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 ).
· ● 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 describi