personality disorders - UNC School of Medicine



Robert A. Bashford, M.D.

Associate Professor

Michael Hill, M.D.

Associate Professor

UNC Department of Psychiatry

What is a personality??

Types of personality traits are limited and can be conceptualized as dimensional

A generally consistent (but personal) style of interacting with the world and other people

Our ‘character’ is reflected in how we think, what and who we like, and how we respond to life

It is generally stable over time

 allows some predictability

No trait or style is automatically indicative of disorder or disease (don’t confuse eccentricity with disorder)

What is a disorder?

Implies functional impairment / failure to achieve what is expected and/or significant and persistent emotional distress

In the case of Personality Disorders this is by definition a result of a ‘maladaptive’ personality style

What are the most ‘basic’ expectations of our culture


What are the most ‘basic’ expectations of our culture


Follow the rules

What are the most ‘basic’ expectations of our culture


Follow the rules

Maintain long-term relationships

Personality Disorders

An enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture.

Manifested in two or more of the following:

(1) cognition

(2) affectivity

(3) interpersonal functioning

(4) impulse control

Personality Disorders

Pattern is enduring, inflexible, pervasive

Pattern is stable, of long duration

Not better accounted for by another mental disorder

Not due to substance or medical condition

Personality Disorders

Maladaptive behavior leads to poor life functioning

Ego syntonic (others are the root of all problems)

High incidence of co-morbidities (depression, anxiety, substance abuse)

Axis I disorders in PD patients are harder to treat

Difference between health and pathology one of degree (personality traits vs personality disorder)

How do personality disorders develop?

Genetic predispositions + environmental influences (including parenting, life experiences) + time = Personality formation

Obviously in a Personality disorder something in this complicated formula has gone wrong to lead to a maladaptive personality, but it is always very hard to pinpoint specific or simple causes.

What are the problems with

Personality Disorders as a diagnostic category?

Labels are often pejorative

Diagnosis is contextual and thus somewhat arbitrary

Bad, obnoxious, hard-to-treat patients often get these labels whether justified or not

Treatment may be mis-directed

Personality Disorder Clusters

Cluster A - Odd, eccentric

Cluster B - Dramatic, emotional, erratic

Cluster C - Anxious, fearful

Cluster A Personality Disorders

(‘odd & eccentric’)




May be premorbid to schizophrenia in some cases

Paranoid Personality Disorder

(diagnostic criteria)

Pervasive distrust and suspiciousness, sees motives of others as malevolent. Four or more of the following:

(1) suspects, without sufficient basis, that others are exploiting, harming, or deceiving him or her

(2) preoccupied with unjustified doubts about the loyalty or trustworthiness of friends or associates

(3) reluctant to confide in others b/c lack of trust

Paranoid Personality Disorder

(4) persistently bears grudges, i.e., is unforgiving of insults, injuries, or slights

(5) reads hidden demeaning or threatening meanings into benign remarks/events

(6) Perceives attacks on character or reputation that are not apparent to others and responds with counterattacks

(7) has recurrent suspicions, without justification, regarding fidelity of spouse or sexual partner

Characteristics of Paranoid

Personality Disorder

Aloof, emotionally cold

Unjustified suspiciousness, hostility

Hypersensitivity to slights, jealousy

Rigid, unforgiving, sarcastic, litigious

Prevalence: 1-2%; M>F

Therapy, including meds, of little value – trusting relationship is key but hard to come by b/o

‘self-fulfilling prophecy’

Schizoid Personality Disorder

(diagnostic criteria)

Pervasive detachment from social relationships and a restricted range of emotional expression interpersonally. Four or more of the following:

(1) neither desires nor enjoys close relationships, including being part of a family

(2) almost always chooses solitary activities

Schizoid Personality Disorder

(3) little interest in having sexual experiences with another person

(4) takes pleasure in few, if any, activities

(5) lacks close friends or confidants

(6) appears indifferent to the praise or criticism of others

(7) emotionally cold, detached

Characteristics of Schizoid

Personality Disorder

Can perform well in solitary activities (computers, night watchman)

Limited emotional range, detached, daydream a lot

NO increased risk for schizophrenia but many may actually suffer from autism-spectrum disease

 “Loners” not necessarily schizoid, unless functioning impaired (traits vs disorder)

Treatment of little help

Prevalence 2%; M>F

Schizotypal Personality Disorder

(diagnostic criteria)

Little capacity for close relationships accompanied by cognitive or perceptual disturbances and eccentricities of behavior

(1) ideas of reference

(2) odd beliefs or magical thinking, inconsistent with cultural norms

(3) unusual perceptual experiences, including bodily illusions

Schizotypal Personality Disorder

(4) odd thinking and speech (e.g.,vague, circumstantial,metaphorical,over elaborate)

(5) suspiciousness or paranoid ideation

(6) inappropriate or constricted affect

(7) behavior or appearance that is odd, eccentric, or peculiar

(8) lack of close friends or confidants

(9) excessive social anxiety r/t paranoid fears

Characteristics of Schizotypal

Personality Disorder

Isolated, anhedonic, aloof but also


Strange intra-psychic experiences, odd and magical beliefs

Reason in odd ways (ideas of reference)

Anxious, detached

NOT psychotic proportions

3% incidence; M=F

Schizotypal Personality Disorder

 This is the closest DX to ‘Hollywood mental illness’

Increased incidence of schizophrenia in family members

Low dose antipsychotic meds may help with more peculiar sx (but if so then what diagnosis do they really have??)

Cluster B Personality Disorders

(‘emotional, dramatic, erratic’)





Antisocial Personality Disorder

(diagnostic criteria)

Pervasive pattern of disregard for and violation of rights of others since age 15 indicated by 3 or more of the following:

(1) repeatedly breaking the law

(2) deceitfulness - repeated lying, use of aliases, conning others for personal profit or pleasure

(3) impulsivity or failure to plan ahead

Antisocial Personality Disorder

(4) irritability and aggressiveness, as indicated by repeated physical fights or assaults

(5) reckless disregard for safety of self or others

(6) consistent irresponsibility - inconsistent work behavior, doesn’t pay bills/debts

Antisocial Personality Disorder

(7) lack of remorse, as indicated by being indifferent to or rationalizing having hurt,mistreated, or stolen from another

B. The individual is at least age 18 years.

C. There is evidence of Conduct Disorder with onset before age 15 years.

D. Antisocial behavior does not occur exclusively during Schizophrenia or a

Manic Episode

Characteristics of Antisocial

Personality Disorder

Aggressive, irresponsible, truant as teens.

Get into fights, abuse substances, run away, cruel to animals, set fires, do poorly in school, repeated lying.

As adults see criminality, assaultiveness, impulsivity, substance abuse

More than 50% of prison population has

ASPD, 3% of population, M:F 3-5:1

Antisocial Personality Disorder

Childhoods: rejection, neglect, abandonment, poverty, inconsistent discipline

30% of fathers criminals, 50% of fathers alcoholics, chronically unemployed

Male first degree relatives have increased incidence of antisocial personality disorder, substance abuse

Antisocial Personality Disorder

Female first degree relatives have increased incidence of Somatization Disorder

Possible genetic component – gender effects may be relevant (BPD in women)

Increased incidence of non-specific EEG changes (increased slow-wave activity)

May be charming, manipulative

Antisocial Personality Disorder

The terms Antisocial PD, sociopathy

(sociopath) and psychopathy (psychopath) are, for the most part, interchangeable

 “Antisocial” does not mean asocial

Rarely seek help for personality change

Treatment is unsuccessful – which is why we often discount this diagnosis

Borderline Personality Disorder

(diagnostic criteria)

Pervasive instability of interpersonal relationships, self-image and affect with marked impulsivity by early adulthood.

Five or more of the following:

(1) Frantic efforts to avoid real or imagined abandonment

(2) Pattern of intense and unstable interpersonal relationships, alternating b/w extremes of idealization and devaluation

Borderline Personality Disorder

(3) identity disturbance: markedly and persistently unstable self-image or sense of self

(4) impulsivity in at least two potentially selfdamaging areas (sex, spending, substance abuse, reckless driving, binge eating)

(5) recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior

(6) affective instability w/ marked reactivity of mood, lasting few hours to few days

(7) chronic feelings of emptiness

Borderline Personality Disorder

(8) inappropriate, intense anger

(9) transient, stress-related paranoid ideation or severe dissociative symptoms (micropsychotic episodes)

Characteristics of Borderline

Personality Disorder

Death by suicide in 8%

2%-4% incidence, M:F 1:2

 Tend to stabilize in their 40’s or 50’s

Increased prevalence of major depression and substance abuse in first degree relatives

 The “borderland” between neurosis and psychosis

Borderline Personality Disorder

Almost always seem in a state of crisis

Unpredictable, impulsive behavior

 Can’t tolerate being alone

Splitting and projective identification as defenses

High incidence of major depression

Treatment is psychotherapy and symptom-targeted pharmacotherapy, DBT

Comprise 10-20% of all psychiatry admissions

Histrionic Personality Disorder

(diagnostic criteria)

Pervasive excessive emotionality and attention seeking. Five or more of these:

(1) is uncomfortable in situations in which he or she is not the center of attention

(2) interaction with others is often characterized by inappropriate sexually seductive or provocative behavior

Histrionic Personality Disorder

(3) displays rapidly shifting and shallow expression of emotions

(4) consistently uses physical appearance to draw attention to self

(5) has a style of speech that is excessively impressionistic and lacking in detail

(6) shows self-dramatization, theatricality, and exaggerated expression of emotion

(7) is suggestible, i.e., easily influenced by others

(8) considers relationships to be more intimate than they actually are

Characteristics of Histrionic

Personality Disorder

Colorful, dramatic, extroverted behavior in excitable, emotional persons

Inability to maintain deep, long-lasting attachments

Prevalence 2-3%, F>>M

Exaggeration of thoughts and feelings everything is catastrophic or of extreme importance

Histrionic Personality Disorder

Temper tantrums, tears, seductive behavior, coy and flirtatious behavior

Endless need for reassurance

Superficial relationships, vain, selfabsorbed

Treatment is directed towards clarification of inner feelings, psychoanalytically oriented psychotherapy

Narcissistic Personality Disorder

(diagnostic criteria)

Pervasive grandiosity, need for admiration, lack of empathy. Five or more:

(1) grandiose sense of self-importance, expects to be recognized as superior

(2) preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love

 (3) believes he/she is “special,” unique and can only be understood by or should associate with other special people

Narcissistic Personality Disorder

(4) requires excessive admiration

(5) sense of entitlement

(6) interpersonally exploitative, i.e., takes advantage of others to achieve his or her own ends

(7) lacks empathy: is unwilling to recognize or identify with the feelings and needs of others

(8) is often envious of others or believes that others are envious of him or her

(9) shows arrogant, haughty behaviors or attitudes

Characteristics of Narcissistic

Personality Disorder

<1% of general population; M>F

Become enraged at criticism

Fragile self-esteem, prone to depression

Their behavior produces interpersonal difficulties, rejection, loss, occupational problems, which they can’t handle

Chronic, difficult to treat

Aging is handled poorly

Treatment: psychotherapy; poor prognosis

Cluster C Personality Disorders

(‘fearful and anxious’)




Avoidant Personality Disorder

(diagnostic criteria)

Pervasive social inhibition, feelings of inadequacy, hypersensitivity to negative evaluation. Four or more:

(1) avoids occupational activities that involve significant interpersonal contact b/c of fears of criticism, disapproval or rejection

(2) is unwilling to get involved with people unless certain of being liked

Avoidant Personality Disorder

(3) shows restraint within intimate relationships because of the fear of being shamed or ridiculed

(4) is preoccupied with being criticized or rejected in social situations

(5) is inhibited in new interpersonal situations because of feelings of inadequacy

(6) views self as socially inept, personally unappealing, or inferior to others

(7) is unusually reluctant to take personal risks or to engage in new activities for fear of embarrassment

Characteristics of Avoidant

Personality Disorder

Extreme sensitivity to rejection leads to socially withdrawn life

 They have “an inferiority complex”

Uncertain, lack self-confidence, selfeffacing

Withdraw and feel hurt if a request is refused or if they feel rejected or ridiculed

0.5-1.0%; M=F

Avoidant Personality Disorder

 Often take jobs “on the sidelines,” shy and eager to please

Subject to depression, anxiety, anger, phobic avoidance

Unlike schizoid, long for relationships

Treatment: Group or individual psychotherapy, SSRIs

Diagnosis overlaps greatly with Generalized

Social Phobia

Dependent Personality Disorder

(diagnostic criteria)

Pervasive and excessive need to be taken care of, leads to submissive and clinging behavior and fears of separation. Five or more:

(1) has difficulty making everyday decisions without an excessive amount of advice and reassurance from others

(2) needs others to assume responsibility for most major areas of his or her life

(3) has difficulty expressing disagreement

Dependent Personality Disorder

(4) has difficulty initiating or doing things on own

(5) goes to excessive lengths to obtain nurturance and support from others

(6) feels uncomfortable or helpless when alone because of exaggerated fears of being unable to care for himself or herself

(7) urgently seeks another relationship as a source of care and support when a close relationship ends

(8) is unrealistically preoccupied with fears of being left to take care of himself or herself

Characteristics of Dependent

Personality Disorder

Persons with chronic physical illness in childhood may be more prone to the disorder

May stay with an abusive, unfaithful or alcoholic partner rather than face being alone

Treatment: Psychotherapy, often successful

Prevalence: very common; M=F

Compulsive Personality Disorder

A pervasive pattern of preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness, and efficiency.

Four (or more) of the following:

(1) preoccupied with details, rules, lists, order, organization, schedules to the extent that the major point of the activity is lost

(2) shows perfectionism that interferes with task completion

Compulsive Personality Disorder

(3) is excessively devoted to work and productivity to the exclusion of leisure activities and friendships

(not accounted for by obvious economic necessity)

(4) is overly-conscientious, scrupulous, and inflexible about matters of morality, ethics,or values

(not accounted for by cultural or religious identification)

(5) is unable to discard worn-out or worthless objects even when they have no sentimental value

Compulsive Personality Disorder

(6) is reluctant to delegate tasks or to work with others unless they submit to exactly his or her way of doing things

(7) adopts a miserly spending style toward both self and others; money is viewed as something to be hoarded for future catastrophes

(8) shows rigidity and stubbornness

Characteristics of Compulsive

Personality Disorder

Prevalence unknown, more common and in oldest children; M=F

Backgrounds: harsh discipline

Stiff, formal and rigid demeanor, constricted affect

Preoccupied with rules, regulations, orderliness, neatness, details and achievement of perfection

Indecisive b/c afraid of making a mistake, ruminate concerning decisions

Formal, serious, may lack a sense of humor

Compulsive Personality Disorder

Lack flexibility, intolerant

Do well with routines and poorly with changes

Unable to compromise in interpersonal relationships

When recurrent obsessions or compulsions are present, a diagnosis of Obsessive Compulsive

Disorder should be made on Axis I

More likely to seek treatment than those with other personality disorders

Personality Disorder Not

Otherwise Specified

 Don’t meet criteria for any specific personality disorder, but traits cause significant impairment in social or occupational functioning

Very common diagnosis

Movies Depicting Personality


Paranoid – The Caine Mutiny

Schizoid – Remains of the Day

Schizotypal –

Antisocial – Natural Born Killers

Borderline – Fatal Attraction, Single White


Movies Depicting Personality


Narcissistic – Titanic (the rich fiancé)

Histrionic – Streetcar Named Desire

(Blanche Dubois)

OCPD – The Odd Couple (Jack Lemmon)

Avoidant –

Dependent – What about Bob? (Bill