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Personality Disorders
Carolyn R. Fallahi, Ph. D.
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High controversy surrounding the personality disorders.
Problems with boundaries between various p.d. & their diagnostic criteria.
Examples.
Theories of Personality
Psychodynamic Models:
 “Character pathologies”. Character = the ability to bring harmony to
the tasks presented by the internal demands and by the external
world.
 Freud’s explanation.
Behavioral Theories of Personality
 Watson & classical conditioning.
 Mid 1980s reinterpretations of traditional assessments – clinically
applied behavioral approaches on Axis I.
 Recently … applying systematic approach to personality.
 Staats (19986): systematic approach & adds a behavioral &
developmental dimension arguing that “basic behavioral
repertoires” begin at birth and proceed hierarchically.
Interpersonal Models
 Personality = social product of interactions with significant others.
 Harry Stack Sullivan – father of interpersonal perspective. Reaction
against the medical model & intrapsychic mode of Freud’s.
 Sullivan = pathology is created & perpetuated through maladaptive
patterns of interactions between people.
Cognitive Models
 Very popular b/c most all clinical syndromes have cognitive
elements.
 Example: Five-factor model.
 Aaron Beck: successful therapies for a wide range of Axis I
diagnoses.
 Beck & Freeman (1990): cognitive theory of personality pathology.
Dysfunctional and distorting schemas give rise to maladaptive
interaction strategies which in turn trigger automatic thoughts and
make the individual susceptible to repetitive and pervasive life
difficulties.
Neurobiological & Temperament models
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Temperament = basic biological foundation of personality.
Hippocrates 4th C B.C. – diseases stem from an excess of or
imbalance of yellow bile, black bile, blood, & phlegm.
1920s Kretschmer – classification system based on thin, muscular,
and obese types of physiques & linked them to psychopathology.
Sheldon – ectomorphy, mesomorphy, and endomorphy.
Cloninger (1987): interrelationship of 3 genetic neurobiological
trait dispositions & associated them with a different NT system.
Schizoid & Avoidant Personality Disorders
 Similarity = interpersonal detachment.
 Schizoids appear emotionally bland & unresponsive & insensitive.
 Avoidants experience social interactions as aversive owing to their
propensity for self=criticism.
 Distinction = motivation for the attachment. Schizoid lack the desire or
ability to form social relationships; Avoidants desire interpersonal contact,
but avoid out of fear of rejection & humiliation.
 Millon (1981) passive (schizoid) versus active (avoidant) detachment.
 Issue with the separation of these 2 disorders.
 Similar issues between schizoid & schizotypal p.d. Share interpersonal
and affective features, especially social isolation & odd/inappropriate
affect, similar to “negative” symptoms of Schizophrenia.
 Similar issues with avoidant and dependent p.d. Dependent p.d. =
interpersonal submission, neediness, & fears of separation. Avoidant =
shunts interpersonal intimacy, while dependent seeks it. Both = low selfesteem & lack of self-assertion.
 Other issues: Avoidant p.d. resembles social phobia.
 Symptoms of Schizoid p.d.
 Symptoms of Avoidant p.d.
 Issues with differential diagnosis.
 Case Study Example
 Comorbidity Issues: Avoidant & Schizotypal = 53%; 38% of schizotypals
= schizoid; lesser degrees of comorbidity with paranoid, antisocial,
borderline, passive-aggressive, dependent.
 Question: Are Schizoid & Avoidant discrete disorders? Overholser (1989)
could not differentiate a sample on measures of anxiety, depression,
psychosis, or introversion.
 Trull et al (1987) could distinguish avoidant p.d. on measures of anxiety,
somatization, dysthymia.
 Issues with Avoidant & Dependent p.d.
 Trull et al (1987) symptoms highly correlated.
 Reich (1990) minor differences between avoidant & dependent on a
variety of psychological tests.
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Schizoid & Avoidant also show comorbidity on Axis I disorders, especially
social phobia. Herbert et al (1992) study found high correlation between
avoidant p.d. & social phobia. Turner et al (1986) found social phobics
have considerable distress & avoidance, but greater impairment found
with avoidant p.d.
Historical Issues
 Eugene Bleuler (1924)
 Kretschmer (1925): anesthetic (e.g. insensitive) and hyperaesthetic (e.g.
hypersensitive) = schizoid versus avoidant.
 Melanie Klein (1996): nurturing and depriving aspects of caregiving figure
= splitting.
 Fairburn (1952) caregiver issues.
 Guntrip: schizoids are starved for love.
 Millon (1981) introduced avoidant p.d. Issues with this diagnosis.
Contemporary Views:
 Psychoanalytic
 Kernberg (1984)
 Torgersen (1985)
 Millon (1981)
 Kagan (1989)
 Stravyniski et al (1989)
Dependent and Histrionic Personality Disorder: they share at least one important
feature = both are rooted in exaggerated, inflexible dependency needs.
 Different presentation styles
 HPD active, seductive stance
 DPD subservient, submissive stance
Dependent P. D.
 Bornstein (1992): 1. motivational, 2. cognitive, 3. affective, 4.
behavioral.
Issues with the diagnosis of DPD:
 Symptoms vary by gender, ethnicity, age
 Men’s symptoms are more indirect & disguised
 Women more likely to talk about dependency needs
 Cultural differences
Epidemiology & Comorbidity:
 47% outpatients; average 5-15%; general population 2-8%
 sex ratio no different according to DSM; research says something else.
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Comorbidity: eating disorders, anxiety, somatization disorders,
depression?, schizoid p.d., avoidant p.d., schizotypal p.d., borderline &
histrionic p.d.
Historically
 Neki (1976) cultural issues
 Early researchers
 Psychoanalytic perspective (Abraham, 1927)
 Fromm (1947), Horney (1945), Sullivan (1947)
 Contemporary models: Freud (1905)
 Biosocial-Learning perspective (Millon, 1990)
 Millon & Davis (1996)
 Parental overprotectiveness & authoritarianism
 Cognitive perspective: role of the self-concept, beliefs about other
people, & expectations regarding self-other interactions.
 HPD tied to physical characteristics – primarily in women & men above
average in physical attractiveness.
 Seductiveness – key feature.
 Gender differences.
 Age differences.
 The older adult.
Epidemiology & comorbidity
 Prevalence: as low as 1% to as high as 44% or 63%.
 HPD occurs more frequently in psychiatric inpatients and outpatients than
in college students or community subjects.
 DSM no gender differences; many settings see more women.
 Comorbidity: anxiety, somatization, dissociative dxs, dysthmia. Also:
antisocial, narcissistic, borderline, & dependent p.d.
Historical perspectives:
 Psychoanalytic: hysterical traits stem from Oedipal fixation.
 Marmar (1953) histrionic traits rooted in oral needs.
 Biosocial – Learning perspective: stimulation & affection.
 Sociable behaviors – impression of independence.
 Fear of autonomy & intense need for approval & attention.
 Why? Parental inconsistency.
Histrionic Personality Disorder
 Little agreement among clinicians & researchers
 Core components: egocentricity, seductiveness, theatrical emotionality,
denial of anger & hostility, & a diffuse cognitive style.
 Gregariousness, manipulativeness, low frustration tolerance, pseudohypersexuality, suggestibility, & somatizing tendencies.
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Women & Men – above average in physical attractiveness.
Seductiveness – key.
Gender differences.
Cultural differences.
Age differences.
Epidemiology: Prevalence rates from 1% to 44% depending on the study.
Appears more frequently in psychiatric inpatients & outpatients than
normal populations.
24% in clinical samples.
Equal rates according to DSM – research says no.
Comorbidity: several axis I disorders; higher rates of p.d.
Historical perspectives: Hipocrates – wandering womb.
Sydenham (1682)
18th and 19th Century – emphasis on sexuality in hysteria.
20th Century – hysteria split into 2 different viewpoints – sexual origins &
immaturity/self-centeredness.
DSM-III & IV: two broad categories have emerged.
Contemporary Theories: psychoanalytical perspective.
Marmor’s classic (1953).
Research.
Obsessive-Compulsive Personality Disorder
 Similarities to Negativistic p.d. ( the old passive-aggressive p.d. lavel)
 Common themes include ambivalent & conflicted personality dynamics
that underlie presentation.
 Ambivalence is defined as a lack of certainty over the source of
reinforcement in one’s life.
 Ambivalent individuals = conflicted over whether they should follow what
others want them to do or follow their own needs and wishes.
 “Anxious – fearful” cluster with anxiety & tension prominent symptoms.
 OCPD: extreme rigidity, preoccupation with details & perfectionism.
 Interpersonal relationships lacking – seen as cold, distant, & authoritarian.
They have an excessive need to control others.
 The issue with subordinate relationships.
 Little motivation to become more flexible.
 OCPD: avoids unwelcome thoughts or impulses & frequently distracts
them by becoming unduly critical and judgmental of others.
 Rigid, perfectionist, & restricted emotional expressivity.
 Millon: intense ambivalence as the central feature.
Prevalence
 5-20% psychiatric patients
 Comorbidity: paranoid, histrionic, borderline, narcissistic, and avoidant
p.d.
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Issues with OCD Axis I.
Historically
 Psychoanalytic theory: intense conflict during the anal stage of
psychosexual development = “anal character”.
 Kraft-Ebing: “compulsion” = constricted thought processes in individuals
with severe depression. Then began to use the term to indicate hidden
emotions, incessant questioning, doubtfulness, & other characteristics.
 Anakastic (Schneider, 1923) = conceal feelings of insecurity, compensates
by adopting an overly correct or scrupulous demeanor, & uses control in
most relationships.
 Kretschmer = “sensitive” personality type.
 Kahn (1931) ambivalent tendencies = “ambitendency”.
 Reich (1949) extreme attention to order, circumstantiality, rumination,
indecision, self-doubt.
Contemporary Theories
 Psychoanalytic: struggles over autonomy
 Erikson (1950): gain autonomy over one’s self & environment.
 Rado (1959) mother’s demandingness & intrusiveness into child’s bowel
patterns = defiance and anger.
 Mallinger (1984) parental rejection, authoritarian attitudes, & lack of
respect for privacy.
 Salzman (1980) & Storr (1980) pervasive threat to security.
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Behaviorial: very little in the literature.
Issues with the term OCPD.
Turkat & Maistro (1985): learns maladaptive emotional reactions in home
& emphasizes hard work & minimizes close interpersonal relationships.
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Cognitive Theory: Beck & Freeman (1990): OCPD clear distortions in
thinking = produce rigidity & perfectionism.
Cognitive disortions
Musts and shoulds
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Interpersonal Theory: Leary (1959) OCPD style defined by actions that
maintain conventionality and security.
Structural Analysis of Social Behavior (Benjamin, 1974): intense fears of
making a mistake / being viewed as imperfect.
Endler & Edwards (1988)
Pincus & Wiggins (1990)
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Biological perspective: limited attention
Issues with anxiety.
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Clonginger’s (1987) neurobiological theory – novelty seeking, reward
dependence, harm avoidance.
Millon & Davis (1996) limbic system.
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Integrative Model: Millon (1996)
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Issues with Negativistic P.D.: stubbornness, passive resistance to fulfilling
routine demands, procrastination, and inefficiency. Also sullen & irritable.
Borderline Personality Disorder
Essential Symptoms:
 Impulsivity
 Affective Instability
 Cognitive Symptoms
Reliability & Validity Concerns
Prevalence
 1-2% general population
 ¾ women. Why? Stone (1993)
Comorbidity
 Axis I mood disorders. Is it a form of depression?
 Gunderston & Phillips (1991)
 Trauma research: Kolk (1987)
 The “borderline child”
 Remits by early middle age.
 15 years = 75%
 1/10 commits suicide.
 Highest risk: substance abuse + borderline
 Stone (1993) less likely to marry or have children
Historically
 Problems with the term “borderline”
 Adolf Stern (1938)
 “hysteria” or “pseudo-neurotic schizophrenia”
 unstable personality disorder or emotionally unstable personality
Contemporary Theories
 Biological: relatives have impulse spectrum disorders and/or affective
disorders.
 No specific pattern of inheritance has been found.
 Torgersen (1984) twin studies – no MZ-DZ differences, but numbers
small.
 Torgersen (1996) BPD large heritable component.
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No adoption studies.
No identifiable biological markers yet to be found. Similar markers to
depression, e.g. abnormal REM latency; serotonergic activity.
Soft neurological signs, e.g. limbic activity issues.
Siever & Davis (1991)
Most likely = multiple receptors & multiple subsystems associated with
each NT.
Linehan (1993) “emotional vulnerability”.
Psychological Factors: psychoanalytic emphasis on early experience.
Large number of negative events in childhood.
Borderlines also report a high frequency of childhood sexual abuse, e.g.
50-70%.
Incest abuse with penetration.
Physical abuse, frequency, duration, & severity.
Gender issues.
Herman et al (1989)
Zanarini et al (1989)
Van der Kolk et al (1991) & self-mutilation
Separation & loss b/f 16 (51%)
Parental psychopathology
Parental bonding issues; Gunderson et al (1980)
Adler (1985)
Linehan (1993)
Narcissistic Personality Disorder
 Normal narcissism versus pathological narcissism
 Definition: “a pervasive pattern of grandiosity, need for admiration, &
lack of empathy”
 Associated features: vulnerable self-esteem, sensitivity, intense reactions
of humiliation, emptiness or disdain to criticism or defeat, vocational
problems, feelings of shame, social withdrawal.
 Antisocial or borderline characteristics
 High achievement, promiscuity, excessive rage, suicidal behavior.
NPD Clinical Features
 The Arrogant Narcissist
 The Shy Narcissist
 NPD with Antisocial / Borderline Features
 Comorbid Axis I = depression or dysthymia
 Suicide
 Affect intolerance and vulnerability
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Discriminating behaviors: Ronningstam & Gunderston (1990) boastful &
pretentious behavior; self-centered & self-referential behavior; reactions
to the envy of others.
Morey (1998): inflated self-esteem & marked affective reactions to
assaults of self-esteem; marked need for interpersonal control; hostility;
lack of overtly self-destructive behaviors.
Prevalence
 2-22%. Gender differences?
 Late teens & early 20s; middle age very critical.
Sociocultural Factors
 Lash (1979)
Comorbidity
 Dramatic cluster, e.g. histrionic, borderline, paranoid, avoidant, passiveaggressive, antisocial.
 Bipolar patients, substance abuse, major depression, anorexia nervosa.
Differential Diagnosis
 Antisocial p.d.
 Borderline p.d.
 Histrionic p.d.
 Obsessive-Compulsive p.d.
 Paranoid p.d.
 Schizoid p.d.
 Mania & hypomania