Bi-Ling Shieh, PhD ©2005 謝碧玲副教授
 有目的的學習 vs. 不經意的好奇心
 學習的層級
• 內容
• 思考方法
• 價值觀與評斷
• 解構 (deconstruction)
具體經驗
觀察/審思
應用/行動
抽象概念
 心理疾患 Mental disorders
 各類心理疾患
 變態心理學 Abnormal psychology
 了解現象：症狀 Symptoms
 探究原因：病因 Etiology
 促進改變：治療與處置
 Personality disorders: Symptomatology
 How many kinds of personality disorders?
 The construct of personality disorders
 How reliable are the personality disorder diagnoses?
 How do Axis I & Axis II disorders differ and are they
related?
 Epidemiology & comorbility
 Etiology of personality disorders
 Trait model; interpersonal strategies; other approaches
 Personality as a holistic system
 Treatment
DSM-IV
A. An enduring pattern of inner experience and behavior
that deviates markedly from the expectations of the
individual's culture. This pattern is manifested in two
(or more) of the following areas:
(1) cognition (ie, ways of perceiving and interpreting self, other
people, and events)
(2) affectivity (ie, the range, intensity, lability, and
appropriateness of emotional response)
(3) interpersonal functioning
(4) impulse control
B. The enduring pattern is inflexible and pervasive across a
broad range of personal and social situations.
C. The enduring pattern leads to clinically significant
distress or impairment in social, occupational, or other
important areas of functioning.
D. The pattern is stable and of long duration and its onset
can be traced back at least to adolescence or early
adulthood.
E. The enduring pattern is not better accounted for as a
manifestation or consequence of another mental
disorder.
F. The enduring pattern is not due to the direct
physiological effects of a substance (eg, a drug of abuse,
a medication) or a general medical condition (eg, head
trauma).
 The gradual development of inflexible and
distorted personality patterns
 ie, persistently maladaptive ways of perceiving,
thinking about, and relating to the world
 Behavioral patterns become disorders, when
people
 Consistently use the behaviors vs. occasionally
 Showing a more extreme level of the behavior,
eg, being orderly vs. being compulsive
 The behavior resulting in serious and prolonged
problems with functioning or happiness
Self, Interpersonal, & pathology
~ Dr. Sam Vaknin
 Self
 Self-centeredness
 that manifests itself through a me-first, self-
preoccupied attitude
 Lack of individual accountability
 that results in a victim mentality and blaming others,
society and the universe for their problems
 Distorted or superficial understanding of self
and others' perceptions
 being unable to see his or her objectionable,
unacceptable, disagreeable, or self-destructive
behaviors or the issues that may have contributed to
the personality disorder
 Interpersonal
 Lack of perspective-taking and empathy
 Socially maladaptive
 changing the rules of the game, introducing new
variables, or otherwise influencing the external world
to conform to their own needs
 Manipulative and exploitative behavior
 Pathology
 Unhappiness
 suffering from depression and other mood and anxiety
disorders; only aware of the distress, but not the cause
 No hallucinations, delusions or thought disorders
 (except for the brief psychotic episodes of Borderline
Personality Disorder)
 Vulnerability to other mental disorders
 such as obsessive-compulsive tendencies and mood swings
Thought disturbance
(quasi-psychotic)
Unstable mood
(depression, anger)
Self-mutilation
(impulsive)
Poor interpersonal
relationships and
Lack of identity
There are four major symptom areas in the borderline
personality disorder.
Odd/
Dramatic/
Anxious/
Eccentric
Erratic
Fearful
• Paranoid
• Schizoid
• Schizotypal
•
•
•
•
• Avoidant
• Dependent
• Obsessivecompulsive
Antisocial
Borderline
Histrionic
Narcissistic
 A: Odd/Eccentric cluster
 Similarity to the symptoms of schizophrenia
(prodromal and residual phases); with withdrawn
behavior
 B: Dramatic/Erratic cluster
 A variety of symptoms (inflated self-esteem,
exaggerated emotional displays, and antisocial
behavior);
with highly noticeable and unpredictable behavior
 C: Anxious/Fearful cluster
 Fearful in social situations; lacking self-reliance;
having a perfectionistic approach to life
DSM-IV Diagnostic Criteria
Pinkofsky (1997)
 SUSPECT (4 criteria of 7)
S: Spouse fidelity suspected
U: Unforgiving (bears grudges)
S: Suspicious of others
P: Perceives attacks (and reacts quickly)
E: "Enemy or friend" (doubts about loyalty of friends)
C: Confiding in others feared
T: Threats perceived in benign events
*No hallucinations or full blown delusions
*Excessive or irrational suspiciousness and distrustfulness of
others
 DISTANT (4 criteria of 7)
D: Detached (or flattened) affect
I: Indifferent to criticism and praise
S: Sexual experiences of little interest
T: Tasks (activities) done solitarily
A: Absence of close friends
N: Neither desires nor enjoys close relations
T: Takes pleasure in few activities
 ME PECULIAR (5 criteria of 9)
M: Magical thinking or odd beliefs
E: Experiences unusual perceptions
P: Paranoid ideation
E: Eccentric behavior or appearance
C: Constricted (or inappropriate) affect
U: Unusual (odd) thinking and speech
L: Lacks close friends
I: Ideas of reference
A: Anxiety in social situations
*R: Rule out psychotic disorders and
pervasive developmental disorder
 Interpersonal difficulties similar to schizoid
 Odd beliefs or magical thinking
 Superstitious
 Telepathic
 Illusions
 Feels the presence of a force or person not actually
present.
 Odd/eccentric behavior or appearance
 Wears strange clothes
 Talks to self
 Ideas of reference
 CORRUPT (3 criteria of 7)
C: Conformity to law lacking
O: Obligations ignored
R: Reckless disregard for safety of self or others
R: Remorse lacking
U: Underhanded (deceitful, lies, cons others)
P: Planning insufficient (impulsive)
T: Temper (irritable and aggressive)
 Pervasive disregard for the rights of others since
age 15
 Conduct disorder before age 15
 Truancy, running away, lying, theft, arson, destruction of
property
 Substance abuse most common comorbid disorder
 Culture/society plays a role
 More common in US than Scotland
 More common among lower SES groups
 AM SUICIDE (5 criteria of 9)
A: Abandonment
M: Mood instability (marked reactivity of mood)
S: Suicidal (or self-mutilating) behavior
U: Unstable and intense relationships
I: Impulsivity (in two potentially self-damaging areas)
C: Control of anger lacking
I: Identity disturbance
D: Dissociative (or paranoid) symptoms
that are transient and stress-related
E: Emptiness (chronic feelings of)
 Onset during adolescence or early adulthood
 Prognosis poor within 10 years of diagnosis
 Later in life, most no longer meet diagnostic criteria
(Paris, 2002)
 Cormorbidity high with PTSD, MDD, substance-
related, and eating disorders
 Comorbidity predicts symptoms 6 years later
 Suicide rates high
 Self-mutilation also a problem
 PRAISE ME (5 criteria of 8)
P: Provocative (or sexually seductive) behavior
R: Relationships (considered more intimate
than they are)
A: Attention (uncomfortable when not the
center of attention)
I: Influenced easily
S: Style of speech (impressionistic, lacks detail)
E: Emotions (rapidly shifting and shallow)
M: Made-up (physical appearance used to
draw attention to self)
E: Emotions exaggerated (theatrical)
 SPECIAL ME (5 criteria of 9)
S: Special (believes he or she is special and unique)
P: Preoccupied with fantasies (of unlimited success,
power, brilliance, beauty, or ideal love)
E: Entitlement
C: Conceited (grandiose sense of self-importance)
I: Interpersonal exploitation
A: Arrogant (haughty) behaviors
L: Lacks empathy
M: Me admired
E: Envious of others
 CRINGES (4 criteria of 7)
C: Certainty of being liked required (before
involved with others)
R: Rejection (or criticism) preoccupies one's
thoughts in social situations
I: Intimate relationships restrained (fear of
being shamed)
N: New interpersonal relationships (in which
feeling of inadequacy and being inhibited)
G: Gets around occupational activities (with
significant interpersonal contact)
E: Embarrassment prevents new activity or taking
personal risks
S: Self viewed as unappealing, inept, or inferior
*High comorbidity with major depression and generalized social phobia
 RELIANCE (5 criteria of 8)
R: Reassurance required for decisions
E: Expressing disagreement difficult (due to fear of loss
of support or approval)
L: Life responsibilities (needs to have these assumed by
others)
I: Initiating projects difficult (due to lack of selfconfidence)
A: Alone (feels helpless and discomfort when alone)
N: Nurturance (goes to excessive lengths to obtain
nurturance and support)
C: Companionship (another relationship) sought
urgently when close relationship ends
E: Exaggerated fears of being left to care for self
 LAW FIRMS (4 criteria of 8).
L: Loses point of activity (preoccupation with details, rules)
A: Ability to complete tasks (compromised by perfectionism)
W: Worthless objects (unable to discard)
F: Friendships (and leisure activities)
excluded (due to a preoccupation with work)
I: Inflexible, scrupulous, and overconscientious
(on ethics, values, or morality, not
accounted for by religion or culture)
R: Reluctant to delegate (unless others
submit to exact guidelines)
M: Miserly (toward self and others)
S: Stubbornness (and rigidity)
*Does not have the obsessions/compulsions of OCD
 Personality disorders are “qualitatively distinct
clinical syndromes” (p. 689).  Widely doubted
 Normal vs. disordered
 The "diagnostic thresholds" between normal and abnormal are
either absent or weakly supported.
 Contains little discussion of what distinguishes -Normal
character (personality), Personality traits, or Personality style
(Millon) - from Personality disorders.
 Diagnostic heterogeneity
 Only a subset of the criteria is adequate grounds for a diagnosis;
people diagnosed with the same personality disorder may share
only one criterion or none
 The emergence of dimensional alternatives to the
categorical approach is acknowledged in the
DSM-IV-TR:
 “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” (p.689)
 Five-factor model (McCrae & Costa, 1990)
 OCEAN
 Dimensional approach involves rating each
individual on the five factors
 Avoids applying a categorical label which may not
completely fit
 Personality traits form a continuum
 Individuals with PDs endorse the extremes
 Marginal disorders - More serious
 Symptoms like some of those found in schizophrenia
 Trait disorders - Less serious
 The exaggeration of normal personality traits
 Antisocial personality disorder
 Appeared to be well adjusted
 Most interpersonally destructive and emotionally
harmful
 The people around the
disordered individual suffered
Marginal disorders
 Cluster A: Odd/Eccentric
Paranoid Distrust and
suspiciousness of others
Schizoid Detachment from
social relationships & restricted
range of expression of emotions
Schizotypal Discomfort with
close relationships; cognitive
and perceptual distortions;
eccentricities of behavior

Cluster B: Dramatic/Erratic
Antisocial Disregard for &
frequent violation of the rights
of others
Borderline Instability of interpersonal relationships, self image,
emotions, & control over impulses
Trait disorders
 Cluster C: Anxious/Fearful
Avoidant Social inhibition,
feelings of inadequacy, and
hyper-sensitivity to negative
evaluation
Dependent Excessive need to
be taken care of, leading to
submissive & clinging
behavior
Obsessive-compulsive
Preoccupation with
orderliness and perfectionism
at the expense of flexibility
Histrionic Excessive emotionality;
attention seeking
Narcissistic Grandiosity; need for
admiration; lack of empathy
 DSM-IV-TR categorical approach
 Diagnostic reliability
 Initially poor; improved since DSM-III
 Test-retest reliability (diagnostic stability)
 ½ of those initially diagnosed with PD did not
receive same diagnosis 1 year later (Shea et al.,
2002)
 Gender bias
 Certain diagnoses applied more often to men,
others to women
Diagnosis
Paranoid
Schizoid
Schizotypal
Borderline
Histrionic
Narcissistic
Antisocial
Dependent
Avoidant
Obsessive-compulsive
Interrater Reliability
.75
.83
.82
.89
.81
.83
.88
.89
.82
.82
Test-Retest Reliability
.57
---.11
.56
.40
.32
.84
.15
.41
.52
Source. Figures for interrater reliability are from the Loranger et al. (1994) crossnational study and reflect the amount of agreement above chance. Test-retest figures
are rates of agreement from Zimmerman's (1994) summary of longer (generally more
than a year) studies.
[A]
B
C
.
A
[B]
C
FIGURE 9-3: The proportion of patients meeting the DSM-111-R criteria for
antisocial personality disorder who also met the diagnostic criteria for each of the other
types of personality disorder.
Source: From L.C. Morey (1988). Personality disorders in DSM-m and DSM-m-R: Convergence,
coverage, and internal consistency American Journal of Psychiatry, 145, 576
A
[B]
C
Problems with mood,
cognitions, selfmutilation, and interpersonal
relationships are higher in
individuals with the borderline
personality disorder than
in individuals with other
personality disorders.
 Personality disorder classifications are unreliable
 Comorbidity
 Not mutually exclusive from each other
 Association with Axis I disorders
 Inferred construct: Trait
 At best, mental health professionals record symptoms
(as reported by the patient) and signs (as observed).
Then, they group them into syndromes and, more
specifically, into disorders. This is descriptive, not
explanatory science.
 Normality vs disorder
Antisocial behaviors
Detached, exploitative
relationships
Antisocial
Good role function
Admiration seeking
Narcissistic
Stability of role and identity
Esteem tied to sexuality
Histrionic
Criticism sensitive
Hostility
Manipulative
Projection sensitive
Attention seeking
Borderline
Personality
Disorder
Borderline
Personality
Disorder
Borderline
Personality
Disorder
Intense, dependent relationships
Self-destructive behaviors
Cognitive distortions
Nurturance seeking
Impulsive
Cognitive distortions
Hostility
Impulsive
Manipulative
The borderline personality disorder has some characteristics that overlap with other personality disorders
in the dramatic, emotional, or erratic behavior category. The similar characteristics are shown in the
overlapping circle segments. Characteristics that distinguish between the two disorders are shown in the
boxes above and below each pair. SOURCE: Adapted from Gunderson and Zanarini, "Current Overview
of the Borderline Diagnosis.“ Journal of Clinical Psychiatry, Supplement 48(8), (1 987), p. 7.
Axis I
Axis II
 Symptom disorders
 Personality disorders;
Mental retardation
 Come and go (episodic)  (Near-) lifetime
duration and stability
 Triggered by events or
environmental factors;
disappear when
conditions change, or
when a person learns
new behaviors.
 See oneself having
problem
 Inflexible, narrow,
characteristic ways of
responding
 See the environment
having problem
 Comorbid
 Often comorbid with Axis I disorders
 More severe symptoms and poorer outcome when
comorbid
 50+% of people diagnosed with a personality disorder
meet criteria for another personality disorder
 More than two-thirds meet lifetime criteria for an Axis
I disorder (Lenzenwenger et al., 2007)
 As a context for Axis I problems
 Perceiving and coping with symptoms differently
 Anxiety disorder; avoidant vs histrionic PD
 Vulnerability for symptom disorders
 Milder form of symptom disorders
 eg, schizotypal personality disorders and schizophrenia
 Different combinations of Axis I and II
Trait
Learning
• Five-factor
• Interpersonal
Psychodynamic
• Object
Relation
Vulnerability
-stress
model
• Genetics,
Neurological
• Family
environment
 Dimensional vs Categorical
Borderline PD
Antisocial PD
 Five-factor model: OCEAN
 Five factors are heritable
 Able to differentiate between different personality
disorders
Extraversion Neuroticism
Schizoid
Low
(Lower)
Avoidant
Low
High
Personality Traits
DSM-IV
category
Neuroticism
negative
affect
Extraversion
Agreeable- ConscientiousOpenness
positive affect
ness
ness
Paranoid
Schizoid
Schizotypal
Low
Low
Low
High
Borderline
Narcissistic
Histrionic
Antisocial
High
High
High
Low
High
High
High
Dependent
Avoidant
Obsessivecompulsive
High
High
High
Low
High
low
Low
Low
High
Low
Low
High
Low
Low
High
Low
Low
High
Low
High
Boldface letters indicate features that are strongly associated with the definition of the disorder (defining features). Letters in
regular typeface indicate "associated features" that are frequently associated with the disorder, sometimes based on clinical
experience. Blank spaces indicate that the trait is not relevent to this DSM-IV category.
Source: Adapted from T.A. Widiger (1993). The DSM-III-R categorical personality disorder diagnoses: A critique and an
alternative. PsychologicalInquiry, 4, 83.
 High neuroticism and antagonism (low
agreeableness)
 Most personality disorders
 Extraversion
 High extraversion (involve dramatic behavior):
histrionic and narcissistic disorders
 Low extraversion (involve social isolation): schizoid,
schizotypal, and avoidant personality disorders
Personality Disorder
Overdeveloped
Underdeveloped
Schizoid
Autonomy
Isolation
Intimacy
Reciprocity
Paranoid
Vigilance
Mistrust
Suspiciousness
Serenity
Trust
Acceptance
Personality Disorder
Overdeveloped
Underdeveloped
Narcissistic
Self-aggrandizement
Competitiveness
Sharing
Group identification
Antisocial
Combativeness
Exploitativeness
Predation
Empathy
Reciprocity
Social sensitivity
Histrionic
Exhibitionism
Expressiveness
Impressionism
Reflectiveness
Control
Systematization
Personality Disorder
Overdeveloped
Underdeveloped
Obsessive-compulsive
Control
Responsibility
Systematization
Spontaneity
Playfulness
Dependent
Help seeking
Clinging
Self-sufficiency
Mobility
Avoidant
Social vulnerability
Avoidance
Inhibition
Self-assertion
Gregariousness
 Consistent use of interpersonal space
 Schizoid: move away
 Histrionic: use the space to draw others toward them
 Narcissist: position themselves above others
 Avoidant: move closer and then back off
 Dependent: move toward and often below
 Compulsive: move above in the interest of control
 Histrionic
 Sex, seduction, "conquests", flirtation, romance,
body-building, demanding physical regime
 Narcissistic
 Adulation, admiration, attention, being feared
 Antisocial PD
 Money, power, control, fun
*Narcissistic Supply: important reinforcement for self/ego
 Borderline
 The presence of their mate or partner (they are
terrified of abandonment)
 Can be described as narcissist with an
overwhelming separation anxiety.
 They DO care deeply about not hurting others
(though often they cannot help it) – but not out of
empathy. Theirs is a selfish motivation to avoid
rejection. Borderlines depend on other people for
emotional sustenance.
 But Borderlines also have deficient impulse control,
as do Antisocials.
 Hence their emotional lability, erratic behaviour, and the
abuse they do heap on their nearest and dearest.
Etiology
 Highly heritable
 Schizotypal PD: family studies; brain structure
and functions
 Links to schizophrenia
 Relatives of individuals with schizophrenia at
greater risk for schizotypal
 Individuals with schizotypal PD show
problems similar to those found in
schizophrenia
 Cognitive and neuropsychological deficits
 Enlarged ventricles
 Less temporal gray matter
Etiology
Etiology
 Genetics
 Antisocial behavior heritable
 Estimates as high as .96
 Genetic risk for APD, psychopathy, conduct
disorder, and substance abuse related.
 Family environment
 Lack of warmth, negativity, and parental
inconsistency predict APD
 Poverty, exposure to violence
 Family environment interacts with genetics
 Emotion and
psychopathy
 Lack of fear or anxiety
 Low baseline levels of
skin conductance
 Skin conductance
reactivity at age 3
predicted APD at age
28 (Glenn et al., 2007)
 Makes it difficult for
them to avoid
behavior that leads to
punishment
 Also show less SCR to
other’s distress - Lack
empathy
Persons with the antisocial personality disorder classically
condition more slowly than other people.
Individuals with the
antisocial personality disorder
were exposed to neglect and
abuse as children.
Source: Data form Roff (1974)
Etiology
 Genetic component
 Highly heritable
 May play a role in impulsivity and emotional
dysregulation
 Decreased functioning of serotonin system
(impulsivity)
 Frontal lobe dysfunction
 Increased activation of amygdala
 Parental separation
 Childhood abuse and trauma
 Verbal and emotional abuse
 Object-Relations Theory (Kernberg, 1985)
 Object-representation
 BPD involves disturbed object representations, possibly
due to inconsistent parenting
 Poorly developed view of self and others
 Insecure ego; defense mechanism – splitting
 Shifting concepts between “all good” or “all bad”
 Linehan’s Diathesis-Stress Theory
 Individuals with BPD have difficulty
controlling their emotions
 Possible biological diathesis
 Family invalidates or discounts emotional
experiences and expression
 Interaction between extreme emotional
reactivity and invalidating family → BPD
Etiology
 Histrionic and narcissistic personality disorders
 low self-esteem
 Histrionic personality disorders
 Psychoanalytic theory
 Emotional displays and seductiveness result from parental
seductiveness
 Father’s sexual attention towards daughter
 Conflicting family attitudes towards sexuality
 Negative attitudes towards sex while simultaneously
acknowledging titillation
 Theory untested
Etiology
 Kohut’s Self-Psychology Model
 Characteristics mask low self-esteem
 In childhood, narcissist valued as a means to increase
parent’s own self-esteem
 Not valued for his or her own competency and self worth
 People with high levels of narcissism report cold
parents who overemphasized child’s
achievement
 Social cognitive model
 Narcissist has low self esteem
 Sense of self depends on “winning”
 Interpersonal relationships are a way to bolster sagging
self esteem rather than increase closeness to others
 Lab studies reveal cognitive biases that maintain
narcissism
Etiology
 Not much available research
 Avoidant PD
 Overly protective and authoritarian parents
 Taught to be fear people and situations that are harmless
 Obsessive-Compulsive PD
 Fixation at anal stage of development (Freud)
 More recent theorists
 Cope with fears of losing control by overcompensation
 Dependent PD
 Abnormal attachment behaviors
 Disruption of early childhood attachment by death,
neglect, rejection, or overprotectiveness
Perspectives on causes & treatment
Perspective
Causes
Treatment
Psychodynamic
Disturbed mental representations of self and
others, stemming from childhood
mistreatment (e.g., child ignored by selfabsorbed parents sees the self as fragile and
unacceptable and compensates by becoming
narcissistic).
Uncover the origins of the
disorder but also
emphasize support
and practical guidance.
Biological
Biological abnormalities, such as slow
brain waves at rest, have been noted
among psychopaths. Genetically transmitted
vulnerabilities also appear to influence the
appearance of schizotypal and at least some
forms of borderline personality disorder.
Medication such as
Prozac for impulsive
borderlines
Perspective
Causes
Treatment
Family
system
Poor parenting (e.g., inadequate discipline,
abuse) can predict increased risk of
personality disorders, with prospective
studies supporting a link to antisocial
personality disorder,
Family therapy, or ideally
prevention through
better education for,
and support of, parents.
Behavioral
Defective learning repertoires (e.g.,
psychopaths'failure to attend to punishment).
Identify and repair
specific skill deficits
(e.g., dialectical
behavior therapy for
borderlines).
Cognitive
Biased negative beliefs regarding the self,
others, and the environment (e.g.,
psychopath: I am infallible; others are
irrelevant; consequences do not matter).
Challenge dysfunctional
beliefs gradually and
with careful attention to
patient-therapist
relationship.
 Axis I disorder usually drives individual to
treatment
 Presence of PD, reduces success of treatment for Axis I
 Medications
 Avoidant PD
 Antianxiety medication or antidepressants
 Schizotypal PD
 Antipsychotic medications
 Psychotherapy
 Psychodynamic
 Seek awareness of early childhood problem
 Cognitive behavioral
 Break personality disorder down into discrete problems
 Treat sensitivity to criticism with social skills training
Copyright 2009 John Wiley & Sons, NY
93
 Difficult to treat
 Interpersonal problems play out in therapy
 Attempts to manipulate therapist
 Object Relations Therapy (Kernberg et al., 1985)
 Dialectical Behavioral Therapy (Linehan, 1987)
 Acceptance and empathy plus CBT, emotion regulation,
and social skills
 Schema-Focused Cognitive Therapy for BPD
 Identify maladaptive assumptions that underlie
cognitions
 Medications
 Antidepressants
 Antipsychotics
 Olanzapine