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PERSONALITY DISORDERS

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Personality
 Characteristics that describe how a person behaves and
thinks
 Disorder occurs when personality:
 Interferes with a person’s relationships
 Causes distress or impairment in daily life activities

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Personality disorders
 Personality disorder:
 A persistent pattern of emotions, cognitions, and behaviors
that results in enduring emotional distress for the person
affected and/or others and may cause difficulties with work
or relationships
 Chronic course
 Stems from childhood and continues on
 Comorbid with depressive, anxiety disorders

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Cluster A Disorders
Paranoid Personality Disorder
Schizoid Personality Disorder
Schizotypal Personality Disorder

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Paranoid Personality Disorder: Criteria

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 ≥4 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.

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Paranoid Personality Disorder: Criteria

5. Persistently bears grudges.
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

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Paranoid Personality Disorder

 Unjustified distrust
 Suspicions unfounded
 Can be argumentative and sensitive to criticism
 Can be short-tempered

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Paranoid Personality Disorder: Etiology

 Biological contribution
 Strong genetic contribution
 Psychological contribution
 Weak contribution
 Early traumatic childhood experiences → distorted schemas that
develop in childhood
 Sociocultural contribution
 Prisoners, refugees, people with hearing impairments more likely to
develop this disorder
 We don’t really know why

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Paranoid Personality Disorder: Treatment

 Unlikely to seek professional help
 Difficulty in developing a trusting relationship with the therapist
 Usually present to clinic following a crisis or for other disorders
 Cognitive therapy
 Change distorted schemas “everyone is untrustworthy”
 No documented effectiveness

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Schizoid Personality Disorder: Criteria

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 ≥4 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.

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Schizoid Personality Disorder: Criteria

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.

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Schizoid Personality Disorder

 “Loner”
 Detached and lack emotional expression
 Do not appear affected by praise or criticism
 “Observers”
 Do not have unusual thought processes

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Schizoid Personality Disorder: Etiology

 Very little empirical research
 Precursors
 Heightened shyness in childhood
 Abuse and neglect in childhood
 Connection with Autism spectrum disorders
 Low dopamine receptors ~ detachment

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Schizoid Personality Disorder: Treatment

 Rarely seek treatment
 Psychotherapy
 Increase value of social relationships
 Social skills training
 No documented effectiveness

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Schizotypal Personality Disorder

 Possibly on a continuum with schizophrenia

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Schizotypal Personality Disorder: Criteria

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 ≥5 of the following:
1. Ideas of reference.
2. Odd beliefs or magical thinking that influences behavior and is
inconsistent with subcultural norms.
3. Unusual perceptual experiences, including bodily illusions.

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Schizotypal Personality Disorder: Criteria

4. Odd thinking and speech.
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.

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Schizotypal Personality Disorder: Etiology

 Biological contribution
 Connection with Schizophrenia
 E.g. Catechol-O-methyltransferase (COMT)
 Brain alterations
 E.g. Temporal lobe
 Odd speech, odd beliefs

Rosell et al., 2014, Current Psychiatry

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Schizotypal Personality Disorder: Treatment

 30-50% of individuals seeking help for other symptoms
 Psychotherapy:
 Social skills training
 Modestly effective
 Medication
 Antipsychotics
 Not always effective
 High drop outs
 Negative side effects
 Huge difficulties with medication compliance

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Cluster B Disorders
Antisocial Personality Disorder
Borderline Personality Disorder
Histrionic Personality Disorder
Narcissistic Personality Disorder

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Antisocial Personality Disorder: Criteria

A. A pervasive pattern of disregard for and violation of the
rights of others, occurring since age 15 years, as indicated by
≥3 of the following:
1. Failure to conform to social norms with respect to lawful behaviors,
as indicated by repeatedly performing acts that are grounds for
arrest.
2. Deceitfulness, as indicated by repeated lying, use of aliases, or
conning others for personal profit or pleasure.
3. Impulsivity or failure to plan ahead.
4. Irritability and aggressiveness, as indicated by repeated physical
fights or assaults.

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Antisocial Personality Disorder: Criteria

5. Reckless disregard for safety of self or others.
6. Consistent irresponsibility, as indicated by repeated failure to
sustain consistent work behavior or honor financial obligations.
7. Lack of remorse, as indicated by being indifferent to or
rationalizing having hurt, mistreated, or stolen from another.
B. The individual is at least age 18 years.
C. There is evidence of conduct disorder with onset before age
15 years.
D. The occurrence of antisocial behavior is not exclusively during
the course of schizophrenia or bipolar disorder.

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Conduct Disorder: Criteria

A. A repetitive and persistent pattern of behavior in which the
basic rights of others or major age-appropriate societal norms
or rules are violated, as manifested by the presence of ≥3 of
the following criteria in the past 12 months from any of the
categories below, with at least one criterion present in the
past 6 months:
Aggression to People and Animals
1. Often bullies, threatens, or intimidates others.
2. Often initiates physical fights.
3. Has used a weapon that can cause serious physical harm to others.
4. Has been physically cruel to people.

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Conduct Disorder: Criteria

5. Has been physically cruel to animals.
6. Has stolen while confronting a victim.
7. Has forced someone into sexual activity.

Destruction of Property
8. Has deliberately engaged in fire setting with the intention of
causing serious damage.
9. Has deliberately destroyed others’ property (other than by fire
setting).

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Conduct Disorder: Criteria

Deceitfulness or Theft
10. Has broken into someone else’s house, building, or car.
11. Often lies to obtain goods or favors or to avoid obligations (i.e.,
“cons” others).
12. Has stolen items of nontrivial value without confronting a victim.
Serious Violations of Rules
13. Often stays out at night despite parental prohibitions, beginning
before age 13 years.
14. Has run away from home overnight at least twice while living in the
parental or parental surrogate home, or once without returning for
a lengthy period.
15. Is often truant from school, beginning before age 13 years.
B.The disturbance in behavior causes clinically significant
impairment in social, academic, or occupational functioning.

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Psychopathy subset
 Psychopathy: subset of individuals with antisocial
personality disorder with the following additional
characteristics
 Glibness, superficial charm
 Grandiose sense of self-worth
 Proneness to boredom, need for stimulation
 Pathological lying
 Conning, manipulative
 Lack of remorse

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Antisocial Personality Disorder: Etiology

 Heightened risk for males
 Genetic influences
 Family, twin, adoption studies support this claim
 ↑ ASPD rate in adopted children of biological mothers with
criminal history
 Gene x environment
 ↑ ASPD rate in adopted children of biological mothers with
criminal history x who spent more time in an orphanage

Rhee & Waldman, 2002; Crowe, 1974, 1995; Roth & Finley, 1998

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Antisocial Personality Disorder: Etiology

 Neurobiological influences
 Underarousal hypothesis
 Low levels of arousal
 Experience negative affect
 Need more stimulation  sensation-seeking and risk-taking

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Antisocial Personality Disorder: Etiology

 Neurobiological influences
 Fearlessness hypothesis
 Higher threshold for experiencing fear
 Inability to learn and respond from negative consequences
 No remorse, no empathy

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Antisocial Personality Disorder: Etiology

 Neuropsychological influences
 BIS-BAS disbalance
 Weak Behavioral Inhibition System vs Overactive Behavioral
Activation System
 ↓ prominent anxiety and ↑ impulsivity

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Antisocial Personality Disorder: Etiology

 Psychological influences
 Do not let go of goals
 Emotionally distant and mistrustful ~ ↑ violent crime
 Social influences
 Parental attitudes early in life (psychodynamic theory)
 Low parental involvement
 Inconsistent discipline
 Stress

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Antisocial Personality Disorder: Treatment

 Few documented treatments
 CBT
 Violent acts reduced 5 years later, except for those who are
particularly “selfish, remorseless”
 Psychotherapy in childhood
 Parent training
 Children less responsive to treatment if high stress and family
dysfunction

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Borderline Personality Disorder: Criteria

A. A pervasive pattern of instability of interpersonal
relationships, self-image, and affects, and marked impulsivity,
beginning by early adulthood and present in a variety of
contexts, as indicated by ≥5 of the following:
1. Frantic efforts to avoid real or imagined abandonment.
2. A pattern of unstable and intense interpersonal relationships
characterized by alternating between extremes of idealization
and devaluation.
3. Identity disturbance: markedly and persistently unstable self-
image.

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Borderline Personality Disorder: Criteria

5. Impulsivity in at least two areas that are potentially self-
damaging.
6. Recurrent suicidal behavior, gestures, or threats, or self-mutilating
behavior.
7. Affective instability due to a marked reactivity of mood.
8. Chronic feelings of emptiness.
9. Inappropriate, intense anger or difficulty controlling anger.
10. Transient, severe dissociative symptoms.

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Borderline Personality Disorder

 More common than other personality disorders
 Worldwide lifetime prevalence: ~2%
 Prognosis better than other personality disorders
 88% remission after 10 years of therapy
 Core: impulsivity, emotional instability
 High comorbidity with mood disorders

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Borderline Personality Disorder: Etiology

 Biological influences
 Support for genetic component
 Possible shared link with mood disorders
 Psychological influences
 Memory bias
 Social influences
 Early trauma (more common in women)

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Borderline Personality Disorder: Treatment

 Few studies on treatment efficacy
 Complicated by comorbidity
 Medication
 Lithium
 Antidepressants
 Antipsychotics
 Dialectical Behavior Therapy (DBT)
 Identify and regulate emotions
 Cope with stressors that trigger suicidal ideation

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Histrionic Personality Disorder: Criteria

A. A pervasive pattern of excessive emotionality and attention
seeking, beginning by early adulthood and present in a
variety of contexts, as indicated by ≥5 of the following:
1. Is uncomfortable in situations in which he or she is not the center of
attention.
2. Interaction with others is often characterized by inappropriate
sexually seductive or provocative behavior.
3. Displays rapidly shifting and shallow expression of emotions.
4. Consistently uses physical appearance to draw attention to self.

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Histrionic Personality Disorder: Criteria

5. Has a style of speech that is excessively impressionistic and
lacking in detail.
6. Shows self-dramatization, theatricality, and exaggerated
expression of emotion.
7. Is suggestible.
8. Considers relationships to be more intimate than they actually
are.

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Histrionic Personality Disorder

 Histrionic = theatrical in manner
 More common in women

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Histrionic Personality Disorder: Etiology

 In the past, uterus used to be blamed
 Sex-typed alternative of antisocial personality disorder?

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Histrionic Personality Disorder: Treatment

 Few studies on treatment efficacy
 Psychotherapy:
 Try to minimize attention-getting behaviors
 Try to improve interpersonal relationships

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Narcissistic Personality Disorder: Criteria

A. A pervasive pattern of grandiosity, need for admiration, and
lack of empathy, beginning by early adulthood and present
in a variety of contexts, as indicated by ≥5 of the following:
1. Has a grandiose sense of self-importance.
2. Is preoccupied with fantasies of unlimited success, power, brilliance,
beauty, or ideal love.
3. Believes that he or she is “special” and unique and can only be
understood by, or should associate with, other special or high-status
people or institutions.

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Narcissistic Personality Disorder: Criteria

4. Requires excessive admiration.
5. Has a sense of entitlement.
6. Is interpersonally exploitative.
7. Lacks empathy: is unwilling to recognize or identify with the
feelings and needs of others.
8. Is often envious of others or believes that others are envious of him
or her.
9. Shows arrogant, haughty behaviors or attitudes.

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Narcissistic Personality Disorder: Etiology

 Psychological influences
 Failure of empathetic mirroring
 Self-centered
 Stemming early in life
 Social influences
 Parenting (overindulgent or over-controlling) attitudes
 Societal pressure on individualism, competitiveness, and
success

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Narcissistic Personality Disorder: Treatment

 Psychotherapy
 Address grandiosity, sensitivity to evaluation, and lack of
empathy
 Remove fantasies
 Treat and prevent depression

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Cluster C Disorders
Avoidant Personality Disorder
Dependent Personality Disorder
Obsessive Compulsive Personality Disorder

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Avoidant Personality Disorder: Criteria

A. A pervasive pattern of social inhibition, feelings of
inadequacy, and hypersensitivity to negative evaluation,
beginning by early adulthood and present in a variety of
contexts, as indicated by ≥4 of the following:
1. Avoids occupational activities that involve significant interpersonal
contact because of fears of criticism, disapproval, or rejection.
2. Is unwilling to get involved with people unless certain of being
liked.
3. Shows restraint within intimate relationships because of the fear of
being shamed or ridiculed.

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Avoidant Personality Disorder: Criteria

4. Is preoccupied with being criticized or rejected in social situations.
5. Is inhibited in new interpersonal situations because of feelings of
inadequacy.
6. Views self as socially inept, personally unappealing, or inferior to
others.
7. Is unusually reluctant to take personal risks or to engage in any new
activities because they may prove embarrassing.

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Avoidant Personality Disorder: Etiology

 Biological influences
 Heritability
 Behavioral inhibition temperament
 Psychological influences
 Behavioral inhibition temperament
 Low self-esteem
 Social influences
 Parenting (rejecting, neglecting, unaffectionate) attitudes →
no attachment

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Avoidant Personality Disorder: Etiology

 Connection with social anxiety disorder?
 Similar characteristics, shared traits

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Avoidant Personality Disorder: Treatment

 Psychotherapy
 Address thoughts of rejection through exposure to feared
situation
 Improve social skills
 Role playing

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Dependent Personality Disorder: Criteria

A. A pervasive and excessive need to be taken care of that leads
to submissive and clinging behavior and fears of separation,
beginning by early adulthood and present in a variety of
contexts, as indicated by ≥5 of the following:
1. Has difficulty making everyday decisions without an excessive
amount of advice and reassurance from others.
2. Needs others to assume responsibility for most major areas of his
or her life.
3. Has difficulty expressing disagreement with others because of fear
of loss of support or approval.

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Dependent Personality Disorder: Criteria

4. Has difficulty initiating projects or doing things on his or her
own.
5. Goes to excessive lengths to obtain nurturance and support
from others, to the point of volunteering to do things that
are unpleasant.
6. Feels uncomfortable or helpless when alone because of
exaggerated fears of being unable to care for himself or
herself.
7. Urgently seeks another relationship as a source of care
and support when a close relationship ends.
8. Is unrealistically preoccupied with fears of being left to
take care of himself or herself.

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Dependent Personality Disorder: Etiology

 Biological influences
 Support for genetic component
 Psychological influences
 Personality trait of sociotropy
 Strong investment in positive social interactions
 Social influences
 Trauma in childhood

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Dependent Personality Disorder: Treatment

 Few studies on treatment efficacy
 Psychotherapy
 Increase independence

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Obsessive-Compulsive Personality Disorder: Criteria

A. A pervasive pattern of preoccupation with orderliness,

perfectionism, and mental and interpersonal control, at the
expense of flexibility, openness, and efficiency, beginning by
early adulthood and present in a variety of contexts, as
indicated by ≥4 of the following:
1. Is preoccupied with details, rules, lists, order, organization, or
schedules to the extent that the major point of the activity is lost.
2. Shows perfectionism that interferes with task completion .
3. Is excessively devoted to work and productivity to the exclusion of
leisure activities and friendships (not accounted by socioeconomic
demands).

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Obsessive-Compulsive Personality Disorder: Criteria

4. Is over-conscientious, scrupulous, and inflexible about matters of

morality, ethics, or values.
5. Is unable to discard worn-out or worthless objects even when
they have no sentimental value.
6. Is reluctant to delegate tasks or to work with others unless they
submit to exactly his or her way of doing things.
7. Adopts a miserly spending style toward both self and others;
money is viewed as something to be hoarded for future
catastrophes.
8. Shows rigidity and stubbornness.

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Obsessive-Compulsive Personality Disorder

 Only slightly related to OCD

 Generally, lacking specific obsessive thoughts and
compulsions

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Obsessive-Compulsive Personality Disorder: Etiology

 More often in men

 Biological influences weak
 Psychological influences
 Perfectionism
 Potential social influences
 Trauma faced during childhood

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Obsessive-Compulsive Personality Disorder: Treatment

 Few studies on treatment efficacy

 Psychotherapy
 Changing maladaptive behaviors into healthier productive
behaviors

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