chapter 10 case study for personality disorders margaret

Module 12: Personality Disorders

Case studies: personality disorders, learning objectives.

• Identify personality disorders in case studies

Case Study: Latasha

Latasha was a 20-year-old college student who lived in the dorms on campus. Classmates described Latasha as absent-minded and geeky because she didn’t interact with others and rarely, if ever, engaged with classmates or professors in class. She usually raced back to her dorm as soon as classes were over. Latasha primarily stayed in her room, did not appear to have any friends, and had no interest in the events happening on campus. Latasha even asked for special permission to stay on campus when most students went home for Thanksgiving break.

Now let’s examine some fictional case studies.

Case Study: The Mad Hatter

The Mad Hatter, from Alice in Wonderland , appears to be living in a forest that is part of Alice’s dream. He appears to be in his mid-thirties, is Caucasian, and dresses vibrantly. The Mad Hatter climbs on a table, walks across it, and breaks plates and teacups along the way. He is rather protective of Alice; when the guards of the Queen of Hearts come, he hides Alice in a tea kettle. Upon making sure that Alice is safe, Mad Hatter puts her on his hat, after he had shrunk her, and takes her for a walk. While walking, he starts to talk about the Jabberwocky and becomes enraged when Alice tells him that she will not slay the Jabberwocky. Talking to Alice about why she needs to slay the Jabberwocky, the Mad Hatter becomes emotional and tells Alice that she has changed.

The Mad Hatter continues to go to lengths to protect Alice; he throws his hat with her on it across the field, so the Queen of Heart’s guards do not capture her. He lies to the Queen and indicates he has not seen Alice, although she is clearly sitting next to the Queen. He decides to charm the Queen, by telling her that he wants to make her a hat for her rather large head. Once the White Queen regained her land again, the Mad Hatter is happy.

Case Study: The Grinch

The Grinch, who is a bitter and cave-dwelling creature, lives on the snowy Mount Crumpits, a high mountain north of Whoville. His age is undisclosed, but he looks to be in his 40s and does not have a job. He normally spends a lot of his time alone in his cave. He is often depressed and spends his time avoiding and hating the people of Whoville and their celebration of Christmas. He disregards the feelings of the people, knowingly steals and destroys their property, and finds pleasure in doing so. We do not know his family history, as he was abandoned as a child, but he was taken in by two ladies who raised him with a love for Christmas. He is green and fuzzy, so he stands out among the Whos, and he was often ridiculed for his looks in school. He does not maintain any social relationships with his friends and family. The only social companion the Grinch has is his dog, Max. The Grinch had no goal in his life except to stop Christmas from happening. There is no history of drug or alcohol use.

• Modification, adaptation, and original content. Authored by : Julie Manley for Lumen Learning. Provided by : Lumen Learning. License : CC BY: Attribution
• Case Studies: The Grinch. Authored by : Dr. Caleb Lack and students at the University of Central Oklahoma and Arkansas Tech University. Located at : https://courses.lumenlearning.com/abnormalpsychology/chapter/antisocial-personality-disorder/ . License : CC BY-NC-SA: Attribution-NonCommercial-ShareAlike
• The Mad Hatter. Authored by : Loren Javier. Located at : https://www.flickr.com/photos/lorenjavier/4031000212/ . License : CC BY-ND: Attribution-NoDerivatives
• The Grinch. Located at : https://pixy.org/1066311/ . License : CC0: No Rights Reserved

• Social Science
• Abnormal Psychology

CHAPTER 10: Personality Disorders

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Identify problems associated with diagnosis of personality disorders

There are substantial limitations to the category and cluster designations of the DSM. One of the primary issues is that there are simply too many overlapping features across both categories and clusters.

More misdiagnoses probably occur here than in any other category of disorder. Reasons include that diagnostic criteria are not as sharply defined as they are for most axis I diagnostic categories so they are often not very precise or easy to follow in practice. Because the criteria are defined by inferred traits or consistent patterns of behaviour rather than buy more objective behavioural standards, the clinician must exercise more judgement in making the diagnosis that is the case for many Axis I disorders.

The development of semistructured interviews and self-report inventories has increased certain aspects of diagnostic reliability. However, the agreement between the diagnoses made on the basis of different structured interviews or self-report inventories is often rather low and there are still substantial problems with the reliability and validity of these diagnoses.

What does cluster A of the personality disorders include?

Paranoid, schizoid, and schizotypal personality disorders.

People with these disorders often seem odd or eccentric, with unusual behaviour ranging from distrust and suspiciousness to social detachment.

What do cluster B personality disorders include?

Histrionic, narcissistic, antisocial, and borderline personality disorders.

Individuals share a tendency to be dramatic, emotional, and erratic

What disorders are included in cluster C personality disorders?

Avoidant, dependent, and obsessive-compulsive personality disorders

Often show anxiety and fearfulness

Discuss the difficulties in studying the causes of personality disorders

Little is known partly because such disorders have received consistent attention by researchers only since DSM – I I I was published in 1980 and partly because they are less amenable to thorough study. One major problem in studying the causes a personality disorder stems from the high level of comorbidity among them. Another problem is that most research is retrospective instead of the more valuable prospective research.

Biological factors seem to be the infants temperament or inborn disposition to react affectively to environmental stimuli which predisposes them to the development of particular personality traits and disorders. There is also increasing evidence for genetic contributions. When it comes to psychological factors, psychodynamic theories originally attributed great importance in the development of character disorders to an infant getting excessive versus insufficient gratification of his or her impulses in the first few years of life. Learning based habit patterns and maladaptive cognitive styles have received more attention as possible cause of factors recently. May also originate in disturbed parent-child attachment relationships. Parental psychopathology and ineffective parenting practises have also been implicated. Early emotional, physical, and sexual abuse may also be important factors.

A personality disorder characterized by pervasive suspiciousness and distrust of others.

Tend to see themselves as blameless, instead blaming others for their own mistakes and failures even to the point of ascribing evil motives to others. Are chronically tens and en garde, constantly expecting trickery and looking for clues to validate their expectations while disregarding all evidence to the contrary. Preoccupied with doubts about the loyalty of friends and our hence reluctant to confide in others. Commonly bear grudges, refuse to forgive pereceived insults and slights, and are quick to react with anger and sometimes violent behavior.

They are not usually psychotic; that is, most of the time they are in clear contact with reality, although they may experience transient psychotic symptoms during periods of stress. Share some symptoms found in paranoid personality, but they have any additional problems including more persistent loss of contact with reality, delusions, and hallucinations. Do appear to be at elevated liability for schizophrenia

Paranoid personality disorder

A personality disorder characterized by the inability to form social relationships or express feelings and lack of interest in doing so.

Consequently, they typically do not have good friends, with the possible exception of a close relative. Unable to express their feelings and are seen by others as cold and distant. Often lack social skills and can be classified as loaners or introverts, with solitary interests and occupations. Tend not to take pleasure in many activities, including sexual activity, and rarely marry. Are not very emotionally reactive, rarely experiencing strong positive or negative emotions, but rather a generally apathetic mood.

Schizoid personality disorder

A personality disorder characterized by excessive introversion, pervasive social interpersonal deficits, cognitive and perceptual distortions, and eccentricities in communication and behaviour.

Although contact with reality is usually maintained, highly personalized and superstitious thinking is characteristic, and under extreme stress they may experience transient psychotic symptoms. Often believe they have magical powers and may engage in magical rituals. Other cognitive-perceptual problems include ideas of reference – the belief that conversations or gestures of others have special meaning or personal significance –, odd speech, and paranoid beliefs. Oddities in thinking, speech, and other behaviours are the most stable characteristics and are similar to those often seen in schizophrenic patients.

Schizotypal personality disorder

Causal factors: several studies have shown the same deficit in the ability to track a moving target visually that is common in schizophrenia. Also show numerous other mild impairment in cognitive functioning including deficits in their ability to sustain attention, working memory, both of which are common in schizophrenia. Also show deficits in their ability to inhibit attention to a second stimulus that rapidly follows presentation of a first stimulus similar to schizophrenia.

Associated with elevated exposure to stressful life events and low family socioeconomic status.

A personality disorder characterized by excessive attention seeking, emotional instability, and self-dramatization.

Tend to feel unappreciated if they are not the centre of attention; their life we, dramatic, and excessively extroverted styles often ensure that they can charm others into attending to them. But these qualities do not need to stable and satisfying relationships because others tire of providing this level of attention. Their appearance and behaviour are often quite theatrical and emotional as well as sexually provocative and seductive. May attempt to control their partners through seductive behaviour and emotional manipulation but they also show a good deal of dependence. Speech is often vague and impressionistic, and they are usually considered self-centered, vain, and excessively concerned about the approval of others, who see them as overly reactive, shallow, and insincere

Histrionic personality disorder

A personality disorder characterized by an exaggerated sense of self importance, preoccupation with being admired, and lack of empathy for the feelings of others.

Subtypes: grandiose and vulnerable. Grandiose presentation is manifested by trace related to grandiosity, aggression, and dominance. Reflected in a strong tendency to overestimate their abilities and accomplishments while underestimating the abilities and accomplishments of others. Sense of entitlement is frequently a source of astonishments to others, although they themselves seem to regard there lavish expectations as merely what they deserve. Behave in stereotypical ways to gain the acclaim and recognition they crave. Because they believe they are so special, they often think they can be understood only by other high status people or that they should associate only with such people. Their sense of entitlement is also associated with their unwillingness to forgive others for perceived slights, and they easily take offense.

Vulnerable presentation have a very fragile and unstable sense of self-esteem, and for these individuals, arrogance and condescension is merely a façade for intense shame and hypersensitivity to rejection and criticism. May become completely absorbed and preoccupied with fantasies of outstanding achievement but at the same time experience for found shame about their ambitions. May avoid interpersonal relationships due to fear of rejection or criticism.

Unwilling or unable to take the perspective of others, to see things other than through their own eyes. If they do not receive the validation or assistance they desire, they are inclined to be hypercritical and retaliatory.

Narcissistic personality disorder

A personality disorder characterized by impulsivity and instability in interpersonal relationships, self-image, and moods.

Affective instability – manifested by unusually intense emotional responses to environmental triggers, with the lead recovery to a baseline emotional state. Highly unstable self image – impoverished and/or fragmented. Impulsivity – rapid responding to environmental triggers without thinking or caring about long-term consequences. Often leads to erratic,, self-destructive behaviours such as gambling sprees or reckless driving. Self-mutilation – such as repetitive cutting behaviour associated with relief from anxiety or dysphoria and to communicate the person’s level of distress to others.

Borderline personality disorder

A personality disorder characterized by extreme social inhibition and introversion, hypersensitivity to criticism and rejection, limited social relationships, and low self-esteem.

They do not seek out other people, yet they desire affection and are often lonely and bored. Unlike skis avoid personalities, they do not enjoy their aloneness; their inability to relate comfortably to other people cause acute anxiety and is accompanied by low self-esteem and excessive self-consciousness, which in turn are often associated with depression. The two most prevalent and stable features are feeling inept and socially inadequate.

Avoidant personality disorder

The key difference between the loner with schizoid personality disorder and the loner who is avoidant is that the one with an avoidant personality is shy, insecure, and hypersensitive to criticism, whereas the one with the schizoid personality is aloof, cold, and relatively indifferent to criticism. The avoidant personality also desires interpersonal contact but avoids it for fear of rejection, whereas the schizoid lacks the desire or ability to form social relationships. A less clear distinction is that between avoidant personality disorder and generalized social phobia. There is substantial overlap leading some investigators to conclude that avoidant personality disorder may simply be a somewhat more severe manifestation of generalized social phobia.

A personality disorder characterized by extreme dependence on others, particularly the need to be taken care of, leading to clinging and submissive behaviour.

Usually build their lives around other people and the board made their own needs and views to keep these people involved with them. Maybe indiscriminate in their selection of meats. Often fail to get appropriately angry with others because of a fear of losing their support, which means that people may remain in psychologically or physically abusive relationships. Difficulty making even simple, every day decisions without a great deal of advice and reassurance because they lack self-confidence and feel helpless even when they actually develop the good work skills or other competencies. May function well as long as they are not required to be on their own.

Dependent personality disorder

Some features overlap with those of borderline, histrionic, and avoidant personality disorder’s, but there are also differences. For example, both borderline personalities and dependent fear abandonment however, the borderline who usually has intense and stormy relationships, reacts with feelings of emptiness or rage if abandonment occurs, whereas the dependent personality reacts initially with submissiveness and appeasement and then finally with an urgent seeking of a new relationship. Histrionic and dependent personalities both have strong need for reassurance and approval, but the histrionic personality is much more gregarious, flamboyant, and actively demanding of attention, whereas the dependent personality is more docile and self-effacing. It can also be hard to distinguish between dependent and avoidant personality’s. Dependent personalities have great difficulty separating in relationships because they feel incompetent on their own and have a need to be taken care of, whereas avoidant personalities have trouble initiating relationships because they fear criticism or rejection, which will be humiliating.

This personality disorder is characterized by perfectionism and excessive concern with maintaining order, control, and adherence to rules.

They are very careful in what they do so as not to make mistakes, but because the details there preoccupied with are often trivial they use their time poorly and have a difficult time seeing the larger picture. This perfectionism is often quite dysfunctional in that it can result in their never finishing projects. They also tend to be devoted to work to the exclusion of leisure activities and may have difficulty relaxing or doing anything just for fun. On an interpersonal level, they have difficulty delegating tasks to others and are quite rigid, stubborn, and cold, which is how others tend to view them. Rigidity, stubbornness, and perfectionism, as well as reluctance to delegate, are the most prevalent and stable features.

Obsessive compulsive personality disorder or OCPD

Do not have true obsessions or compulsive rituals that are the source of extreme anxiety or distress. Instead they have lifestyles characterized by over conscientiousness, inflexibility, and perfectionism but without the presence of true obsessions or compulsive rituals.

Some features overlap with features of narcissistic, antisocial, and schizoid personality disorders but there are distinguishing factors. For example, individuals with narcissistic and antisocial personality disorder is me share the lack of generosity toward others that characterizes OC PD, but the former tends to indulge themselves, where as those with OC PD are equally unwilling to be generous with themselves. In addition, both the skids the Wade and the obsessive-compulsive personalities may have a certain amount of formality and social attachment, but only this giveaway personality lacks the capacity for close relationships. The person with OC PD has difficulty in interpersonal relationships because of excessive devotion to work and great difficulty expressing emotions.

Describe general socio-cultural causal factors for personality disorders

Not well understood. The incidence and particular features of personality disorders vary somewhat with time and place, although not as much as one might guess. There is less variance across cultures then within cultures. This may be related to findings that all cultures share the same five basic personality traits, and their patterns of covariation also seem universal.

Discuss the difficulties of treating individuals with personality disorders

Generally very difficult to treat, in part because they are relatively enduring, pervasive, and inflexible patterns of behaviour and inner experience. Moreover, many different goals of treatment can be formulated, and some are more difficult to achieve than others. Goals might include reducing subjective distress, changing specific dysfunctional behaviors, and changing whole patterns of behaviour or the entire structure of the personality. People with personality disorders are often forced into treatment, and often do not believe they need to change. And those from the odd/eccentric cluster A and the erratic/dramatic cluster B have general difficulties in forming and maintaining good relationships, including with a therapist. non-completion of treatment is a particular problem. In addition, people who have both an axis I & and axis I I disorder do not, on average, do as well in treatment for their axes I disorders as patients without comorbid personality disorders.

Describe the approaches to treatment for personality disorders

Treating borderline personality disorder:

The most clinical and research attention has been paid to the treatment of borderline personality disorder, partly because the treatment prognosis has typically been considered to be guarded because of these patients long-standing problems and extreme instability.

Biological – the use of medications is controversial because it is so frequently associated with suicidal behaviour in this disorder. Antidepressant medications most often from the SSRI category are considered most safe and useful for treating rapid mood shifts, anger, and anxiety. In addition, low doses of antipsychotic medication have modest but significant effects that are broad-based. Finally, mood-stabilizing medications such as carbazemine May be useful in reducing irritability, suicidality, and impulse of aggressive behaviour. Ever, the consensus is that drugs are only mildly beneficial. Psychosocial – several types of psychotherapy may be effective. However, these treatments share a common weakness: their relative complexity and long duration, which makes them difficult to disseminate to the broader population. Dialectical behaviour therapy is a unique kind of cognitive and behavioural therapy specially adapted for borderline personality disorder her. Linehan believes that patients inability to tolerate strong states of negative affect is central to this disorder, and one of the primary goals of treatment is to encourage patients to except this negative affect without engaging in self destructive or other maladaptive behaviors. It is a problem-focused treatment based on a clear hierarchy of goals, which prioritizes decreasing suicidal and self harming behaviour and increasing coping skills. Appears to be an effective treatment for this disorder. Other psychosocial treatments for BPD involve variance of psychodynamic psychotherapy adapted for the particular problems of persons with this disorder.

Treating other personality disorders:

Treatment of cluster a and other cluster B personality disorders is not as promising as some of the recent advances that have been made in the treatment of borderline personality disorder her. In schizotypal personality disorder, low doses of antipsychotic drugs may result in modest improvement, and antidepressants from the SSRI category may also be useful. There are no systematic, controlled studies of treating people with either medication or psychotherapy for paranoid, schizoid, narcissistic, or histrionic disorder. Treatment of some of the personality disorders from cluster C, such as dependent and avoidant personality disorder’s, has not been extensively studied but appear somewhat more promising then for the disorders from cluster a and B. A form of short-term psychotherapy that is active and confrontational seems to provide significant improvement for cluster C disorders. Several studies using cognitive behavioural treatment with avoidant personality disorder have also reported significant gains as well as antidepressants from the M a O I and SSRI categories.

A personality disorder characterized by continual violation of and disregard for the rights of others through deceitful, aggressive, or antisocial behavior, typically without remorse or loyalty to anyone.

Have a lifelong pattern of unsocialized and irresponsible behaviour with little regard for safety – either their own or that of others. These characteristics bring them into repeated conflict with society, and a high proportion become incarcerated. Only individuals 18 or over are diagnosed with this disorder.

Antisocial personality disorder

A condition involving the features of antisocial personality disorder and such traits as lack of empathy, inflated and arrogant self appraisal, and glib and superficial charm.

Psychopathy

Often called sociopathy.

Compare and contrast the DSM – IV concept of antisocial personality and Cleckley’s concept of psychopathy

According to Cleckley, psychopathy includes the defining features of antisocial personality, but also includes such affective and interpersonal traits as lack of empathy, inflated and arrogant self appraisal, and glib and superficial charm.

There are two related but separable dimensions of psychopathy:

• Involves the affective and interpersonal core of the disorder and reflects traits such as lack of remorse or guilt, callousness/lack of empathy, glibness/superficial charm, grandiose sense of self worth, and pathological lying
• Reflects behaviour – the aspects of psychopathy that involve an antisocial, impulsive, and socially deviant lifestyle such as the need for stimulation, poor behaviour controls, irresponsibility, and a parasitic lifestyle

When comparisons have been made in prison settings to determine what percentage of prison inmates qualify for a diagnosis of psychopathy versus antisocial personality disorder, it is typically found that about 70 to 80% qualify for a diagnosis of a SPD but that only about 25 to 30% meet the criteria for psychopathy.

Because the psychopath a diagnosis has been shown to be a better predictor of a variety of important facets of criminal behaviour then the ASP diagnosis, many researchers continue to use the Cleckley/hair psychopathy diagnosis rather then the DSM one.

Overall, a diagnosis of psychopathy appears to be the single best predictor we have a violent and recidivism or offending again after imprisonment

List the clinical features of psychopathy and antisocial personality

Inadequate conscience development: appear unable to understand and accept ethical values except on a verbal level

irresponsible and impulsive behavior: learn to take rather than earned what they want. Prone to thrillseeking and deviant and unconventional behavior, they often break the law and possibly and without regard for the consequences. Seldom forgo immediate pleasure for future games and long-range goals. High rates of alcohol abuse and dependence and other substance abuse disorders. Elevated rates of suicide attempts and completed suicide.

ability to impress and exploit others: often charming and likeable, with a disarming manner that easily wins new friends. Seem to have good insight into other people’s needs and weaknesses and are adept at exploiting them. These frequent liars usually seen sincerely sorry if caught in a lie and promised to make amends, but will not do so. Are seldom able to keep close friends.

Summarize the causal factors in psychopathy and antisocial personality

Genetic influences: a moderate heritability, although non-shared environmental influences play an equally important role. Strong environmental influences interact with genetic predisposition’s, a genotype-environment interaction, to determine which individuals become criminals or antisocial personalities. Jean-environment interaction has identified a candidate gene, the monoamine oxidase-a gene, which is involved in the breakdown of neurotransmitters like norepinephrine, dopamine, and serotonin – all neurotransmitters affected by the stress of maltreatment that can lead to aggressive behavior.

The low-fear hypothesis and conditioning: psychopath who are high on the egocentric, Calais, and exploitative dimension have low trait anxiety and show poor conditioning of fear. As a result, psychopaths presumably fail to acquire many of the conditioned reactions essential to normal passive avoidance of punishment, to conscience development, and to socialization. For them conscience is little more than an intellectual awareness of rules others make up or empty words. The deficient conditioning of fear seems to stem from psychopaths having a deficient behavioural inhibition system, the neural system underlying anxiety. It is also the neural system responsible for learning to inhibit responsive to cues that signal punishment. In this passive avoidance learning, one learns to avoid punishment by not making a response. Deficiencies in the system or associate both with deficits in conditioning of anticipatory anxiety and, in turn, with deficits in learning to avoid punishment. Psychopaths do not show the fear-potentiated startle, A larger startle response if a startle probe stimulus is presented when the subject is already in an anxious state. The behavioural activation system which activates behaviour in response to cues for record as well as to cues for active avoidance of threatened punishment, is thought to be normal or possibly overactive in psychopaths, which may explain why they are quite focussed on obtaining reward. And if they are caught in a miss deed, they are very focussed on actively avoiding threatened punishment.

More general emotional deficits: psychopaths show less significant physiological reactivity to distress cues, not under responsive to unconditioned threat cues such as slides of sharks. Such emotional deficits seem to be due to the disfunction in the amygdala that is commonly seen in psychopathy.

Early parental loss, parental rejection, and inconsistency: reactive and instrumental aggression are influenced by the damaging effects of parental rejection, abuse, and neglect accompanied by inconsistent discipline.

Describe the integrated developmental perspective for psychopathy and antisocial personality disorder

These disorders generally begin in early childhood and the number of antisocial behaviours exhibited in childhood is the single best predictor of who will develop an adult diagnosis of a SPD. These early symptoms are associated with a diagnosis of conduct disorder and include theft, truancy, running away from home, and associating with delinquent peers. Family factors that are the most important in predicting which children will show the most antisocial behaviours include poor parental supervision, harsh or erratic parental discipline, physical abuse or neglect, disrupted family life, and a convicted mother. Children with an early history of oppositional defined disorder characterized by a pattern of hostile and defined behaviour toward authority figures that usually begins by the age of six years, followed by early onset conduct disorder around age 9, are most likely to develop a SPD as adults. Children without the pathological background who developed conduct disorder in adolescents do not usually become lifelong antisocial personalities but instead have problems largely limited to the adolescent years.

The second early diagnosis that is often a precursor to adult psychopath he or a SPD is attention-deficit/hyperactivity disorder or ADHD characterized by restless, inattentive, and impulse of behavior, a short attention span, and high distractibility. When ADHD co-occurs with conduct disorder, this leads to a high likelihood that the person will develop a severely aggressive form of a speedy and possibly psychopathy.

Explain why it is difficult to treat psychopathy and antisocial personality

Most do not suffer from much personal distress and do not believe they need treatment.

Describe the most promising of the as yet unproven approaches to treatment for Psychopathy and antisocial personality

Cognitive-behavioral treatments: common targets of this intervention include – increasing self-control, self critical thinking, and social perspective taking; increasing victim awareness; teaching anger management; changing anti-social attitudes; and curing drug addiction. Such interventions required a controlled situation in which the therapist can administer or withhold reinforcement and the individual cannot lead treatment because when treating antisocial behavior, we are dealing with a total lifestyle rather than a few specific, maladaptive behaviors. Even the best of these approaches generally produces only modest changes, although they are somewhat more effective in treating young offenders.

Fortunately, the criminal activities of many psychopathic and antisocial personalities seem to decline after the age of 40 even without treatment, possibly because of week or biological drives, better insight into selfie defeating behaviors, and the cumulative effects of social conditioning. Often referred to as “burned-out psychopaths”. It is only the antisocial behaviour dimension of psychopath that seems to diminish with age; the egocentric, Calais, and exploitative affect of an interpersonal dimensions persist.

A unique kind of cognitive and behavioural therapy specifically adapted for treating borderline personality disorder

Dialectical behaviour therapy

Gradual development of inflexible and distorted personality and behavioural patterns that result in persistently maladaptive ways of perceiving, thinking about, and relating to the world

Personality disorder

According to general DSM criteria, the persons enduring pattern of behaviour must be pervasive and inflexible, as well as stable and of long to ration. It must also cause either clinically significant distress or impairment in functioning and be manifested in at least two of the following areas: cognition, affectivity, interpersonal functioning, or impulse control.

Decks in Abnormal Psychology Class (15):

• Chapter 1 Abnormal Psychology: An Overview
• Chapter 2 Historical And Contemporary Views Of Abnormal Behaviour
• Chapter 3 Causal Factors And Viewpoints
• Chapter 4 Clinical Assessment And Diagnosis
• Chapter 5 – Stress And Physical And Mental Health
• Chapter 6 – Panic, Anxiety, And Their Disorders
• Chapter 7 – Mood Disorders And Suicide
• Chapter 9 – Eating Disorders And Obesity
• Chapter 12 – Sexual Variance, Abuse, And Dysfunction
• Chapter 8 – Somatoform And Dissociative Disorders
• Chapter 10 – Personality Disorders
• Chapter 11 – Substance Related Disorders
• Chapter 13 – Schizophrenia And Other Psychotic Disorders
• Chapter 14 – Neurocognitive Disorders
• Chapter 15 – Disorders Of Childhood And Adolescence
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Major Theories of Personality Disorder, Second Edition

• ROBERT  STERN M.D., Ph.D. ,

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People with personality disorders share an uneasiness in their own skin. There are no birds here with deployed plumage flying toward the silvery tree (1) , only women and men “each unhappy…in [his or her] own way” (2) . They may feel aimless or ashamed, disgraced or doubtful, empty or envious, fearful of others or insatiably needing them. They may forever search for figures to admire while also being unable to commit to life-long goals, nurturing relationships, intimacy, and the pursuit of meanings. They may try to divine what life holds for them through magical signs from far-away planets and galaxies. They may be hesitant or impulsive, or unstable, needing constant admiring recognition, or they may entirely lack feelings for others and become social outcasts. Their lack of ease thus interferes with their human relationships and their creative, productive activities. Indeed, they may well feel like Huraki Murakami’s Frog: “What you see with your eyes is not necessarily real. My enemy is, among other things, the me inside me. Inside me is the un-me” (3) .

Ultimately, theories of disordered personalities are hypotheses—working models—of the pathogenic sources and developmental evolution of these persons’ affects, behavior, perception of self or others, of their anguish, as well as of potential ways to relieve their inordinate malaise and enable them to alter their unsuccessful adaptation to life.

In this second edition of Major Theories of Personality Disorder, the editors, Dr. Mark Lenzenweger and Dr. John Clarkin, two distinguished authorities in personality disorder research, have assembled a group of recognized leaders in their respective fields to present a rich collection of different perspectives on these disturbances. The current edition has two new points of view added to those represented in the earlier version. The senior authors of the other chapters are the same as in the 1996 edition. References are complete through 2003, with occasional 2004 citations.

In the introductory chapter, The Personality Disorders, the editors confront the following significant issues: 1) the controversial nature of categorical versus dimensional conceptualizations of personality disorder diagnostic features; 2) the high degree of overlap among currently defined axis II personality disorders; 3) the absence of published data derived from a large sample of carefully assessed cases in which individual criterion items confirm our current DSM-IV-TR disorder structure; 4) the lack of long-term stability in actual patients of the current criteria of personality disorders; and, finally, 5) the lack of a “gold standard” of validity against which personality disorder diagnoses could be measured.

This introduction is followed by in-depth discussions of seven major theories of personality disorders.

“A Cognitive Theory of Personality Disorders” is presented by Dr. James L. Pretzer and Dr. Aaron T. Beck. The discussion of goals, principles, process, assessment instrumentation, and treatment, including a three-page section on Future Directions, is unchanged from that in the first edition of this volume. New material is only in the seven pages covering validity and effectiveness. Among the 106 references cited, only seven date since 1996. A difference between cognitive therapy and dialectical behavior therapy is alluded to but not discussed.

The following chapter, “A Psychoanalytic Theory of Personality Disorders,” by Dr. Otto Kernberg and Dr. Eve Caligor, is a creative, lucid, updated conceptualization and retelling of Dr. Kernberg’s seminal and broadly based contributions to the field of personality organization and of personality disorders. Although Dr. Kernberg has told the details of his theory—that such patients have disorders of self-object relations—many times with great vigor, persuasive capacity, and passion—starting first with his 1967 article on Borderline Personality Organization (4) —the authors’ narrative here is fleshed out with a myriad of details that posses immediacy, emotional power, and resonance, including a discussion of temperament, of inborn activation thresholds for both rewarding and aggressive affects, and of the capacity for “effortful control.” Dr. Kernberg has originated a structural interview to evaluate personality organization and has developed, together with his collaborators, a specific approach for the treatment of patients with severe personality disorders, expressive, transference-focused psychotherapy (TFP-B) (5) , as well as an approach for individuals with neurotic personality organization (TFP-N) (6) , both of which are briefly described in this chapter. The authors integrate their theory with those of Margaret Mahler, on pre-oedipal separation-individuation and object constancy (p. 125), and of developmentalists like Daniel Stern, on inborn capacities for differentiation of self from non-self and the cross-modal transfer of sensorial experiences in early infancy to construct a model of self (p. 123).

The chapter on attachment-based Interpersonal Theory of Personality Disorders, using a structural analysis of social behavior (SASB) to undertake interpersonal reconstructive therapy (IRT), has been completely and very successfully re-written for this edition by Dr. Lorna Smith Benjamin. With such concepts as free associative path and internalized representations on the one hand, and learned interpersonal patterns and gifts of love on the other, it pays homage to both its psychoanalytic and cognitive behavioral therapeutic antecedents, but draws on optimally effective interventions from many schools of psychotherapy. According to Dr. Benjamin, most of the goals described in the 1996 version of this chapter have been achieved; a treatment manual and software have been published.

In a related chapter entitled “A Contemporary Integrative Interpersonal Theory of Personality Disorders,” new to the current edition, Dr. Aaron Pincus describes “individual differences in personality disorder phenomenology through the structural models, operational definitions, and empirical methods of the interpersonal tradition” (p. 316). Analysis of social behavior on the Interpersonal Circle allows him, for instance, to distinguish valuably between two forms of narcissism: the grandiose and the hypersensitive, closet narcissist. Overall, a tremendous effort is expended on rather mechanical taxonomy: the accountancy, classification, and quantification of phenomenology, less on clinical interpretation or personal meaning of instantaneously observed behavior.

Missing at this juncture is, surprisingly, a chapter on Heinz Kohut’s perspective on narcissistic personality disorders as resulting from a developmental arrest caused by early traumatization from chronically failing attitudes of early caregivers. According to Kohut, and self-psychologists in general, under such circumstances the therapist’s difficult rehabilitative task is to recognize the patient’s inevitable feelings of unmet expectations and to interpret, hopefully to resolve, these reactivated narcissistic needs within the framework of the idealizing and mirroring transferences these individuals develop (7) .

The chapter entitled “An Attachment Model of Personality Disorders,” by Dr. Björn Meyer and Dr. Paul Pilkonis, is an important new addition to the current edition. They discuss Bowlby’s work on the attachment behavioral system, Ainsworth and colleagues’ discovery of distinct infant attachment patterns—secure, ambivalent, and avoidant—as causal factors in the development of personality disturbances and the complex evidence for the role attachment disturbances can play in the etiology and maintenance of personality pathology. They conclude sensibly that insecure attachment should be viewed as a risk factor, but not as an absolute determinant of adult personality disturbances.

In the chapter “Personology: A Theory Based on Evolutionary Concepts,” Dr. Theodore Millon and Dr. Seth D. Grossman describe their creation of a clinical taxonomy, linked to assessment instruments, and their synergistic model of psychotherapy as “a psychologically designed composite and progression among diverse techniques” (p. 385), e.g. behavior modification procedures, cognitive methods, followed by interpersonal techniques. They memorably consider each DSM disorder a “‘pure prototype’…an anchoring referent about which ‘real patients’ vary” (p. 375).

The final daunting and provocative chapter of this volume, “A Neurobehavioral Dimensional Model of Personality Disturbances,” by Dr. Richard A. Depue and Dr. Mark F. Lenzenweger, examines the neurobiology of anxiety, impulsivity, and aggression as they relate to higher-order neurobehavioral systems, personality traits, and personality disturbances. The authors “conceive of personality disturbance as emergent phenotypes arising from the interaction of…neurobehavioral systems underlying major personality traits” (p. 436). They have created a multidimensional visual model of personality disturbance, the three axes of which “are defined by neurobehavioral systems rather than traits” (p. 436): 1) behavioral approach on the vertical y-axis, 2) affiliative reward on the z-axis, and 3) neural constraint on the horizontal x-axis. Within this three-dimensional model “the phenotypical expression of personality disturbance represented by the… reaction surface in the figure…is continuous in nature, changing in character gradually but seamlessly across the surface in a manner that reflects the changing product of the multidimensional interactions…[T]he magnitude of disturbance at any point of the surface is variable, waxing and waning with fluctuations in environmental circumstances, stressors, and interpersonal disruptions…over time” (p. 437). I cannot even begin to do justice in this space to the authors’ uncanny articulation of the subject’s complex, sophisticated details.

These cutting edge essays allow the post-postmodern psychiatrist to view personality disorders through various windows; to choose a paradigm; to decide what he or she needs to listen for, perceive, and comprehend; to use, whenever necessary, “impure interventions” culled from other modes of understanding; and, finally, to hone his or her own voice. Reading this illuminating volume, then consulting it again, will serve that purpose.

This review (doi: 10.1176/appi.ajp.2007.07061021) was accepted for publication in May 2007.

Reprints are not available; however, Book Forum reviews can be downloaded at http://ajp.psychiatryonline.org.

1. Miró J: L’oiseau au plumage déployé vole vers l’arbre argenté. Oil painting on canvas, 1953. Reproduced in Carolyn Lanchner: Joan Miró. New York, The Museum of Modern Art, 1993, pp. 281, 427 Google Scholar

2. Tolstoy L: Anna Karenina. Translated by Pevear R, Volokhonsky L. New York, Viking, 2001, p. 1 Google Scholar

3. Murakami H: Super-frog saves Tokyo, in Huraki Murakami: After the Quake: Stories. Translated by Rubin J. New York, Viking International, 2001, p. 137 Google Scholar

4. Kernberg O: Borderline Personality Organization. J Am Psychoanal Assoc 1967; 15:641-685 Google Scholar

5. Clarkin JF, Yeomans FE, Kernberg OF: Psychotherapy for Borderline Personality: Focusing on Object Relations. Arlington, Va, American Psychiatric Publishing, 2006 Google Scholar

6. Caligor E, Kernberg OF, Clarkin JF: Handbook of Dynamic Psychotherapy for Higher Level Personality Pathology. Arlington, Va, American Psychiatric Publishing, 2007 Google Scholar

7. Ornstein PH: On Narcissism: Beyond the Introduction, Highlights of Heinz Kohut’s Contributions to the Psychoanalytic Treatment of Narcissistic Personality Disorders. New York, International Universities Press, The Annual of Psychoanalysis 1974; 2:127-149 Google Scholar

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Chapter 10 Personality Disorders

10.1. introduction.

Research studies have demonstrated that nine percent of Americans have a personality disorder. A large proportion of this population also has one or more other mental health disorders. [ 1 ] This chapter will describe the signs and symptoms of ten personality disorders and associated treatments. The nursing process will be applied to caring for a client with borderline personality disorder.

10.2. BASIC CONCEPTS

A person’s  personality  is a relatively stable pattern of thinking, feeling, and behaving that evolves over their lifetime. It is unique to each individual and influenced by their experiences, environment (surroundings and life situations), and inherited characteristics.  Personality traits  are characteristics, whether considered positive or negative, that make up one’s personality. Healthy personality traits include characteristics such as the following:

• Demonstrating healthy personal boundaries
• Accepting responsibility for personal actions
• Communicating in a healthy and effective manner
• Obeying laws
• Showing mutual respect in relationships
• Being independent
• Displaying confidence
• Behaving in a non-impulsive manner

Review healthy personal boundaries in the “ Foundational Mental Health Concepts ” chapter. An individual’s personality is considered unhealthy and classified as a disorder when it impacts their interpersonal relationships and results in impaired functioning in social, occupational, or other important areas of their life. [ 1 ]

The  Diagnostic and Statistical Manual of Mental Disorders (DSM-5)  defines a  personality disorder  as an enduring pattern of inner experience and behavior that deviates significantly from the expectations of one’s culture. Its onset can be traced back to adolescence or early adulthood and is present in a variety of contexts. This abnormal pattern of behavior is manifested in two or more of the following areas [ 2 ]:

• Cognition (i.e., ways of perceiving and interpreting self, other people, and events)
• Affect (i.e., the range, intensity, lability, and appropriateness of emotional response)
• Interpersonal functioning
• Impulse control

There are ten different personality disorders that are categorized into three clusters (A, B, and C) in the  DSM-5 . Personality disorders within each cluster have similar patterns of behavior. The ten disorders include Cluster A (paranoid, schizoid, schizotypal), Cluster B (antisocial, narcissistic, borderline, histrionic), and Cluster C (dependent, avoidant, and obsessive-compulsive personality disorder). [ 3 ]

Based on several research studies, obsessive-compulsive personality disorder is the most common personality disorder in the United States, followed by narcissistic and borderline personality disorders. However, the most common personality disorder varies from country to country. [ 4 ]

Each personality disorder is further described in the following sections. As you read through each section, keep in mind that these disorders are more than just personality traits; they are diagnosed based on patterns of behaviors that significantly impair a person’s functioning.

Cluster A Personality Disorders

Cluster A personality disorders include paranoid personality disorder, schizoid personality disorder, and schizotypal personality disorder. Cluster A is characterized as the odd, eccentric cluster. Individuals with these types of disorders often experience social awkwardness.

Paranoid Personality Disorder

The  DSM-5  defines  paranoid personality disorder  as a “pervasive distrust and suspiciousness of others such that their motives are interpreted as malevolent.” [ 5 ] It is diagnosed in individuals with four or more of the following characteristics [ 6 ]:

• Suspects without evidence that others are exploiting, harming, or deceiving them
• Preoccupied with unjustified doubts about the loyalty or trustworthiness of friends or associates
• Reluctant to confide in others because of unwarranted fear that the information will be used maliciously against them
• Reads hidden meaning or threatening meanings into benign remarks or events
• Persistently bears grudges (i.e., is unforgiving of insults, injuries, or slights)
• Perceives attacks on their character or reputation that are not apparent to others and is quick to react angrily or to counterattack
• Has recurrent suspicions without justification regarding fidelity of spouse or sexual partner

See Figure 10.1 [ 7 ] for a word cloud image representing paranoid personality disorder.

Figure 10.1

Schizoid Personality Disorder

The  DSM-5  defines  schizoid personality disorder  as a “pervasive pattern of detachment from social relationships and a restricted range of expression of emotions in interpersonal settings.” [ 8 ] It is diagnosed in individuals with four or more of the following characteristics [ 9 ]:

• Neither desires nor enjoys close relationships including being part of a family
• Almost always chooses solitary activities
• Has little, if any, interest in having sexual experiences with another person
• Takes pleasure in few, if any, activities
• Lacks close friends other than first-degree relatives
• Appears indifferent to the praise or criticism of others
• Shows emotional coldness, detachment, or flat affect

See Figure 10.2 [ 10 ] for a word cloud image representing schizoid personality disorder.

Figure 10.2

Schizotypal Personality Disorder

The  DSM-5  defines  schizotypal personality disorder  as a “pervasive pattern of social and interpersonal deficits marked by acute discomfort with and reduced capacity for close relationships, as well as by cognitive or perceptual distortions and eccentricities of behavior.” [ 11 ] It is diagnosed in individuals with five or more of the following characteristics [ 12 ]:

• Ideas of reference  (i.e., the false belief that coincidental events relate to oneself). For example, a person shopping in a store sees two strangers laughing and believes that they are laughing at them, when, in reality, the other two people do not even notice them.
• Odd beliefs or magical thinking that influence behavior and are inconsistent with cultural norms ( Magical thinking  refers to the idea that one can influence the outcome of specific events by doing something that has no bearing on the circumstances. For example, a person watching a baseball game exhibits magical thinking when believing that holding the remote control in a certain position caused their favorite player to hit a home run.)
• Unusual perceptual experiences including bodily illusions (A  body illusion  refers to a perception that one’s body is significantly different from its actual configuration. For example, a person lying in bed feels as if they are levitating.)
• Odd thinking and speech
• Suspiciousness or paranoid ideation
• Inappropriate or constricted affect
• Behavior or appearance that is odd, eccentric, or peculiar
• Lack of close friends or confidants other than first-degree relatives
• Excessive social anxiety that does not diminish with familiarity and tends to be associated with paranoid fears rather than negative judgments about self

See Figure 10.3 [ 13 ] for a word cloud image representing schizotypal personality disorder.

Figure 10.3

Cluster b personality disorders.

Cluster B personality disorders include antisocial, borderline, histrionic, and narcissistic personality disorders. Cluster B personality disorders are characterized by dramatic, overly emotional, or unpredictable thinking or behavior.

Antisocial Personality Disorder

The  DSM-5  defines  antisocial personality disorder  as a “pervasive pattern of disregard for and violation of the rights of others since age 15.” [ 14 ] It is diagnosed in individuals with three or more of the following characteristics [ 15 ]:

• Failure to conform to social norms with respect to lawful behaviors, as indicated by repeatedly performing acts that are grounds for arrest
• Deceitfulness, as indicated by repeated lying, use of aliases, or conning others for personal profit or pleasure
• Impulsivity or failure to plan ahead
• Irritability and aggressiveness, as indicated by repeated physical fights and assaults
• Reckless disregard for the safety of self or others
• Consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or honor financial obligations
• Lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another person

See Figure 10.4 [ 16 ] for a word cloud image representing antisocial personality disorder.

Figure 10.4

Borderline Personality Disorder

The  DSM-5  defines  borderline personality disorder  as a “pervasive pattern of instability of personal relationships, self-image, and affect with significant impulsivity.” [ 17 ] It is diagnosed in individuals with five or more of the following characteristics [ 18 ]:

• Frantic efforts to avoid real or imagined abandonment
• A pattern of unstable and intense personal relationships characterized by alternating between extremes of idealization and devaluation (referred to as  splitting )
• Identity disturbance with significantly and persistently unstable self-image or sense of self
• Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance misuse, reckless driving, or binge eating)
• Recurrent suicidal behavior or self-mutilating behavior
• Unstable affect with significant mood reactivity (i.e., intense anxiety or irritability usually lasting only a few hours)
• Chronic feelings of emptiness
• Inappropriate, intense anger or difficulty controlling anger
• Transient, stress-related paranoid ideation or severe dissociative symptoms ( Dissociative symptoms  include the experience of detachment or feeling as if one is outside one’s body. It is often associated with loss of memory of the experience. Dissociative disorders are associated with an individual’s previous experience of trauma.)

See Figure 10.5 [ 19 ] for a word cloud image representing borderline personality disorder.

Figure 10.5

Histrionic Personality Disorder

The  DSM-5  defines  histrionic personality disorder  as a “pervasive pattern of excessive emotionality and attention seeking.” [ 20 ] It is diagnosed in individuals with five or more of the following characteristics [ 21 ]:

• Uncomfortable in situations in which they are not the center of attention
• Interaction with others is characterized by inappropriate sexually seductive or provocative behavior
• Rapidly shifting and shallow expression of emotion
• Consistently uses physical appearance to draw attention to oneself
• Excessively impressionistic speech that is lacking in detail
• Shows self-dramatization, theatricality, and exaggerated expression of emotion
• Suggestible (i.e., easily influenced by others)
• Considers relationships to be more intimate than they actually are

See Figure 10.6 [ 22 ] for a word cloud image representing histrionic personality disorder.

Figure 10.6

Narcissistic Personality Disorder

The  DSM-5  defines  narcissistic personality disorder as a “pervasive pattern of grandiosity (in fantasy or behavior), need for attention, and lack of empathy.” [ 23 ] It is diagnosed in individuals with five or more of the following characteristics [ 24 ]:

• Has a grandiose sense of self-importance (i.e., exaggerates achievements and talents)
• Is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love
• Believes they are “special” and can only be understood by, or should only associate with, other “special” or high-status people (or institutions)
• Requires excessive admiration
• Has a sense of  entitlement  (i.e., unreasonable expectations of especially favorable treatment)
• Exploits others to achieve their own goals
• Lacks empathy and the ability to identify with the feelings and needs of others
• Is often envious of others or believes that others are envious of them
• Shows arrogant or haughty behaviors or attitudes

See Figure 10.7 [ 25 ] for a word cloud image representing narcissistic personality disorder.

Figure 10.7

Cluster c personality disorders.

Cluster C personality disorders include avoidant, dependent, and obsessive-compulsive personality disorders. Cluster C personality disorders are characterized by anxious, fearful thinking or behavior.

Avoidant Personality Disorder

The  DSM-5  defines  avoidant personality disorder  as a “pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation.” [ 26 ] It is diagnosed in individuals with four or more of the following characteristics [ 27 ]:

• Avoids occupational activities that involve significant interpersonal contact because of fears or criticism, disapproval, or rejection
• Is unwilling to get involved with people unless certain of being liked
• Shows restraint within intimate relationships because of the fear of being shamed or ridiculed
• Is preoccupied with being criticized or rejected in social situations
• Is inhibited in new interpersonal situations because of feelings of inadequacy
• Views self as socially inept, personally unappealing, or inferior to others
• Is unusually reluctant to take personal risks or to engage in any new activities because they may prove embarrassing

See Figure 10.8 [ 28 ] for a word cloud image representing avoidant personality disorders.

Figure 10.8

Dependent Personality Disorder

The  DSM-5  defines  dependent personality disorder  as a “pervasive and excessive need to be taken care of that leads to submission and clinging behavior and fears of separation.” [ 29 ] It is diagnosed by five or more of the following characteristics [ 30 ]:

• Has difficulty making everyday decisions without an excessive amount of advice and reassurance from others
• Needs others to assume responsibility for most major areas of their life
• Has difficulty expressing disagreement with others because of fear of loss or support or approval
• Has difficulty initiating projects or doing things on their own because of lack of self-confidence in judgment or abilities
• Goes to excessive lengths to obtain nurturance and support from others to the point of volunteering to do things that are unpleasant
• Feels uncomfortable or helpless when alone because of exaggerated fears of being unable to care for themselves
• Urgently seeks another relationship as a source of care and support when a close relationship ends
• Is unrealistically preoccupied with fears of being left to take care of themselves

See Figure 10.9 [ 31 ] for a word cloud image representing dependent personality disorder.

Figure 10.9

Obsessive-Compulsive Personality Disorder

The  DSM-5  defines  obsessive-compulsive personality disorder  as a “pervasive pattern or preoccupation with orderliness, perfectionism, and mental and interpersonal control at the expense of flexibility, openness, and efficiency.” [ 32 ] It is diagnosed in individuals with four or more of the following characteristics [ 33 ]:

• Is preoccupied with details, rules, lists, order, organization, or schedules to the extent that the major point of the activity is lost
• Shows perfectionism that interferes with task completion (i.e., is unable to complete a project because their overly strict standards are not met)
• Is excessively devoted to work and productivity to the exclusion of leisurely activities and friendships
• Is overconscientious, scrupulous, and inflexible about matters of morality, ethics, or values (not accounted for by cultural or religious identification)
• Is unable to discard worn-out or worthless objects even when they have no sentimental value
• Is reluctant to delegate tasks or work with others unless they submit to exactly their way of doing things
• Adopts a miserly spending style towards self and others; money is viewed as something to be hoarded for future catastrophes
• Shows rigidity and stubbornness

Obsessive-compulsive personality disorder (OCPD) is a different disorder than obsessive-compulsive disorder (OCD). OCPD includes long-term personality traits characterized by extreme perfectionism, rigidity, and adherence to rules. A person with OCPD is often proud of these personality traits. Conversely, OCD includes uncontrollable, recurring thoughts (obsessions) and/or behaviors (compulsions) that cause the individual significant emotional distress.

Review the “ Obsessive-Compulsive Disorder ” section of the “Anxiety Disorders” chapter for more details about obsessive-compulsive disorder.

See Figure 10.10 [ 34 ] for a word cloud image representing obsessive-compulsive personality disorder.

Figure 10.10

View the following khan academy youtube video explaining personality disorders [ 35 ]:  personality disorders., reflective question:.

When does one’s personality become a disorder versus just personality traits?

Risk Factors for Personality Disorders

Research suggests that genetics, childhood trauma, peer influences, and other factors can contribute to the development of personality disorders. [ 36 ]

• Genetics:  Researchers have identified possible genetic factors behind personality disorders. One study identified a malfunctioning gene that may be a factor in obsessive-compulsive personality disorder. Research reveals the importance of gene-environment interactions in the development of antisocial behavior and psychopathic traits. [ 37 ],[ 38 ]
• Childhood trauma:  Research has linked childhood trauma and the development of personality disorders, especially if the individual’s caregiver(s) do not validate the feelings associated with the trauma. People with borderline personality disorder, for example, had especially high rates of childhood sexual trauma. [ 39 ] In another study of 793 mothers and children, researchers asked mothers if they had screamed at their children, told them they didn’t love them, or threatened to send them away. Children who had experienced such verbal abuse were three times as likely as other children to have borderline, narcissistic, obsessive-compulsive, or paranoid personality disorders in adulthood. [ 40 ]
• Overactive or sensitive nervous system response:  Overly sensitive children who have a high reactivity to light, noise, texture, and other stimuli are more likely to develop shy, timid, or anxious personalities. [ 41 ]

Certain positive factors can help prevent children from developing personality disorders. For example, a single strong relationship with a relative, teacher, or friend can offset negative influences. Strong resiliency factors contribute to health and development of a child. [ 42 ]

10.3. TREATMENT FOR PERSONALITY DISORDERS

Clients with some types of personality disorders do not exhibity insight for their condition and are unlikely to seek treatment. They often go undiagnosed unless they seek treatment for another psychiatric or medical diagnosis. Some may also be forced to seek treatment at the influence of family members or as required by law if legal infractions have occurred. Personality disorders can be challenging for mental health professionals to treat. Individuals with personality disorders struggle to recognize that their difficulties in life are related to their personalities. They may truly believe their problems are a result of other people or outside factors. It is very common for clients with personality disorders to also have substance abuse, anxiety, depression, or eating disorders. [ 1 ]

Psychotherapy is the first line of treatment for personality disorders. Medications may also be prescribed to treat underlying co-occurring conditions such as anxiety or depression.

Psychotherapy

During psychotherapy, an individual can gain insight and knowledge about the personality disorder and what is contributing to their symptoms. They talk about their thoughts, feelings, and behaviors and ideally will develop an understanding of the impact of their thoughts and behaviors on themselves and others. They learn strategies for managing and coping with their symptoms. This treatment can help reduce problematic behaviors that impact an individual’s relationships and functioning. [ 2 ]

Common types of psychotherapy used to treat personality disorders are as follows [ 3 ]:

• Cognitive behavior therapy
• Dialectical behavior therapy
• Interpersonal therapy
• Psychoanalytic/psychodynamic therapy
• Psychoeducation

Cognitive behavior therapy (CBT) teaches the client to become more aware of the way they think so they can ultimately change the way they behave.

Dialectical behavior therapy (DBT) is a type of cognitive behavioral therapy that was originally created for clients with borderline personality disorder to help them cope with stress, control emotions, and establish healthy relationships. It is considered the gold standard for treating borderline personality disorder and is also used for other types of disorders. The client learns how to be aware of how thoughts, feelings, behaviors link together. They learn how to use their senses to be aware of what is happening around them and how to use strategies (such as mindfulness, distress tolerance, interpersonal effectiveness, and emotion regulation) to react calmly in a crisis, avoid negative impulsive behavior, and improve relationships. [ 4 ] See Figure 10.11 [ 5 ] for an illustration of how thoughts, feelings and behaviors are linked together.

Figure 10.11

Dialectical Behavior Therapy

Interpersonal therapy focuses on developing healthy relationships with others. Negative aspects of relationships, such as social isolation and aggression, are identified, and strategies to improve relationships are discussed and planned.

Psychodynamic therapy promotes self-reflection and self-examination of problematic relationship patterns and unresolved conflicts. It can bring awareness of how one’s past has an influence on one’s present behavior.

Psychoeducation teaches the client about their medications, psychotherapies, and support groups available in the community. Wraparound services may be planned with an individualized plan of care that brings multiple services/supports together for the client.

Pharmacotherapy

There are no specific medications approved to treat personality disorders. However, clients who have severe symptoms may be prescribed medications as off-label use that are not necessarily approved by the U.S. Food and Drug Administration (FDA) for personality disorders but are guided by expert opinion and experience. The decision to treat an individual with a personality disorder with medication should be made through shared decision-making with the client based on drug efficacy for their symptoms, potential adverse effects, and their degree of impairment. [ 6 ]

Symptom domains that cause impairment and distress across personality disorders and medications commonly used to treat them include the following [ 7 ]:

• Cognitive-perceptual symptoms (e.g., hallucinations and paranoid ideation): Treated with low-dose antipsychotics such as aripiprazole, risperidone, and quetiapine.
• Impulsive behaviors (e.g., self-injury, theft, interpersonal conflict): Treated with mood stabilizers (such as lithium and lamotrigine). Omega-3 is used as an adjunct to treat clients who demonstrate recurrent self-harm.
• Affective dysregulation (e.g., depressed mood, mood lability, anxiety, anger): Treated with low-dose antipsychotics and mood stabilizers.

Some guidelines apply to medications prescribed to clients with personality disorders for safety reasons. For example, medications that can be fatal in overdose should be avoided, as well as those that can induce physiological dependence and tolerance. Benzodiazepines can be especially toxic when combined with alcohol or opioids, and they can also cause behavioral disinhibition in patients with personality disorders. [ 8 ] Nurses should keep these safety guidelines in mind when teaching clients about their medications.

10.4. APPLYING THE NURSING PROCESS TO PERSONALITY DISORDERS

This section will apply the nursing process to caring for a client diagnosed with borderline personality disorder who is hospitalized due to self-injurious behavior.

Assessment includes interviewing the client, observing verbal and nonverbal behaviors, completing a mental status examination, and performing a psychosocial assessment. Review information about performing a mental status examination and psychosocial assessment in the “ Application of the Nursing Process in Mental Health Care ” chapter.

Assessment findings for clients hospitalized with borderline personality disorder may include the following [ 1 ]:

• Feelings of emptiness
• Self-mutilation and self-harm
• Suicidal behaviors, gestures, or threats
• Extreme mood shifts that occur in a matter of hours or days
• Impulsive behavior such as reckless driving, unsafe sex, substance use, gambling, overspending, or binge eating
• Intense feelings of abandonment
• A tendency towards anger, sarcasm, and bitterness
• Intense and unstable relationships

Review how to assess for suicide risk in the “ Foundational Mental Health Concepts ” chapter.

Diagnostic and lab work.

There is no specific laboratory test that diagnoses personality disorders. Laboratory or diagnostic tests may be used to rule out other possible causes for the behaviors the client is exhibiting. For example, a thyroid stimulating hormone (TSH) test may be ordered because thyroid disorders can affect mood.

Mental health disorders are diagnosed by mental health providers using the diagnostic criteria in the  DSM-5 . Personality disorder diagnoses are typically not made until late adolescence or over the age of 18 because it is important to determine if the symptoms are traits of a developmental stage or pervasive traits of a personality disorder in multiple contexts.

Nurses create individualized nursing care plans based on the client’s response to their mental health disorder(s). Common nursing diagnoses related to the clusters of personality disorders include the following:

• Cluster A:   Social Isolation, Disturbed Thought Process, Risk for Loneliness
• Cluster B:   Risk for Suicide, Risk for Self-Directed Violence, Social Isolation, Chronic Low Self-Esteem, Ineffective Coping
• Cluster C:   Anxiety, Risk for Loneliness, Social Isolation

Common nursing diagnoses for clients diagnosed and hospitalized with borderline personality disorder are further described in Table 10.4 .

Common Nursing Diagnoses for Clients With Borderline Personality Disorder [2],[3]

Outcomes Identification

In the acute care setting, the focus for setting goals and outcomes is the reason for admission, which may include conditions such as suicidal ideation, self-injurious behavior, severe depression, or severe anxiety. Outcomes should address the acute nursing diagnoses with prioritization on safety. For example, if the client has a nursing diagnosis of  Risk for Self-Mutilation , a SMART outcome could be, “The client will refrain from intentional self-inflicted injury during hospitalization.” Read more information about setting SMART outcomes in the “ Application of the Nursing Process in Mental Health Care ” chapter.

Examples of other SMART outcomes for clients hospitalized with borderline personality disorder may include the following [ 4 ]:

• The client will remain safe and free of injury during their hospital stay.
• The client will seek help from staff when experiencing urges to self-mutilate during hospitalization.
• The client will identify three triggers to self-mutilation by the end of the shift.
• The client will describe two preferred healthy coping strategies by the end of the week.

Planning Interventions

Individuals diagnosed with borderline personality disorder may be suicidal, self-mutilating, impulsive, angry, manipulative, or aggressive. Nurses plan interventions according to the symptoms the client is currently exhibiting with the goal of keeping the client and others safe and free of injury. Review interventions for clients diagnosed with  Risk of Suicide  in the “ Application of the Nursing Process in Mental Health Care ” chapter.

Clear boundaries and limits should be set and consistently reinforced by the health care team. When behavioral problems emerge, the nurse should calmly review therapeutic goals, limits, and boundaries with the client. [ 5 ]

Implementing Interventions

Promoting safety.

When implementing planned interventions, the nurse must always consider safety. Develop a crisis/safety plan with the client that includes components such as these:

• Identifying thoughts or behaviors that increase the risk of harming self or others
• Identifying people, events, or situations that trigger those thoughts or behaviors
• Implementing coping strategies
• Reaching out to other coping resources

For example, if a client performs superficial self-injurious behavior, the nurse should act based on agency policy while remaining neutral and dressing the client’s self-inflicted wounds in a matter-of-fact manner. The client may be asked to write down the sequence of events leading up to the injuries, as well as the consequences, before staff will discuss the event. This cognitive exercise encourages the client to think independently about their triggers and behaviors and facilitates discussion about alternative actions. [ 6 ]

De-Escalating

The nurse should implement de-escalation strategies if the client exhibits early signs of increasing levels of anxiety or agitation. Strategies include the following:

• Speaking in a calm voice
• Avoiding overreacting
• Implementing active listening
• Expressing support and concern
• Avoiding continuous eye contact
• Asking how you can help
• Reducing stimuli
• Moving slowly
• Remaining patient and not rushing them
• Offering options instead of trying to take control
• Avoiding touching the client without permission
• Verbalizing actions before initiating them
• Providing space so the client doesn’t feel trapped
• Avoiding arguing and judgmental comments
• Setting limits early and enforcing them consistently across team members
• Addressing manipulative behaviors therapeutically

If the client continues to escalate, measures must be taken to keep the client and others safe. Review signs of crisis and crisis interventions in the “ Stress, Coping, and Crisis Intervention ” chapter. If interventions are not effective in de-escalating a client at risk to themselves or others, seclusion or restraints may be required. Review using seclusion and restraints in the “ Psychosis and Schizophrenia ” chapter.

Coping Strategies

Teaching self-care and coping strategies is helpful for people diagnosed with personality disorders and their loved ones. [ 7 ] Read about stress management and coping strategies in the “ Stress, Coping, and Crisis Intervention ” chapter.

For clients seeking immediate relief from intense symptoms such as panic or depersonalization, nurses can teach how to stimulate the parasympathetic nervous system. Stimulation of the vagal nerve can result in an immediate, direct relief of intense emotions. This can be accomplished by doing the following [ 8 ]:

• Applying ice or ice-cold water to the face
• Performing paced-breathing techniques in which the exhalation phase is at least two to four counts longer than the inhalation phase. For example, advise the client to inhale while counting to four and then exhale while counting to eight.

Collaborative Interventions

First-line treatment for personality disorders is psychotherapy. Examples of psychotherapy used with clients with personality disorders are cognitive behavioral therapy, dialectical behavioral therapy, interpersonal therapy, mentalization-based therapy, psychodynamic psychotherapy, and psychoeducation. Read more about these treatments in the “ Treatment for Personality Disorders ” section of this chapter.

There are no specific medications approved to treat personality disorders. However, clients may be treated for symptoms associated with personality disorders that cause them significant impairment and distress. Read more information about common medications used to treat symptoms of personality disorders in the “ Treatment for Personality Disorders ” section of this chapter.

Refer to the SMART outcomes established for each individual client to evaluate the effectiveness of the planned interventions. Modification of the established nursing care plan may be required based on the effectiveness of the interventions.

10.5. SPOTLIGHT APPLICATION

Kay is a 27-year-old female who is admitted to the mental health unit for feelings of depression and suicidal ideations. She has a history of cutting her legs and arms since she was a teenager. She started psychiatric treatment at age 16 and has been admitted to the psychiatric hospital three times due to overdoses. She admits to a history of promiscuous behavior and occasional marijuana use. She is unmarried but reports having several relationships with male partners. However, she shares that the relationships “never worked out” because the partners didn’t pay enough attention to her or text her as frequently as she expected, which made her angry. She describes feelings she experienced in relationships where one day she felt as if her partner was the “best thing ever,” but the next day she “can’t stand him.” She admits to abusive behaviors toward her partners when she was angry, but states that afterwards she experiences anxiety fearing the loss of the relationship. She acknowledges having trouble getting along with others. She has very few close friends and refers to previous friends as “losers.” She is unemployed with a history of several jobs from which she was terminated because of problems with anger control. There is evidence of scarring and recent cuts on bilateral lower arms. She related these injuries to self-cutting, which she reports “makes me feel better.” She reports attending dialectical behavior therapy (DBT) in the past but hasn’t attended therapy for over a year. She feels therapy helped her to learn how to feel more “in control of her extreme feelings.”

Critical Thinking Questions:

List the symptoms Kay is experiencing that supports the diagnosis of borderline personality disorder (BPD).

Symptoms of BPD include anger, anxiety, impulsiveness, difficulty controlling emotions, self-injury, suicidal, intense/stormy relationships, and risky behaviors.

Identify possible risk factors contributing to BPD.

Possible risk factors include environmental factors that may contribute to BPD, including neglect, abuse, and genetics.

Discuss two types of psychotherapy that may be prescribed for clients diagnosed with BPD.

Cognitive behavioral therapy, dialectical behavioral therapy, interpersonal therapy, mentalization-based therapy, and psychodynamic therapy are types of psychotherapy that may be prescribed for clients.

List at least three nursing interventions that should be included in this client’s care plan.

• Explain policies, expectations, rules, and consequences upon admission.

• Search the client’s belongings and remove anything that could be used to inflict harm to self or others.

• Implement suicide precautions based on a suicide risk screening tool.

• Set and document clear boundaries and limits and share them with team members.

• Encourage consistent implementation of limits by all team members; do not allow bargaining.

• Call out manipulative behavior when it occurs.

• If an episode of cutting occurs during hospitalization, remain neutral and dress the client’s self-inflicted wounds in a matter-of-fact manner. Ask the client to write down the sequence of events leading up to the injuries before discussing the event. Encourage the client to think independently about her triggers and behaviors and facilitate discussion about alternative actions.

10.6. LEARNING ACTIVITIES

Learning activities, (answers to “learning activities” can be found in the “answer key” at the end of the book. answers to the interactive activities are provided as immediate feedback.).

Please respond to the following questions.

Compare the difference between obsessive-compulsive personality disorder and the anxiety disorder of obsessive-compulsive disorder (OCD).

Name that personality disorder. Read each scenario and choose a personality disorder associated with the traits included in the scenario:

Darla enters the breakroom at her job. She is dressed provocatively with excessive jewelry. She makes eye contact with everyone. She sits down and quickly interjects herself into the conversation. When one of her coworkers shares pictures of her new puppy, she pulls out her cell phone to show pictures of herself and tells the group how she had a romantic weekend with her handsome, rich boyfriend.

Bob has been summoned to his supervisor’s office. Despite his adequate job performance, he thinks to himself, “I knew it! She’s out to get me and I am getting fired! She and others walk by my desk several times a day just to check up on me and see what I am doing. And that new employee has been trying to strike conversations with me, but I am not falling for that. I am sure he just wants something from me.”

Debbie is distraught after her boyfriend called her and told her their relationship was over. She began yelling on the phone, “I love you and can’t live without you.” The ex-boyfriend ends the phone call. Debbie begins calling him over and over; however, he doesn’t answer the phone. She then leaves a message stating, “I hate you. I never want to see you again.” Overcome with emotion, she begins to cut her wrist with a bobby pin.

George is a loner and lives alone with his five cats. He has family members who live in the area, but he hasn’t seen them in years, and that is okay with him. He has never been married or been in an intimate relationship. He does not have any close friends. He enjoys his job as a night security guard because there is little requirement for social interaction.

Jordan is always trying to please others. She has trouble starting or completing projects because of a lack of self-confidence. She requires much reassurance and advice when making ordinary decisions. She allows her boyfriend to tell her what to wear, what kind of job to look for, and with whom to associate. She is afraid of him leaving her, so she is very careful not to get him mad at her.

Roger has been arrested several times for domestic abuse and driving while intoxicated. He shows no remorse for any of his actions or the injuries he has caused others. He lies, breaks laws, and has no regard for the feelings of others. As a teenager, he was always in trouble and truant from school. He was incarcerated in the past but found it easy to manipulate the guards into breaking the rules for him.

Deanna has very few friends. She is shy and avoids social interaction, even at work. She is worried that if she did get to know people better, she might say or do something embarrassing, and they might criticize or reject her. During her performance evaluation with her supervisor, she left the office crying because of minor constructive feedback she received. To prevent these painful experiences, she believes it is best to keep to herself.

Billy tells everyone how important he is to his company. He believes there is no way the company would be successful without him. During work meetings, he monopolizes the conversation and strives to be the center of attention. He often asks others, “Don’t you think I did a great job with that?” Although he does not have any close relationships with coworkers, he does collaborate with a few of them because they are able to help him accomplish his goals.

Bobbi works as an administrative assistant. She is very organized and spends a lot of time making lists, scheduling, and reviewing details. Although she has several friends, she often passes on the opportunity to get together because she spends most of her time devoted to work. Sometimes, despite her efforts, she has difficulty finishing a project because she feels the need to check things “one more time.”

Paul is loner and lacks close friends outside of his immediate family. Most view him as being very unusual, including his odd way of dressing. He wears ill-fitting and bizarre clothing combinations, such as winter boots with shorts. He is very superstitious and believes he is psychic. He believes prime numbers are unlucky and avoids objects (e.g., building floors and house numbers) that are prime numbers.

Check your medication knowledge. Select which medications are commonly used to treat severe symptoms of personality disorders.

What medications are used to treat hallucinations and paranoia?

What medications are used to treat depressed mood, mood lability, anger, and anxiety?

What medications are used to treat self-injurious behavior?

Compare normal adolescent development with trait similarities of personality disorders.

X. GLOSSARY

A perception that one’s own body is significantly different from its actual configuration. For example, a person lying in bed may feel as if they are levitating.

The experience of detachment or feeling as if one is outside one’s body with loss of memory.

Unreasonable expectations of especially favorable treatment.

False beliefs that coincidental events relate to oneself. For example, a person shopping in a store sees two strangers laughing and believes they are laughing at them, when in reality the other two people do not even notice them.

The idea that one can influence the outcome of specific events by doing something that has no bearing on the circumstances. For example, a person watching a baseball game exhibits magical thinking when believing that holding the remote control in a certain position caused their favorite player to hit a home run.

A relatively stable pattern of thinking, feeling, and behaving that evolves over a person’s lifetime and is unique to each individual. It is influenced by one’s experiences, environment (surroundings and life situations), and inherited characteristics.

An enduring pattern of inner experience and behavior that deviates significantly from the expectations of one’s culture. Its onset can be traced back to adolescence or early adulthood and is present in a variety of contexts. This pattern of behavior is manifested in two or more of the following areas: cognition/perceptions, affect, interpersonal functioning, and impulse control.

Characteristics, whether considered good or bad, that make up one’s personality.

A pattern of unstable and intense personal relationships characterized by alternating between extremes of idealization and devaluation.

Licensed under a Creative Commons Attribution 4.0 International License. To view a copy of this license, visit https://creativecommons.org/licenses/by/4.0/ .

• Cite this Page Open Resources for Nursing (Open RN); Ernstmeyer K, Christman E, editors. Nursing: Mental Health and Community Concepts [Internet]. Eau Claire (WI): Chippewa Valley Technical College; 2022. Chapter 10 Personality Disorders.
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• INTRODUCTION
• BASIC CONCEPTS
• TREATMENT FOR PERSONALITY DISORDERS
• APPLYING THE NURSING PROCESS TO PERSONALITY DISORDERS
• SPOTLIGHT APPLICATION
• LEARNING ACTIVITIES

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Chapter 10: Personality Overview

What makes two individuals have different personalities? (credit: modification of work by Nicolas Alejandro)

   Three months before William Jefferson Blythe III was born, his father died in a car accident. He was raised by his mother, Virginia Dell, and grandparents, in Hope, Arkansas. When he turned 4, his mother married Roger Clinton, Jr., an alcoholic who was physically abusive to William’s mother. Six years later, Virginia gave birth to another son, Roger. William, who later took the last name Clinton from his stepfather, became the 42nd president of the United States. While Bill Clinton was making his political ascendance, his half-brother, Roger Clinton, was arrested numerous times for drug charges, including possession, conspiracy to distribute cocaine, and driving under the influence, serving time in jail. Two brothers, raised by the same people, took radically different paths in their lives. Why did they make the choices they did? What internal forces shaped their decisions? Personality psychology can help us answer these questions and more.

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The Non-Disclosing Patient pp 121–150 Cite as

Personality Disorders, Psychopathy, and Deceit

• Vishnupriya Samarendra 2  
• First Online: 03 December 2020

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The psychiatric assessment of psychopathy and deceit has a complex history. Deceit is at least one constant. But should we think of it as a disease state, a failure of moral development, or the behavioral aggregate of a constellation of biologically determined temperamental traits? Is deception better understood as a means to an end, or as an indication of an underlying deficit in capacity for interpersonal relations? Where does deception of others stop and self-deception begin? Do the failures of perception found in personality disorders generally reflect the activation of “immature defense mechanisms” or some underlying psychological deficits, or are these two ways of saying the same thing? To what extent is deception best understood as a form of aggression? In the final analysis, the conceptualization of personality disorders tends to reflect the presuppositions and cognitive frame of the clinician, rather than the final answer regarding the condition. A single formulation is rarely sufficient. Deceit, however, is almost always a constant.

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Samarendra, V. (2020). Personality Disorders, Psychopathy, and Deceit. In: The Non-Disclosing Patient. Springer, Cham. https://doi.org/10.1007/978-3-030-48614-3_9

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Behavioral measures of multiple personality: the case of Margaret

Affiliation.

• 1 University of North Carolina, Greensboro 27412.
• PMID: 3667951
• DOI: 10.1016/0005-7916(87)90005-x

This report concerns the systematic study of a 28-year-old subject diagnosed as multiple personality. The purpose of this study was to examine similarities and differences in three of her distinct personalities, utilizing behavioral measures. Three tasks were presented to the personalities: a memory task; a perceptual-motor task; and an attention task utilizing event-related potentials. The memory task and perceptual-motor task indicated that the three personalities shared information and that learning extended from one personality to the next. The attention task indicated that the three personalities were differentially processing the stimuli that were presented to them, as measured by the ERPs. The results are discussed in the context of the individual case and of the phenomena of multiple personality.

Publication types

• Case Reports
• Dissociative Identity Disorder / diagnosis*
• Personality Assessment
• Psychomotor Performance*
• Research Design