traits surpass a particular threshold and begins to interfere with adaptive functioning that they become clinically significant and a possible aspect of a personality disorder.

· The central features of narcissistic personality disorder include an exaggerated, often arrogant sense of self-importance and entitlement, as well as a sense of preoccupation with the self that interferes with a person's ability to feel compassion or empathy for others (APA, 2013). A person with a narcissistic personality disorder appears obsessed with his own sense of being special and all of the wonderful things that he is able to do. People identified with this disorder are often quite successful, but when they are not, or when they fail, it is always attributed to being someone else's fault. The narcissist is not as confident and self-assured as he appears to be and this causes him to be especially sensitive to any form of criticism or personal failures, whether these failures be real or imagined (Kernberg, 1974).

Histrionic Personality Disorder

· The central features of histrionic personality disorder include a pathological need to be at the center of attention and constant behaviors that are directed toward ensuring that the person is being watched, admired and talked about (APA, 2013). People with this disorder can be like ambitious stage actors who are always on, always performing.

· People identified with histrionic personality disorder are very uncomfortable when they not receiving adequate attention from others; and they will often dress or behave in a manner that ensures that they will receive lots of attention. This can often include overly sexual behaviors, dressing in a highly provocative way, as well as assuming that relationships with other people are much more intimate and close than they actually are. The internet and the advent of "reality TV" has offered people with significant histrionic traits many new ways of trying to gain constant attention.

· Again, provocative mannerisms and a wish to be the center of attention in and of itself is not necessarily indicative of a personality disorder. It is only when these behaviors become so pervasive that they overwhelm the person's ability to function and maintain healthy relationships that they enter into the realm of psychopathology.

· There is a good deal of overlap between histrionic personality disorder and narcissistic personality disorder. A central difference between the two disorders is that histrionic personality disorder does not entail an inflated sense of personal greatness and accomplishment. Many people with histrionic personality disorder may actually be very self-effacing, and will use their feelings of personal inadequacy as a means of remaining at the center of attention.

· Histrionic personality disorder may also involve exaggerated gender stereotypes. Men with this disorder may act in an overly "macho" way, bragging about their physical prowess and accomplishments. Women with this disorder, meanwhile, may act in an exaggeratedly feminine way, presenting themselves as sexual objects and/or playing up the idea of being "the weaker sex."

Antisocial Personality Disorder

· The primary characteristics of antisocial personality disorder are a severe deficit in the ability to empathize with others and an inability to fully understand how one's actions may affect others (APA, 2013). People with this disorder were previously often referred to as "sociopaths," although this term is no longer used in the professional literature. Antisocial personality disorder is often associated with criminal behavior and a disregard for the rules and regulations of society. People with this disorder are frequently self-centered and will do and take what they want with little or no regard for the law or how their actions will affect others.In extreme, exceptionally rare cases, antisocial personality disorder can lead to the inhuman types of behavior associated with serial killers and mass murderers. The predominating theory regarding these serial killers is that a lack of empathy and connectedness with others ultimately causes the person to feel extremely dissatisfied, frustrated, and disconnected with life. The person may end up turning to extremely cruel, murderous behaviors as an effort to feel something, to feel somehow connected to the world (Black & Larson, 1999).There is an ongoing debate regarding the etiological causes of antisocial personality disorder. Some argue that an antisocial personality is formed, or created by way of early life traumas and circumstances that impair the person's ability to feel compassion and. Others argue that some people are essentially "born bad" and that antisocial traits are derived from genetic deficits and inborn characteristics (Black & Larson, 1999). In all likelihood, the "causes" of this disorder are an intricate combination of these two factors.

Borderline Personality Disorder

· Borderline personality disorder entails a pervasive pattern of instability of interpersonal relationships, self-image, affects, and control over impulses. People with this diagnosis lead tumultuous and chaotic lives — there is a lot of drama here! Because this diagnosis is one of the more common, it will be discussed on its own page later in this module.

· Cluster C Personality Disorders

The Cluster C disorders are made up of those personality disorders for which the central feature is severe difficulties with anxiety. These disorders include avoidant personality disorder, dependent personality disorder, and obsessive-compulsive personality disorder.

Avoidant Personality Disorder

· In many ways, the addition of avoidant personality disorder was a response to the criticism over how schizoid personality was being clinically described. Recall that many psychologists had argued that, although people with schizoid personality disorder tend to avoid social contact, many secretly wish to form meaningful attachments with others but do not do so due to overwhelming feelings of anxiety and a fear of rejection (Gabbard, 1994).

· Keeping this in mind, avoidant personality disorder can be viewed as involving a lack of close relationship where the person very much wants to connect with others. In other words, schizoid personality disorder entails a lack of interpersonal contact that is ego syntonic (or does not cause conscious feelings of psychic pain or sadness), while avoidant personality disorder involves a lack of interpersonal contact that is ego dystonic (or does cause a great deal of psychic pain; Akhtar, 1986).

· Avoidant personality disorder has a great deal in common with social anxiety disorder. Social anxiety disorder is an anxiety disorder for which the central features are persisting feelings of worry and discomfort in social settings (APA, 2013). Avoidant personality disorder can be seen as an extreme, personality-oriented, version of social anxiety disorder — a version where the worries have become so pervasive that they are an essential component of the individual's overall personality.

Obsessive-Compulsive Personality Disorder

· The final cluster C personality disorder, obsessive-compulsive personality disorder, can be a difficult diagnosis to figure out. Its name makes it seem as though it is a personality disorder based in the symptoms associated with obsessive-compulsive disorder (OCD). This is actually not the case. Whereas people suffering from obsessive-compulsive disorder often debilitating difficulties with intrusive thoughts and compulsive urges, people identified as possessing an obsessive-compulsive personality disorder are not especially troubled by such intrusive thoughts compulsive urges. Instead, these individuals are particularly focused and extremely fastidious — to an extent that the need for perfection interferes with adaptive functioning. The "obsessive-compulsive" part refers to an obsession with perfection and a compulsive attention to detail.

· Many people identified as possessing obsessive-compulsive personality disorder are extremely well suited for work that requires a greater degree of attention to detail. These people are often successful in professions such as architect and lawyer. At the same time that the need for perfection can be a benefit in these jobs, it can also be a huge, sometimes insurmountable, obstacle. Perfection is not always attainable. A person with obsessive-compulsive personality disorder can work on something, such as a legal brief or document, and never be able to finish it. He will review it and re-review it again and again, constantly editing and re-editing, trying to obtain an unattainable level of perfection.

· A good artist knows how to start a painting, but it takes a great artist to know when it is finished. This is a quality that very often remains outside of the grasp of a person who suffers from obsessive-compulsive personality disorder. Treatment strategies for people with this disorder frequently focus on the difficult task of living with imperfection.

Dependent Personality Disorder

· The central features of dependent personality disorder include a pervasive and all-consuming need to be taken care of and deeply involved in close relationships (APA, 2013). Once again, a need to be closely connected with others on its own is not necessarily indicative of pathology. Rather, it is when this need become so pervasive and consuming that it significantly interferes with adaptive functioning that it starts to meet the criteria for a personality disorder.

· In dependent personality disorder, the need for close connection and the fear of losing such connections frequently leads the person to take on a submissive and overly clingy role in relationships. At times, this can lead a person to become so dependent that she relies on her partner to tell her what clothes to wear, decide what television shows or types of music she likes, or even how she should feel about current events. The connection becomes so dependent that the person comes to feel that he cannot exist, or is somehow incomplete, outside of the relationship.

· Many of these dependent relationships are romantic in nature. Others, however, can be based around family ties. Some people with dependent personality disorder may be overly dependent on their parents, continue to live at home as adults, and maintain the type of utter dependency that is usually associated with early childhood. Keep in mind, however, that it is important to attend to cultural factors when assessing the possibility of psychopathology in a dependent relationship. Independence and greater autonomy are viewed as important traits in mainstream American culture, but are less important to other cultures. For instance, an adult son or daughter continuing to live with his or her parents is often much more common and acceptable within Asian and Latin American cultural contexts (Paniagua, 1994).

· The symptoms of dependent personality disorder are often experienced as ego syntonic — that is, they frequently do not cause conscious feelings of pain and anxiety. It is when there is a risk of the person losing the relationship (or has lost the relationship) that he or she experiences overt feelings of distress.

· References

5. Akhtar, S. (1987). Schizoid Personality Disorder: A Synthesis of Developmental, dynamic and Descriptive Features. American Journal of Psychotherapy, Vol. 61, pp. 499-518.

5. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing, Inc.

5. Barlow, D.H., & Durand, V.M. (2018). Abnormal Psychology: An Integrated Approach (8th ed.). Belmont, CA: Wadsworth Cengage Learning.

5. Bergman, A.J., Silverman, J.M., Harvey, P.D., Smith, C.J., & Siever, L.J., (2000). Schizotypal Symptoms in the Relatives of Schizophrenic Patents: An Empirical Analysis of the Factor Structure. Schizophrenia Bulletin, Vol. 26(3), pp. 577-586.

5. Black, D.W., & Larson, C.L., (1999). Bad Boys, Bad Men: Confronting Antisocial Personality Disorder. London: Oxford University Press.

5. Camisa, K., Bockbrader, M., Lysker, P., Rea, L., Brenner C., & O'Donnell, B. (2005). Personality Traits in Schizophrenia and Related Personality Disorders. Psychiatric Research, Vol. 133(1), pp. 23-33.

5. Gabbard, G.O. (1994). Psychodynamic Psychiatry in Clinical Practice: The DSM-IV Edition. Washington, DC: American Psychiatric Press.

5. Green, P. (2004). Schizophrenia Revealed: From Neurons to Social Interactions. New York: WW Norton and Co. Press Hashimoto, T., Tayama, M., Murakawa, K., et al., (2005). Development of the Brainstem and Cerebellum in Autistic patients. Journal of Autism and Developmental Disorders, Vol. 25(1), pp. 1-18.

5. Kernberg, O.T. (1984). Severe Personality Disorders: Psychotherapeutic Strategies. New Haven, CT: Yale University Press.

5. Paniagua, F.A. (1994). Assessing and Treating Culturally Diverse Clients: A Practical Guide. Thousand Oaks, CA: Sage.

5. Ridley, C.R. (1984). Clinical Treatment of The Non-Disclosing Black Client. American Psychologist, Vol. 39(11), pp. 1234-1244.

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