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12.3: Personality Disorders

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    Learning Objectives
    • Define personality disorders and distinguish between the three clusters of personality disordersObjective 1

    The term personality refers loosely to one’s stable, consistent, and distinctive way of thinking about, feeling, acting, and relating to the world. People with personality disorders exhibit a personality style that differs markedly from the expectations of their culture, is pervasive and inflexible, begins in adolescence or early adulthood, and causes distress or impairment (APA, 2013). Generally, individuals with these disorders exhibit enduring personality styles that are extremely troubling and often create problems for them and those with whom they come into contact. Individual maladaptive personality styles frequently bring them into conflict with others, disrupt their ability to develop and maintain social relationships, and prevent them from accomplishing realistic life goals.

    Understanding Personality

    There are literally hundreds of different personality traits. All of these traits can be organized into the broad dimensions referred to as the Five-Factor Model (John, Naumann, & Soto, 2008). These five broad domains are inclusive; there does not appear to be any traits of personality that lie outside of the Five-Factor Model. This model even applies to traits that you may use to describe yourself. Table 1 provides illustrative traits for both poles of the five domains of this model of personality (you can remember them using the acronym OCEAN). A number of the traits that you see in this table may describe you. If you can think of some other traits that describe yourself, you should be able to place them somewhere in this table.

    Table 1. Personality traits in the five-factor model.
    Openness: dreamer, unrealistic, imaginative, aberrant, aesthetic, self-aware, eccentric, strange, odd, peculiar, creative, permissive, broad-minded OR Closedness: practical, concrete, uninvolved, no aesthetic interest, constricted, unaware, alexyhymic, routine, predictable, habitual, stubborn, pragmatic, rigid, traditional, inflexible, dogmatic
    Conscientiousness: perfectionistic, efficient, ordered, methodical, organized, rigid, reliable, dependable, workaholic, ambitious, dogged, devoted, cautious, ruminative, reflective OR Disinhibition: lax, negligent, haphazard, disorganized, sloppy, casual, undependable, unethical, aimless, desultory, hedonistic, negligent, hasty, careless, rash
    Extraversion: cordial, affectionate, attached, sociable, outgoing, dominant, forceful, vigorous, energetic, active, reckless, daring, high-spirited, excitement-seeking OR Introversion: cold, aloof, indifferent, withdrawn, isolated, unassuming, quiet, resigned, passive, lethargic, cautious, monotonous, dull, placid, anhedonic
    Agreeableness: gullible, naïve, trusting, confiding, honest, sacrificial, giving, docile, cooperative, meek, self-effacing, humble, soft, empathetic OR Antagonism: skeptical, cynical, suspicious, paranoid, cunning, manipulative, deceptive, stingy, selfish, greedy, exploitative, oppositional, combative, aggressive, confident, boastful, arrogant, tough, callous, ruthless
    Neuroticism (emotional instability): fearful, apprehensive, angry, bitter, pessimistic, glum, timid, embarrassed, tempted, urgency, helpless, fragile OR Emotional Stability: relaxed, unconcerned, cool, even-tempered, optimistic, self-assured, glib, shameless, controlled, restrained, clear-thinking, fearless, unflappable

    Classifying Personality Disorders

    The DSM-5 defines personality disorders as “an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment.” The consideration of cultural context is perhaps the most significant change in this definition from earlier editions. The DSM-5 suggests that the personality disorders can be grouped into three clusters, plus a “not otherwise specified” category, for a total of 11 specific diagnoses, the authors caution that the identified clusters have not been consistently validated and that individuals may present combinations of personality disorders from different clusters. Cluster A, the odd or eccentric types, are paranoid, schizoid, and schizotypal personality disorders. Cluster B, the dramatic, emotional, or erratic types, are antisocial, borderline, histrionic, and narcissistic personality disorders. And finally, Cluster C, the anxious or fearful types, are the avoidant, dependent, and obsessive-compulsive personality disorders.

    The table provides a description of each of the DSM-5 personality disorders:

    Table 1. DSM-5 Personality Disorders
    DSM-5 Personality Disorder Description Cluster
    Paranoid harbors a pervasive and unjustifiable suspiciousness and mistrust of others; reluctant to confide in or become close to others; reads hidden demeaning or threatening meaning into benign remarks or events; takes offense easily and bears grudges; not due to schizophrenia or other psychotic disorders A
    Schizoid lacks interest and desire to form relationships with others; aloof and shows emotional coldness and detachment; indifferent to approval or criticism of others; lacks close friends or confidants; not due to schizophrenia or other psychotic disorders, not an autism spectrum disorder A
    Schizotypal exhibits eccentricities in thought, perception, emotion, speech, and behavior; shows suspiciousness or paranoia; has unusual perceptual experiences; speech is often idiosyncratic; displays inappropriate emotions; lacks friends or confidants; not due to schizophrenia or other psychotic disorder, or to autism spectrum disorder A
    Antisocial continuously violates the rights of others; history of antisocial tendencies prior to age 15; often lies, fights, and has problems with the law; impulsive and fails to think ahead; can be deceitful and manipulative in order to gain profit or pleasure; irresponsible and often fails to hold down a job or pay financial debts; lacks feelings for others and remorse over misdeeds B
    Histrionic excessively overdramatic, emotional, and theatrical; feels uncomfortable when not the center of others’ attention; behavior is often inappropriately seductive or provocative; speech is highly emotional but often vague and diffuse; emotions are shallow and often shift rapidly; may alienate friends with demands for constant attention B
    Narcissistic overinflated and unjustified sense of self-importance and preoccupied with fantasies of success; believes self is entitled to special treatment from others; shows arrogant attitudes and behaviors; takes advantage of others; lacks empathy B
    Borderline unstable in self-image, mood, and behavior; cannot tolerate being alone and experiences chronic feelings of emptiness; unstable and intense relationships with others; behavior is impulsive, unpredictable, and sometimes self-damaging; shows inappropriate and intense anger; makes suicidal gestures B
    Avoidant socially inhibited and oversensitive to negative evaluation; avoids occupations that involve interpersonal contact because of fears of criticism or rejection; avoids relationships with others unless guaranteed to be accepted unconditionally; feels inadequate and views self as socially inept and unappealing; unwilling to take risks or engage in new activities if they may prove embarrassing C
    Dependent allows others to take over and run his or her life; is submissive, clingy, and fears separation; cannot make decisions without advice and reassurance from others; lacks self-confidence; cannot do things on his or her own; feels uncomfortable or helpless when alone C
    Obsessive-Compulsive pervasive need for perfectionism that interferes with the ability to complete tasks; preoccupied with details, rules, order, and schedules; excessively devoted to work at the expense of leisure and friendships; rigid, inflexible, and stubborn; insists things be done his or her way; miserly with money C

    This list of 10 though does not fully cover all the different ways in which a personality can be maladaptive. DSM-5 also includes a “wastebasket” diagnosis of other specified personality disorder (OSPD) and unspecified personality disorder (UPD). This diagnosis is used when a clinician believes that a patient has a personality disorder but the traits that constitute this disorder are not well covered by one of the 10 existing diagnoses. OSPD and UPD, or as they used to be referred to in previous editions PDNOS (personality disorder not otherwise specified), are often one of the most frequently used diagnoses in clinical practice, suggesting that the current list of 10 is not adequately comprehensive (Widiger & Trull, 2007).

    Slightly over 9% of the U.S. population suffers from a personality disorder, with avoidant and schizoid personality disorders the most frequent (Lezenweger, Lane, Loranger, & Kessler, 2007). Two of these personality disorders, borderline personality disorder and antisocial personality disorder, are regarded by many as especially problematic.

    Watch It

    Watch the following CrashCourse psychology video for an overview of personality disorders:

    You can view the transcript for “Personality Disorders: Crash Course Psychology #34” here (opens in new window).

    Try It

    Description

    Each of the 10 DSM-5 (and DSM-IV-TR) personality disorders is a constellation of maladaptive personality traits, rather than just one particular personality trait (Lynam & Widiger, 2001). In this regard, personality disorders are syndromes. For example, avoidant personality disorder is a pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation (APA, 2013), which is a combination of traits from introversion (e.g., socially withdrawn, passive, and cautious) and neuroticism (e.g., self-consciousness, apprehensiveness, anxiousness, and worrisome). Dependent personality disorder includes submissiveness, clinging behavior, and fears of separation (APA, 2013), for the most part a combination of traits of neuroticism (anxious, uncertain, pessimistic, and helpless) and maladaptive agreeableness (e.g., gullible, guileless, meek, subservient, and self-effacing). Antisocial personality disorder is, for the most part, a combination of traits from antagonism (e.g., dishonest, manipulative, exploitative, callous, and merciless) and low conscientiousness (e.g., irresponsible, immoral, lax, hedonistic, and rash). See the 1967 movie Bonnie and Clyde, starring Warren Beatty, for a nice portrayal of someone with antisocial personality disorder.

    An illustration depicting 5 different figures and their personalities.

    Some of the DSM-5 personality disorders are confined largely to traits within one of the basic domains of personality. For example, obsessive-compulsive personality disorder is largely a disorder of maladaptive conscientiousness, including such traits as workaholism, perfectionism, punctilious, ruminative, and dogged; schizoid is confined largely to traits of introversion (e.g., withdrawn, cold, isolated, placid, and anhedonic); borderline personality disorder is largely a disorder of neuroticism, including such traits as emotionally unstable, vulnerable, overwhelmed, rageful, depressive, and self-destructive (watch the 1987 movie Fatal Attraction, starring Glenn Close, for a nice portrayal of this personality disorder); and histrionic personality disorder is largely a disorder of maladaptive extraversion, including such traits as attention-seeking, seductiveness, melodramatic emotionality, and strong attachment needs (see the 1951 film adaptation of Tennessee William’s play Streetcar Named Desire, starring Vivian Leigh, for a nice portrayal of this personality disorder).

    It should be noted though that a complete description of each DSM-5 personality disorder would typically include at least some traits from other domains. For example, antisocial personality disorder (or psychopathy) also includes some traits from low neuroticism (e.g., fearlessness and glib charm) and extraversion (e.g., excitement-seeking and assertiveness); borderline includes some traits from antagonism (e.g., manipulative and oppositional) and low conscientiousness (e.g., rash); and histrionic includes some traits from antagonism (e.g., vanity) and low conscientiousness (e.g., impressionistic). Narcissistic personality disorder includes traits from neuroticism (e.g., reactive anger, reactive shame, and need for admiration), extraversion (e.g., exhibitionism and authoritativeness), antagonism (e.g., arrogance, entitlement, and lack of empathy), and conscientiousness (e.g., acclaim-seeking). Schizotypal personality disorder includes traits from neuroticism (e.g., social anxiousness and social discomfort), introversion (e.g., social withdrawal), unconventionality (e.g., odd, eccentric, peculiar, and aberrant ideas), and antagonism (e.g., suspiciousness).

    The APA currently conceptualizes personality disorders as qualitatively distinct conditions distinct from each other and from normal personality functioning. However, included within an appendix to DSM-5 is an alternative view that personality disorders are simply extreme and/or maladaptive variants of normal personality traits, as suggested herein. Nevertheless, many leading personality disorder researchers do not hold this view (e.g., Gunderson, 2010; Hopwood, 2011; Shedler et al., 2010). Researchers suggest that there is something qualitatively unique about persons suffering from a personality disorder, usually understood as a form of pathology in sense of self and interpersonal relatedness that is considered to be distinct from personality traits (APA, 2012; Skodol, 2012). For example, it has been suggested that antisocial personality disorder includes impairments in identity (e.g., egocentrism), self-direction, empathy, and capacity for intimacy, which are said to be different from such traits as arrogance, impulsivity, and callousness (APA, 2012).

    Validity of Personality Disorders

    In future revisions of the DSM, some of the personality disorders included in DSM-5 and DSM-4-TR will no longer be included. In fact, for DSM-5 it was originally proposed that four be deleted. The personality disorders that were slated for deletion were histrionic, schizoid, paranoid, and dependent (APA, 2012). The rationale for the proposed deletions was in large part because they are said to have less empirical support than the diagnoses that were at the time being retained (Skodol, 2012). There is agreement within the field with regard to the empirical support for the borderline, antisocial, and schizotypal personality disorders (Mullins-Sweat, Bernstein, & Widiger, 2012; Skodol, 2012). However, there is a difference of opinion with respect to the empirical support for the dependent personality disorder (Bornstein, 2012; Livesley, 2011; Miller, Widiger, & Campbell, 2010; Mullins-Sweat et al., 2012).

    Glossary

    antisocial personality disorder: a pervasive pattern of disregard and violation of the rights of others; behaviors may be aggressive or destructive and may involve breaking laws or rules, deceit, or theft
    avoidant personality disorder: pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation

    borderline personality disorder: a pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity

    dependent personality disorder: a pervasive and excessive need to be taken care of leading to submissive and clinging behavior and fears of separation

    five-factor model: five broad domains or dimensions used to describe human personality
    histrionic personality disorder: a pervasive pattern of excessive emotionality and attention-seeking

    narcissistic personality disorder: a pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy

    paranoid personality disorder: a pervasive distrust and suspiciousness of others such that their motives are interpreted as malevolent

    personality: characteristic, routine ways of thinking, feeling, and relating to others

    personality disorders: when personality traits result in significant distress, social impairment, and/or occupational impairment

    schizoid personality disorder: a pervasive pattern of detachment from social relationships and a restricted range of expression of emotions in interpersonal settings

    schizotypal personality disorder: a pervasive pattern of social and interpersonal deficits marked by acute discomfort with, and reduced capacity for, close relationships as well as perceptual distortions and eccentricities of behavior

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