Chapter 8: The Personality Disorders
Types of Personality Disorders (Axis II)
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DSM-IV-TR criteria:
1.
pattern of behaviour must be manifested in at least 2 of the following areas:
o cog
o emotions
o interpersonal functioning
o impulse control
2.
enduring pattern of behaviour be rigid and consistent across a broad range of personal and social
situations
3.
behaviour should lead to clinically sig distress
4.
stability and long duration of symptoms, with onset in adolescence or prior
5.
behaviour cannot be accounted for by another mental disorder
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personality of individuals with PD:
o rigid & inflexible, across situations
(most people w/o PD will modify behaviour by context …)
o more restricted range of traits
(most likely to be characterized by a single dominant, dysfunctional trait)
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DSM-IV: 10 disorders grouped into 3 clusters:
o Cluster A: Odd & Eccentric Disorders
o paranoid
o schizoid
o schizotypal
o Cluster B: Dramatic, Emotional or Erratic Disorders
o antisocial
o borderline
o histrionic
o narcissistic
o Cluster C: Anx & Fearful Disorders
o avoidant
o dependent
o obsessive-compulsive
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6-9% of the population will have one or more PDs during their life
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80% or more of pp with PDs never seek treatment for their problems
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For many pp with PDs, they perceive their behavior or feelings as egosyntonic: a natural / compatible parts
of themselves; do not perceive a need to change
The Specific Disorders
Cluster A: Odd & Eccentric Disorders
1. Paranoid PD:
Pervasive suspiciousness of others
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pervasive suspiciousness of other people’s motives
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tendency to see everything everyone does as a personal attack
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overly vigilant (and take extreme precautions against potential threats from others)
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consistently misread the actions of others as threatening or critical and expect others to exploit them
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typically humourless and eccentric
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not surprisingly, numerous problems in relationships
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often become socially isolated (which only exacerbates their feelings of persecution)
2. Schizoid PD
Emotional detachment
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avoid intimate involvement with others; appear distant and aloof
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often indicate that they rarely experience intense emotions
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typically loners
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most lack skills for effective social interaction
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maintain better contact w reality (vs people w Sz)
3. Schizotypal PD
Eccentric behaviour and social isolation
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eccentricity of thought and behaviour
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many are extremely superstitious
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their ideation and behaviour are peculiar, and these feature tend to turn other pp away --- typically socially
isolated
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thinking tends to be magical and full of odd beliefs
o typically believe in paranormal phenomenon (e.g., telepathy, clairvoyance)
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odd beliefs or interpret commonplace occurrences in bizarre ways
Cluster B: Dramatic, Emotional or Erratic Disorder
1. Antisocial PD
Disregard for others, rule-breaking, impulsive
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on surface, men diagnosed as having APD appear charming and persuasive, but this covers up a selfcentred and in many cases, criminal lifestyle
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not all pp with APD commit crimes, although most who are diag by a clinician have a criminal record.
However, the behavioural features of APD do predispose them to crime
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distinguishing feature of APD = pervasive pattern of disregard for, and violation of, the rights of others
that begins in childhood and continues to adulthood; ; lack or guilt / remorse
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for DSM-IV:
- 3 of the following 7 exemplars reflecting violation of rights of others:
 nonconformity
 callousness
 deceitfulness
 irresponsibility
 impulsivity
 aggressiveness
 recklessness
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many pp with APD would, as children, have met the criteria for CD
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prevalence: 3% in males and .5% of females (Cdn prisons: 40%)
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Psychological & Biological Factors Associated w Antisocial PD & Psychopathy (pp. 292-3):
- Lack of emotional responsiveness
- The craving-for-stimulation model
- Lack of restraint on impulsivity
- Limbic abnormalities
2. Borderline Personality Disorder
Labile mood, unstable relationships
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Fluctuations in mood
Unstable sense of their own identity
Instability in their relationships
characterize these pp
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unpredictable and impulsive … ; difficulty controlling their anger
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seem unable to tolerate being alone
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typically alternate between idealizing and devaluing their partners / therapists
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Lifetime occurrence in 2% of population (more common among women); typically begins in adolescence,
reasonable stability across time
3. Histrionic PD
Attention-seeking, dramatic, emotional displays
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attention-seeking behaviours:
- flamboyant (apparently intended to make others focus on them)
- overly dramatic (in their emotional displays)
- overresponsive to events other would consider trivial
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insincerity and shallowness (and as a consequence, often have few friends)
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Because of their strong need for attention, they tend to be very demanding and inconsiderate --- not
surprisingly, their relationships are often shortlived and emotional
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often flirtatious, and seem unable to develop intimacy in relationships
4. Narcissistic PD
Grandiosity, egocentricity
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grandiosely consider themselves to have unique & outstanding abilities
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exaggerated sense of self-importance (they expect and demand to be treated as special)
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consumed with their own interests
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fragile self-esteem (devastated by negative feedback)
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their typical behaviours alienate others, and they are freq lonely and unhappy
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when frustrated or slighted, can become vengeful & verbally or phys aggressive
Cluster C: Anx and Fearful Disorders
1. Avoidant PD
Sensitivity to criticism, Avoidance of intimacy
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extreme sensitivity to criticism and disapproval characterize avoidant people
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actively avoid intimacy with others, although they clearly desire affection
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social discomfort and fear of being evaluated negatively are common features
- Restrict social interactions
- These fears cause problems for them in relationships, work, leisure
2. Dependent PD
Cannot function independently, Forfeits own needs
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afraid to rely on themselves to make decisions:
- seek advice and direction from others
- need constant reassurance
- seek out relationships where they can adopt a submissive role
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unable to function independently
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linked to psych disorders & phys problems …
3. Obsessive-Compulsive PD
Inflexibility, Need for Perfection
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inflexibility and a desire for perfection characterize this disorder
o these 2 features and the absence of obsessional thoughts and compulsive behaviours
distinguish this PD from OCD
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preoccupation with rules and order make them rigid and inefficient
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tend to be moralistic and judgmental, causing problems with others
Problems with the Classification of PDs
Undetermined reliability & validity

Inter-rater reliability is modest at best
Problems distinguishing Axis I & Axis II disorders

E.g., may be difficult to discriminate OCD (Axis I) vs Obsessive-compulsive PD (Axis II)

Relative to PDs, Axis I disorders (clinical disorders):
o have more pronounced symptomatology, leading to a greater likelihood of referral to mental health
professionals
o have far more sig impaired functioning (PDs: impaired life circumstances but their actual abilities
appear relatively intact)
o are believed to be more variable over time (PDs: generally more enduring patterns of disturbance);
but …
Overlap among PDs

2/3 pp w PDs meet diagnostic criteria for more than one type of PD
Difficulty in distinguishing between normal behaviour & abnormal behavior

Difficult to know where to draw the line between normal & PD

In general, PD only if:
o Dysfunction (self, interpersonal relationships, societal relationships)
o Significant distress
Sexist Biases

Construction of certain PDs may have sexist connotations
o diagnostic criteria for PDs label stereotypical feminine (vs masculine) behaviour as pathothogical
with greater frequency – e.g., histrionic PD, dependent PD, borderline PD

Clinicians may exhibit a gender bias when making a diagnosis
o E.g., more likely to say borderline PD when same hypothetical case was identified as ♀ vs ♂
Theoretical Perspectives
Very little is known about the factors that cause PDs
Psychodynamic Perspectives
PD = result from disturbances in the parent-child relationship; inappropriate identification

Kohut:
o self psychology & narcissistic PD
o façade of self-importance to cover up feelings of inadequacy
o lack of parental empathy & support  sets the stage for pathological narcissism later on

Kernberg:
o difficulties in the development of self in early childhood; pre-Oedipal failure  Borderline PD
o tendencies toward splitting (shift back and forth between viewing self & others as “all good” or
“all bad”)

Mahler:
o Disruption in normal separation – individuation  Borderline PD
Learning Perspectives
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Need to look at learning histories & situational factors; role of reinforcement
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Childhood experiences may shape the development of maladaptive behaviours:
o Children who are discouraged from speaking their minds / exploring their environments 
Dependent PD
o Children who are exposed to excessive parental discipline or overcontrol  Obsessive-Compulsive PD
o Children who get reinforcement/attention (esp. if inconsistent) for their appearance & willingness to
perform for others  Histrionic PD
o Children who lack consistency & predictability that help other children learn associations between
their behaviours & rewards / punishments  Antisocial PD
Family Perspectives
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Disturbances in family relationships
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Borderline PD:
o remember parents in negative ways (more controlling, less caring); see parents and others close to
them as evil …
o history of physical & sex abuse
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Dependent PD:
o Parental overprotection, authoritarianism
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Obsessive-Compulsive PD:
o Strongly moralistic / rigid family environment
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Antisocial PD
o Child abuse / neglect / rejection
Cognitive-Behavioural Perspectives
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role of observational learning in aggressive behaviours (e.g., Bandura) …
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how individuals interpret their social experiences  influence behaviour …
Biological Factors
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Genetic Factors:
o esp. for antisocial, schizotypal, borderline PDs
o diathesis-stress model: individuals who are genetically vulnerable are more likely to dvp PDs IF
they encounter certain environmental influences (e.g., reared in a dysfunctional family)
o biological & adopted children of pp w antisocial PD  more likely to develop this disorder
themselves
Neuropsychological Factors:
o Eysenck: extroverts: lower level of arousal, thus seek out activities that ↑ arousal vs introverts:
higher level of arousal, thus seek to avoid these kinds of situations
o disturbed neurotransmitters (antisocial PD – reduced levels of serotonin & NE)
o brain dysfunction (borderline – high rates of neurological dysfunctions – encephalitis, epilepsy,
minimal brain damage, all of which pt to dysfunctions in the limbic system)
Sociocultural Views
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SES risk factors (low family income, lone-parent family, low parental education, family dysfunction)
related to ↑ vulnerability to 1+ behavioural problems in young children, esp if …; antisocial PD & low SES
…
Treatment
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* poor response to treatment
Usually do not seek treatment
May see others, not themselves, as the problem
Psychodynamic = CBT in effectiveness
Psychodynamic Approaches
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Aims: ↑ awareness of roots of their behaviour patterns & learn better ways of relating to others
Behaviour Approaches
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Aim: Change maladaptive behaviours
How? Techniques: extinction, modeling, reinforcement
Histrionic PD: instruct partners to not reinforce histrionic behaviours
Avoidant PD: social skills training, cognitive methods (to help ↓ catastophizing beliefs
Borderline PD: Beck – help correct cog distortions (e.g., all-or-none thinking); Linehan: dialectical
behaviour therapy (DBT) = behaviour therapy (e.g., social skills training, problem solving techniques) +
psychotherapy
Biological Approaches
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Drug therapy does not directly treat PDs, but Prozac can ↓ aggression, irritability in individuals w various
PDs, such as antisocial PD by ↑ availability of serotonin