Learning Objectives
- Define personality trait.
- Define personality disorder.
- List the defining features of personality disorders.
- Describe the three clusters.
- Describe how paranoid personality disorder presents.
- Describe how schizoid personality disorder presents.
- Describe how schizotypal personality disorder presents.
- Describe how antisocial personality disorder presents.
- Describe how borderline personality disorder presents.
- Describe how histrionic personality disorder presents.
- Describe how narcissistic personality disorder presents.
- Describe how avoidant personality disorder presents.
- Describe how dependent personality disorder presents.
- Describe how obsessive-compulsive personality disorder presents.
Overview of Personality Disorders
According to the DSM-5-TR, personality traits are “…enduring patterns of perceiving, relating to, and thinking about the environment and oneself that are exhibited in a wide range of social and personality contexts while a personality disorder “…is an enduring pattern of inner experience and behavior that deviates markedly from the norms and expectations of the individual’s culture, is pervasive and inflexible, and has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment” (APA, 2022, pg. 733). Personality disorders have four defining features, which include distorted thinking patterns, problematic emotional responses, over- or under-regulated impulse control, and interpersonal difficulties. While these four core features are universal among all ten personality disorders, the DSM-5-TR divides the personality disorders into three different clusters based on symptom similarities.
Cluster A is described as the odd or eccentric cluster and consists of paranoid, schizoid, and schizotypal personality disorders. The common feature between these three disorders is social awkwardness and social withdrawal. Often these behaviors are similar to those seen in schizophrenia; however, they tend to be not as extensive or impactful on daily functioning as seen in schizophrenia. In fact, there is a strong relationship between Cluster A personality disorders among individuals who have a relative diagnosed with schizophrenia (Chemerinksi & Siever, 2011).
Cluster B is the dramatic, emotional, or erratic cluster and consists of antisocial, borderline, histrionic, and narcissistic personality disorders. Individuals with these personality disorders often experience problems with impulse control and emotional regulation. Due to the dramatic, emotional, and erratic nature of these disorders, it is nearly impossible for individuals to establish healthy relationships with others.
And finally, Cluster C is the anxious or fearful cluster and consists of avoidant, dependent, and obsessive-compulsive personality disorders. As you read through the descriptions of the disorders, you will see an overlap with symptoms from the anxiety and depressive disorders. Cluster C disorders have the most treatment options of all the personality disorders, likely because the overlapping anxiety and depressive disorders have well-established treatment options.
To meet the criteria for any personality disorder, the individual must display the pattern of behaviors in adulthood. Children cannot be diagnosed with a personality disorder. Some children may present with similar symptoms, such as poor peer relationships, odd or eccentric behaviors, or peculiar thoughts and language; however, a formal personality disorder diagnosis cannot be made until the age of 18. The DSM-5-TR reports that median prevalence across several countries is 3.6% for Cluster A disorders, 4.5% for Cluster B, 2.8% for Cluster C, and 10.5% for any personality disorder.
It is also noted that the clustering approach used in the DSM has not been consistently validated and has some serious limitations. As written, “An alternative to the categorical approach is the dimensional perspective that personality disorders represent maladaptive variants of personality traits that merge imperceptibly into normality and into one another” (APA, 2022, pg. 734). Interested readers should consult Section III of the DSM (beginning on page 881) for a full description of the dimensional model for personality disorders and an alternative model for personality disorders that utilizes a hybrid dimensional-categorical model approach.
Cluster A
13.1.2.1. Paranoid personality disorder. Paranoid personality disorder is characterized by a marked distrust or suspicion of others. Individuals interpret and believe that other’s motives and interactions are intended to harm them, and therefore, they are skeptical about establishing close relationships outside of family members—although, at times, even family members’ actions are also believed to be malevolent (APA, 2022). Individuals with paranoid personality disorder often feel as though they have been deeply and irreversibly hurt by others even though they lack evidence to support that these others intended to or did hurt them. Because of these persistent suspicions, they will doubt relationships that show true loyalty or trustworthiness. Compliments are misinterpreted and they may view an offer of help as a criticism that they are not doing a good enough job on their own.
Individuals with paranoid personality disorder are also hesitant to share any personal information or confide in others as they fear the information will be used against them. Additionally, benign remarks or events are often viewed as demeaning or threatening. For example, if an individual with paranoid personality disorder was accidentally bumped into at the store, they would interpret this action as intentional, with the purpose of causing them injury. Because of this, individuals with paranoid personality disorder are quick to hold grudges and unwilling to forgive insults or injuries- whether intentional or not. They are known to quickly and angrily counterattack, either verbally or physically, in situations where they feel they were insulted (APA, 2022).
13.1.2.2. Schizoid personality disorder. Individuals with schizoid personality disorder display a persistent pattern of avoidance of social relationships, along with a limited range of emotional expression in interpersonal settings (APA, 2022). Similar to those with paranoid personality disorder, individuals with schizoid personality disorder do not have many close relationships; however, unlike paranoid personality disorder, this lack of connection is not due to suspicious feelings, but rather, the lack of desire to engage with others and the preference to engage in solitary behaviors. Individuals with schizoid personality disorder are often viewed as “loners” and prefer activities where they do not have to engage with others (APA, 2022). Established relationships rarely extend outside that of the family as they make no effort to start or maintain friendships. This lack of establishing social relationships also extends to sexual behaviors, as these individuals report a lack of interest in engaging in sexual experiences with others.
Regarding the limited range of emotion, individuals with schizoid personality disorder are often indifferent to criticisms or praises of others and appear not to be affected by what others think of them. Individuals will rarely show any feelings or expressions of emotion and are often described as having a “bland” exterior (APA, 2022). In fact, individuals with schizoid personality disorder rarely reciprocate facial expressions or gestures typically displayed in normal conversations such as smiles or nods. Because of this lack of emotion, there is a limited need for attention or acceptance.
13.1.2.3. Schizotypal personality disorder. Schizotypal personality disorder is characterized by a range of impairment in social and interpersonal relationships due to discomfort in relationships, along with odd cognitive or perceptual distortions and eccentric behaviors (APA, 2022). Similar to those with schizoid personality disorder, individuals also seek isolation and have few, if any established relationships outside of family members.
One of the most prominent features of schizotypal personality disorder is ideas of reference, or the belief that unrelated events pertain to them in a particular and unusual way. Ideas of reference also lead to superstitious behaviors or preoccupation with paranormal activities that are not generally accepted in their culture (APA, 2022). The perception of special or magical powers, such as the ability to mind-read or control other’s thoughts, has also been documented in individuals with schizotypal personality disorder. Similar to schizophrenia, unusual perceptual experiences such as auditory hallucinations, as well as unusual speech patterns of derailment or incoherence, are also present.
Like the other personality disorders within cluster A, there is a component of paranoia or suspiciousness of other’s motives. Additionally, individuals with schizotypal personality disorder display inappropriate or restricted affect, thus impacting their ability to appropriately interact with others in a social context. Significant social anxiety is often also present in social situations, particularly in those involving unfamiliar people. The combination of limited affect and social anxiety contributes to their inability to establish and maintain personal relationships; most individuals with schizotypal personality disorder prefer to keep to themselves to reduce this anxiety.
Cluster B
13.1.3.1. Antisocial personality disorder. The essential feature of antisocial personality disorder is the persistent pattern of disregard for, and violation of, the rights of others. This pattern of behavior begins in late childhood or early adolescence and continues throughout adulthood. While this behavior presents before age 15, the individual cannot be diagnosed with antisocial personality disorder until the age of 18. Prior to age 18, the individual would be diagnosed with conduct disorder. Although not discussed in this book as it is a disorder of childhood, conduct disorder involves a repetitive and persistent pattern of behaviors that violate the rights of others or major age-appropriate norms. Common behaviors of individuals with conduct disorder that go on to develop antisocial personality disorder are aggression toward people or animals, destruction of property, deceitfulness or theft, or serious violation of rules (APA, 2022).
While commonly referred to as “psychopaths” or “sociopaths,” individuals with antisocial personality disorder fail to conform to social norms. This also includes legal rules as individuals with antisocial personality disorder are often repeatedly arrested for property destruction, harassing/assaulting others, or stealing (APA, 2022). Deceitfulness is another hallmark symptom of antisocial personality disorder as individuals often lie repeatedly, generally to gain profit or pleasure. There is also a pattern of impulsivity—decisions made in the moment without forethought of personal consequences or consideration for others (Lang et al., 2015). This impulsivity also contributes to their inability to hold jobs as they are more likely to impulsively quit their jobs (Hengartner et al., 2014). Employment instability, along with impulsivity, also impacts their ability to manage finances; it is not uncommon to see individuals with antisocial personality disorder with large debts that they are unable to pay (Derefinko & Widiger, 2016).
While also likely related to impulsivity, individuals with antisocial personality disorder tend to be extremely irritable and aggressive, repeatedly getting into fights. The marked disregard for their safety, as well as the safety of others, is also observed in reckless behavior such as speeding, driving under the influence, and engaging in sexual and substance abuse behavior that may put themselves at risk (APA, 2022).
Of course, the most known and devastating symptom of antisocial personality disorder is the lack of remorse for the consequences of their actions, regardless of how severe they may be. Individuals often rationalize their actions as the fault of the victim, minimize the harmfulness of the consequences of their behaviors, or display indifference (APA, 2022). Overall, individuals with antisocial personality disorder have limited personal relationships due to their selfish desire and lack of moral conscience.
13.1.3.2. Borderline personality disorder. Individuals with borderline personality disorder display a pervasive pattern of instability in interpersonal relationships, self-image, and affect (APA, 2022). The combination of these symptoms causes significant impairment in establishing and maintaining personal relationships. They will often go to great lengths to avoid real or imagined abandonment. Fears related to abandonment can lead to inappropriate anger as they often interpret the abandonment as a reflection of their own behavior. It is not uncommon to experience intense fluctuations in mood, often observed as volatile interactions with family and friends (Herpertz & Bertsch, 2014). Those with borderline personality disorder may be friendly one day and hostile the next.
To prevent abandonment, individuals with borderline personality disorder will often exhibit impulsive behaviors such as self-harm and suicidal behavior. In fact, individuals with borderline personality disorder engage in more suicide attempts, and completion of suicide is higher among these individuals than the general public (Linehan et al., 2015). Other impulsive behaviors, such as non-suicidal self-injury (cutting) and sexual promiscuity, are frequently seen within this population, typically occurring during high-stress periods (Sansone & Sansone, 2012). They often have chronic feelings of emptiness along with painful feelings of aloneness. Occasionally, hallucinations and delusions are present, particularly of a paranoid nature; however, these symptoms are often transient and recognized as unacceptable by the individual (Sieswerda & Arntz, 2007).
13.1.3.3. Histrionic personality disorder. Histrionic personality disorder is the first personality disorder that addresses pervasive and excessive emotionality and attention-seeking. These individuals are usually uncomfortable in social settings unless they are the center of attention. To help gain attention, the individual is often vivacious and dramatic, using physical gestures and mannerisms along with grandiose language. These behaviors are initially very charming to their audience; however, they begin to wear due to the constant need for attention to be on them. If the theatrical nature does not gain the attention they desire, they may go to great lengths to draw attention, such as using a fictitious story or creating a dramatic scene.
To ensure they gain the attention they desire, individuals with histrionic personality disorder frequently dress and engage in sexually seductive or provocative ways. These sexually charged behaviors are not only directed at those in which they have a sexual or romantic interest but to the general public as well (APA, 2022). They often spend a significant amount of time on their physical appearance to gain the attention they desire.
Individuals with histrionic personality disorder are easily suggestible. Their opinions and feelings are influenced by not only their friends but also by current fads (APA, 2022). They also tend to exaggerate relationships, considering casual acquaintanceships as more intimate than they are.
13.1.3.4. Narcissistic personality disorder. Like histrionic personality disorder, narcissistic personality disorder also centers around the individual; however, with narcissistic personality disorder, individuals display a pattern of grandiosity along with a lack of empathy for others (APA, 2022). The grandiose sense of self leads to an overvaluation of their abilities and accomplishments. They often come across as boastful and pretentious, repeatedly proclaiming their superior achievements. These proclamations may also be fantasized to enhance their success or power. Oftentimes they identify themselves as “special” and will only interact with others of high status.
Given the grandiose sense of self, it is not surprising that individuals with narcissistic personality disorder need excessive admiration from others. While it appears that their self-esteem is hugely inflated, it is very fragile and dependent on how others perceive them (APA, 2022). Because of this, they may constantly seek out compliments and expect favorable treatment from others. When this sense of entitlement is not upheld, they can become irritated or angry that their needs are not met.
A lack of empathy is also displayed in individuals with narcissistic personality disorder as they often struggle to (or choose not to) recognize the desires or needs of others. This lack of empathy also leads to exploitation of interpersonal relationships, as they are unable to understand other’s feelings (Marcoux et al., 2014). They often become envious of others who achieve greater success or possessions than them. Conversely, they believe everyone should be envious of their achievements, regardless of how small they may be.
Cluster C
13.1.4.1. Avoidant personality disorder. Individuals with avoidant personality disorder display a pervasive pattern of social inhibition due to feelings of inadequacy and increased sensitivity to negative evaluations (APA, 2022). The fear of being rejected drives their reluctance to engage in social situations so that they may prevent others from evaluating them negatively. This fear extends so far that it prevents individuals from maintaining employment due to their intense fear of negative evaluation or rejection.
Socially, they have very few if any friends, despite their desire to establish social relationships. They actively avoid social situations in which they can develop new friendships out of the fear of being disliked or ridiculed. Similarly, they are cautious of new activities or relationships as they often exaggerate the potential negative consequences and embarrassment that may occur; this is likely a result of their ongoing preoccupation with being criticized or rejected by others. Within intimate relationships, their fear of being shamed or ridiculed leads to restraint, and they view themselves as socially inept (APA, 2022).
Making Sense of the Disorders
As you read the clinical description of avoidant personality disorder, did you think it sounded a lot like social anxiety disorder? You likely did as there is a great deal of overlap between the two disorders. So, how do they differ if they are to be regarded as separate diagnostic categories in the DSM? This difference is linked to self-concept. How so?
- In social anxiety disorder the negative self-concept is unstable and less pervasive and entrenched.
- In avoidant personality disorder, the negative self-concept is more stable as an enduring and pervasive pattern, typical of personality traits.
Additionally, avoidant personality disorder frequently occurs in the absence of social anxiety disorder and some separate risk factors have been identified for the two.
13.1.4.2. Dependent personality disorder. Dependent personality disorder is characterized by pervasive and excessive need to be taken care of by others (APA, 2022). This intense need leads to submissive and clinging behaviors as they fear they will be abandoned or separated from their parent, spouse, or another person with whom they are in a dependent relationship. They are so dependent on this other individual that they cannot make even the smallest decisions without first consulting with them and gaining their approval or reassurance. They often allow others to assume complete responsibility for their life, making decisions in nearly all aspects of their lives. Rarely will they challenge these decisions as their fear of losing this relationship greatly outweighs their desire to express their own opinion. Should the relationship end, the individual experiences significant feelings of helplessness and quickly seeks out another relationship to replace the old one (APA, 2022).
When they are on their own, individuals with dependent personality disorder express difficulty initiating and engaging in tasks on their own. They lack self-confidence and feel helpless when they are left to care for themselves or engage in tasks on their own. So that they do not have to engage in tasks alone, individuals will go to great lengths to seek out support of others, often volunteering for unpleasant tasks if it means they will get the reassurance they need (APA, 2022).
13.1.4.3. Obsessive-compulsive personality disorder (OCPD). OCPD is defined by an individual’s preoccupation with orderliness, perfectionism, and ability to control situations that they lose flexibility, openness, and efficiency in everyday life (APA, 2022). One’s preoccupation with details, rules, lists, order, organization, or schedules overshadows the larger picture of the task or activity. In fact, the need to complete the task or activity is significantly impacted by the individual’s self-imposed high standards and need to complete the task perfectly, that the task often does not get completed. The desire to complete the task perfectly often causes the individual to spend an excessive amount of time on the task, occasionally repeating it until it is to their standard. Due to repetition and attention to fine detail, the individual often does not have time to engage in leisure activities or engage in social relationships. Despite the excessive amount of time spent on activities or tasks, individuals with OCPD will not seek help from others, as they are convinced that the others are incompetent and will not complete the task up to their standard.
Personally, individuals with OCD are rigid and stubborn, particularly with their morals, ethics, and values. Not only do they hold these standards for themselves, but they also expect others to have similarly high standards, thus causing significant disruption to their social interactions. The rigid and stubborn behaviors are also seen in their financial status, as they are known to live significantly below their means to prepare financially for a potential catastrophe (APA, 2022). Similarly, they may have difficulty discarding worn-out or worthless items, despite their lack of sentimental value.
Though on the surface it may appear that OCPD and OCD are one and the same, there is a distinct difference as the personality disorder lacks definitive obsessions and compulsions (APA, 2022). In fact, most individuals with OCD do not have a pattern of behavior that meets criteria for this personality disorder.
Key Takeaways
You should have learned the following in this section:
- Personality disorders share the features of distorted thinking patterns, problematic emotional responses, over- or under-regulated impulse control, and interpersonal difficulties and divide into three clusters.
- Cluster A personality disorders are described as the odd/eccentric cluster and share as the common feature social awkwardness and social withdrawal. It consists of paranoid, schizoid, and schizotypal personality disorders.
- Cluster B personality disorders are described as the dramatic, emotional, or erratic cluster and consists of antisocial, borderline, histrionic, and narcissistic personality disorders.
- Cluster C is the anxious/fearful cluster and consists of avoidant, dependent, and obsessive-compulsive personality disorders.
- Paranoid personality disorder is characterized by a marked distrust or suspicion of others.
- Schizoid personality disorder is characterized by a persistent pattern of avoidance of social relationships, along with a limited range of emotion among social relationships.
- Schizotypal personality disorder is characterized by a range of impairment in social and interpersonal relationships due to discomfort in relationships, along with odd cognitive or perceptual distortions and eccentric behaviors.
- Antisocial personality disorder is characterized by a persistent pattern of disregard for, and violation of, the rights of others. They show no remorse for their behavior
- Borderline personality disorder is characterized by a pervasive pattern of instability in interpersonal relationships, self-image, and affect.
- Histrionic personality disorder is characterized by pervasive and excessive emotionality and attention-seeking.
- Narcissistic personality disorder is characterized by a pattern of grandiosity along with a lack of empathy for others.
- Avoidant personality disorder is characterized by a pervasive pattern of social anxiety due to feelings of inadequacy and increased sensitivity to negative evaluations.
- Dependent personality disorder is characterized by pervasive and excessive need to be taken care of by others.
- OCPD is characterized by an individual’s preoccupation with orderliness, perfectionism, and the ability to control situations that they lose flexibility, openness, and efficiency in everyday life.
Review Questions
- What are personality traits and how do they lead to personality disorders?
- What are the three clusters? How are disorders grouped into these three clusters? Discuss the differences in symptom presentation between the three personality clusters.
- Create a chart identifying each of the disorders among the three clusters. Be sure to include personality characteristics of each disorder. It is important to find characteristics unique to each personality disorder to aid in their identification.
