Chapter 19.docx

**Chapter 19** **Disorders of Personality** The Concept of Disorder Today, a psychological disorder is a pattern of behavior or experience that is distressing and painful to the person, that leads to disability or impairment in important life domains (e.g., problems with work, marriage or relation...

**Chapter 19** **Disorders of Personality** The Concept of Disorder Today, a psychological disorder is a pattern of behavior or experience that is distressing and painful to the person, that leads to disability or impairment in important life domains (e.g., problems with work, marriage or relationship difficulties), and that is associated with increased risk for further suffering, loss of function, death, or confinement. the statistical and social definitions of abnormality are always somewhat tentative because society changes. Combining all these approaches to abnormality (statistical, social, and psychological), psychologists and psychiatrists have developed the field of psychopathology, or the study of mental disorders. **The Diagnostic and Statistical Manual of Mental Disorders** The most widely used system for diagnosing mental disorders, including personality disorders, is the Diagnostic and Statistical Manual of Mental Disorders, published by the American Psychiatric Association (APA) and currently in its fifth edition (called the DSM-5). The previous edition---DSM-IV--- was based on a **categorical view** of personality disorders; one either had the disorder or did not have the disorder. In contrast to this categorical view is the **dimensional view** of personality disorders. In the dimensional view, each disorder is seen as a continuum, ranging from normality at one end to severe disability or disturbance at the other. According to this view, people with and without the disorder differ in degree only. The DSM-5 maintains the categorical model of personality disorders and retains the criteria for 10 specific personality disorders that were described in the previous edition. The DSM-5 does contain a section---Section III---that describes which issues need further research. **What Is a Personality Disorder?** A personality disorder is an enduring pattern of experience and behavior that differs greatly from the expectations of the individual's culture (DSM-5). A personality disorder is usually manifest in more than one of the following areas: in how people think, in how they feel, in how they get along with others, or in their ability to control their own behavior. To be classed as a personality disorder, the pattern must not result from drug abuse, medication, or a medical condition, such as head trauma Culture, Age, and Gender: The Effect of Context A person's social, cultural, and ethnic background must be taken into account whenever there is a question about personality disorders. Immigrants, for example, often have problems fitting into a new culture. Persons who originate in a different culture often have customs, habits, expressions, and values that are at odds with, or that create social problems within, a new culture. Before judging that a behavior is a symptom of a personality disorder, we must first become familiar with a person's cultural background, especially if it is different from the majority culture. Age also is relevant to judgments about personality disorder. Adolescents, for example, often go through periods of instability that may include identity crises (see Chapter 14), a symptom that is often associated with certain personality disorders. Most adolescents experiment with various identities yet do not have a personality disorder. Also, adults who undergo severe loss, such as the death of a spouse or the loss of a job, sometimes undergo periods of instability or impulsive behavior that may look like a personality disorder. gender is another context in which to frame our understanding of personality disorders. Certain disorders, such as the antisocial personality disorder, are diagnosed much more frequently in men than women. Other personality disorders are diagnosed more frequently in women than men. These gender differences may reflect underlying gender differences in how people cope. **Specific Personality Disorders** **The Erratic Cluster: Ways of Being Unpredictable, Violent, or Emotional** Persons who are diagnosed with disorders belonging to the erratic group tend to have trouble with emotional control and to have specific difficulties getting along with others. People with one of these disorders often appear dramatic and emotional and are unpredictable. This group consists of four disorders: *antisocial, borderline, histrionic, and narcissistic personality disorders*. *Antisocial Personality Disorder* The antisocial person shows a general disregard for others and cares very little about the rights, feelings, or happiness of other people. The antisocial person has also been referred to as a sociopath or a psychopath. Adults with this disorder typically had a childhood that was fraught with behavioral problems. Such early childhood behavioral problems generally take the form of violating the rights of others (such as minor thefts) and breaking age-related social norms (such as smoking at an early age or fighting with other children). Other common childhood behavioral problems include behaving aggressively or cruelly toward animals, threatening and intimidating younger children, destroying property, lying, and breaking rules. Once childhood behavioral problems become an established pattern, the possibility of an antisocial personality disorder becomes more likely. As a child with behavioral problems grows up, the problems tend to worsen as the child develops physical strength, cognitive power, and sexual maturity. Minor problems, such as lying, fighting, and shoplifting, evolve into more serious ones, such as breaking and entering and vandalism. Severe aggression, such as rape or cruelty to a theft victim, might also follow. Some children with these behavioral problems rapidly develop to a level of dangerous and even sadistic behavior. If a child exhibits no signs of conduct problems by age **16,** it is unlikely that he or she will develop an antisocial personality as an adult. Moreover, even among children with conduct problems, the majority simply grow out of them by early adulthood. Children with earlier-onset conduct problems (e.g., by age six or seven) are much more likely to grow into an antisocial personality disorder as an adult than are children who displayed a few conduct problems in high school. The term antisocial implies that the person has a lack of concern for social norms. Repeated lying is another feature of the antisocial personality. The pattern of lying starts early in life with minor deceptions and grows into a pattern of deceitfulness. Another common characteristic of the antisocial personality is **impulsivity**, which is often manifested as a failure to plan ahead. A more common form of impulsivity is to simply make everyday decisions without much forethought or without considering consequences. Antisocial persons also tend to be easily irritated and to respond to even minor frustrations with aggression. Losing some coins in a vending machine might be all it takes for such a person to fly into a rage. Antisocial persons tend to be assaultive, particularly to those around them, such as spouses or children. Fights and physical attacks are common. Recklessness is another characteristic, with antisocial persons showing little regard for their own safety and that of others. **Irresponsibility** is another key feature of the antisocial personality. Antisocial persons get bored easily and find monotony or routine to be stressful. **Lack of remorse and guilt** feelings and indifference to the suffering of others are the hallmarks of the antisocial mind. The antisocial person can be ruthless, without the normal levels of human compassion, charity, or social concern. One interesting concept is the notion of the "successful" psychopath. Certainly there are some features of psychopathy that may be adaptive in some circumstances, such as interpersonal charm and charisma, fearlessness, and a willingness to take calculated risks. Some psychologists have speculated that these features of psychopathy may facilitate success in certain professions, such as financial consulting, politics, and contact sports. *Borderline Personality Disorder* The lives of persons with borderline personality disorder are marked by **instability**. Their relationships are unstable, their behavior is unstable, their emotions are unstable, and even their images of themselves are unstable. The relationships of borderline individuals tend to be intense, emotional, and potentially violent. They suffer from strong fears of abandonment. If such persons sense separation or rejection in an important relationship, profound changes in their self-image and in how they behave may result, such as becoming very angry at other people. Borderline individuals show marked difficulties in their relationships. When others leave them, they feel strong abandonment fears and sometimes become angry or aggressive. Sometimes, in their efforts to manipulate people back into their relationships, they engage in self-mutilating behavior (burning or cutting themselves) or suicide attempts. Borderline persons also have shifting views of themselves. Their values and goals are shallow and change easily. Their opinions may change suddenly. They may experiment with different kinds of friends or with different sexual orientations. Usually, they view themselves as, at heart, evil or bad. Self-harming acts are common and increase when others threaten to leave or demand that the borderline person assume some new responsibilities. Strong emotions are common in the borderline personality, including panic, anger, and despair. Mostly, these emotions are caused by interpersonal events, especially abandonment or neglect. When stressed by others, the borderline person may lash out, becoming bitter, sarcastic, or aggressive. Periods of anger are often followed by shame, guilt, and feelings of being evil or bad. Borderline persons often complain of feeling empty. They also have a way of undermining their own best efforts, such as dropping out of a training program just before finishing or destroying a caring relationship just when it starts going smoothly. Persons with borderline personality disorder, compared with those without, have a higher incidence rate of childhood physical or sexual abuse, neglect, or early parental loss. Children in such circumstances may come to believe that others are not to be trusted. Although borderline persons have difficulty with relationships, they may form stable relationships if given enough structure and support. *Histrionic Personality Disorder* The hallmarks of histrionic personality disorder are excessive attention seeking and emotionality. Often such persons are overly dramatic, preferring to be the center of attention. They may appear charming or even flirtatious. Many are inappropriately seductive or provocative. And this sexually provocative behavior is often undirected and occurs in inappropriate settings, such as in professional settings. Physical appearance is often very important to histrionic persons, and they work to impress others and obtain compliments. Often, however, they overdo it and appear gaudy or flamboyant. Histrionic individuals express their opinions frequently and dramatically. However, their opinions are shallow and easily changed. Such a person may say, for example, that some political official is a great and wonderful leader yet be unable to give any supporting details or actual examples of leadership. Such persons prefer impressions to facts and often act on intuition. They may display strong emotions in public, sometimes to the embarrassment of friends and family. They may throw temper tantrums over minor frustrations or cry uncontrollably over a sentimental little event. To others, their emotions appear insincere and exaggerated, to the point of being theatrical. Histrionic individuals are also highly suggestible. Because their opinions are not based on facts, they can be easily swayed. Socially, histrionic individuals are difficult to get along with, due to their excessive need for attention. They may become upset and act impulsively when not given the attention they think they deserve. Such persons may use suicidal gestures and threats to get attention from others and to manipulate others into caring for them. Their seductiveness may put them at risk for sexual victimization. *Narcissistic Personality Disorder* The calling cards of narcissistic personality disorder are a strong need to be admired, a strong sense of self-importance, and a lack of insight into other people's feelings. Narcissists see themselves in a very favourable light, inflating their accomplishments and undervaluing the work of others. Narcissists daydream about prosperity, victory, influence, adoration from others, and power. They routinely expect adulation from others, believing that homage is generally long overdue. They exhibit feelings of entitlement, believing that they should receive special privileges and respect, even though they have done nothing in particular to earn that special treatment. A sense of superiority also pervades the narcissistic personality. They feel that they are special and should associate only with others who are similarly unique or gifted. The narcissistic paradox is that although narcissists have high self-esteem, their grandiose self- esteem is actually quite fragile. Narcissists thus depend on others to validate their self-importance. To say that narcissists' self-esteem is vulnerable does not mean that they are covering up low self- esteem, but rather that they are exquisitely sensitive to criticism, that they can fly into a rage when they don't get what they think they deserve. Further making the narcissist socially difficult is an inability to recognize the needs or desires of others. In conversation, they tend to talk mostly about themselves--- "I" this and "my" that. A final social difficulty that creates problems for narcissists is the ease with which they become envious of others. **The Eccentric Cluster: Ways of Being Different** Some people have no interest in others; some are extremely uncomfortable with others; and some are suspicious of others. When carried to extremes, these interpersonal styles form the three personality disorders known as the schizoid, schizotypal, and paranoid personalities. Schizoid and schizotypal personality disorders both take their root from schizophrenia and are closely tied to the history of this diagnostic category. Schizophrenia literally means cutting the mind off from itself and from reality. It is a serious mental illness that involves hallucinations, delusions, and perceptual aberrations. The personality disorders of schizoid and schizotypal exhibit some lowgrade nonpsychotic symptoms of schizophrenia. For example, the schizotype is eccentric and is interested in odd and unusual beliefs, whereas the schizoid displays social apathy. Schizophrenics display both of these characteristics plus delusions or hallucinations. Thus these personality disorders have much in common with this more severe mental illness. In the case of schizotypal disorders, persons are likely to possess the genotype that makes them vulnerable to schizophrenia. A large proportion of the family members of persons with schizophrenia exhibit odd and unusual behaviors that would contribute to a diagnosis of schizotypal personality disorder *Schizoid Personality Disorder* The schizoid personality is split off (schism), or detached, from normal social relations. The schizoid person simply appears to have no need or desire for intimate relationships or even friendships. Family life usually does not mean much to such people, and they do not obtain satisfaction from being part of a group. They have few or no close friends, and they would rather spend time by themselves than with others. They typically choose hobbies that can be done and appreciated alone, such as stamp collecting. They also typically choose solitary jobs, often with mechanical or abstract tasks, such as machinists or computer programmers. Usually, the schizoid personality experiences little pleasure from bodily or sensory experiences, such as eating or having sex. The person's emotional life is typically constricted. At best, the schizoid person appears indifferent to others, neither bothered by criticism nor buoyed by compliments. "Bland" would be one description of such a person's emotional life. Often, the schizoid person does not respond to social cues and so appears inept or socially clumsy. *Schizotypal Personality Disorder* Whereas the schizoid person is indifferent to social interaction, the schizotypal person is acutely **uncomfortable** in social relationships. Schizotypes are anxious in social situations, especially if those situations involve strangers. Schizotypal persons also feel that they are different from others or that they do not fit in with the group. Interestingly, when such persons have to interact with a group, they do not necessarily become less anxious as they become more familiar with the group. For example, while attending a group function, the schizotype will not become less anxious as time wears on, but instead will become more and more tense. This is because schizotypes tend to be suspicious of others and are not prone to trust others or to relax in their presence. Another characteristic of people with schizotypal personalities is that they are odd and eccentric. It is not unusual for them to harbor many superstitions such as believing in ESP and many other psychic or paranormal phenomena that are outside of the norms for their culture. They may believe in magic or that they possess some magical or extraordinary power, such as the ability to control other people or animals with their thoughts. They may have unusual perceptions that border on hallucinations, such as feeling that other people are looking at them or hearing murmurs that sound like their names. Because of their suspiciousness of others, social discomfort, and general oddness, schizotypal persons have difficulty with social relationships. They often violate common social conventions in such ways as not making eye contact, dressing in unkempt clothing, and wearing clothing that does not go together. In many ways, the schizotype simply does not fit into the social group. *Paranoid Personality Disorder* the paranoid person is extremely distrustful of others and sees others as a constant threat. Such persons assume that others are out to exploit and deceive them, even though there is no good evidence to support this assumption. Paranoid persons feel that they have been injured by others and are preoccupied with doubts about the motivations of others. Paranoids are constantly on the lookout for hidden meanings and disguised motivations in the comments and behaviors of others. The person with a paranoid personality disorder often holds resentments toward others for slights or perceived insults. Pathological jealousy is a common manifestation of paranoid personality disorder. People with paranoid personality disorder are at risk of harming those who threaten their belief systems. Their argumentative and hostile nature may provoke others to a combative response. This hostile response from others, in turn, validates the paranoids' original suspicion that others are out to get them. **The Anxious Cluster: Ways of Being Nervous, Fearful, or Distressed** *Avoidant Personality Disorder* The major feature of the avoidant personality disorder is a pervasive feeling of inadequacy and sensitivity to criticism from others. Clearly, no one likes to be criticized. However, avoidant persons will go to great lengths to avoid situations in which others may have opportunities to criticize their performance or character, such as in school, at work, or in other group settings. The main reason for this anxiety about performance is an extreme fear of criticism or rejection from others. Such persons may avoid making new friends or going to new places, through fear of criticism or disapproval. Friends may have to plead and promise lots of support and encouragement in order to get them involved in new activities. Because avoidant persons fear criticism, they may restrict their activities to avoid potential embarrassments. However, by avoiding the anxiety, they create other problems, often in the form of missed opportunities. Avoidant persons are sensitive to what others think of them. They typically have very low self-esteem and feel inadequate to many of life's day-to-day challenges. The paradox is that, in avoidantly coping with their social anxiety, they shun the supportive relationships with caring others that could actually help boost their self-esteem. *Dependent Personality Disorder* the dependent personality disorder is an excessive need to be taken care of, to be nurtured, coddled, and told what to do. Dependent persons act in submissive ways so as to encourage others to take care of them or take charge of the situation. has great difficulty making such decisions, and seeks out reassurance from others. However, such a person tends to seek advice about even minor decisions, such as whether to carry an umbrella today. of others, dependent persons avoid disagreements with those on whom they are dependent. Because of their extreme need for support, dependent personalities might even agree with decisions or opinions that they feel are wrong to avoid angering the persons on whom they depend. Because of their low self-confidence and need for constant reassurance, dependent persons may not work well independently. Persons with dependent personalities may tolerate extreme circumstances to obtain reassurance and support from others. Such people may submit to unreasonable demands, may tolerate abuse. *Obsessive-Compulsive Personality Disorder* The obsessive-compulsive person is preoccupied with order and strives to be perfect. The high need for order can manifest itself in the person's attention to details, however trivial, and fondness for rules, rituals, schedules, and procedures. obsessive-compulsive personality disorder hold very high standards for themselves. However, they may work so hard at being perfect that they are never satisfied with their work. Another characteristic is a devotion to work at the expense of leisure and friendships. Even their play looks a lot like work. The obsessive-compulsive person may also appear inflexible with regard to ethics and morals. Such persons set high principles for themselves and tend to follow the letter of the law. A few other odd characteristics are often present in the obsessive-compulsive person. One is the preference to hang on to worn-out or useless things; many obsessive-compulsive people have trouble throwing things away. Many are miserly or stingy, hoarding their money and resources. There is another disorder---obsessive-compulsive disorder (OCD)---that is often confused with obsessive-compulsive personality disorder (OCPD). **OCD is an anxiety disorder that is, in several ways, more serious and debilitating than OCPD**. In OCD a pattern of unwanted and intrusive thoughts is recurrent and troubling to the person, such as the persistent thought that he or she may harm someone. In addition, OCD is characterized by the presence of ritualistic behaviors, such as frequent hand washing or the tendency to repeat actions a set number of times (e.g., having to touch an object three times before leaving a room, or repeating words to oneself three times). Obsessive-compulsive personality disorder, on the other hand, really involves a collection of traits, such as excessive need for order or extremely high conscientiousness. Nevertheless, people with OCPD are at risk for developing OCD as well as other kinds of anxiety disorders. **Prevalence of Personality Disorders** **obsessive-compulsive personality** disorder is the most common, at just over 4 percent prevalence rate. Next most common are the schizotypal, histrionic, and dependent personality disorders, approximately 2 percent prevalence each. The least common is narcissistic personality disorder, affecting only 0.2 percent of the population. However, because the data are based on self-report through structured interviews, they may actually underestimate the prevalence of some of the disorders, especially narcissism. The total prevalence rate for having at least one personality disorder is about 13 percent. That is, at any given time, approximately 13 percent of the population is diagnosable with a personality disorder of one or more types. A **differential diagnosis** is one in which, out of two or more possible diagnoses, the clinician searches for evidence in support of one diagnostic category over all the others. **Gender Differences in Personality Disorders** The overall prevalence rate for personality disorders is fairly equal in men and women. A few specific disorders, however, show a tendency to be more prevalent in men or in women. The one disorder with the most disparate gender distribution is antisocial personality disorder, which occurs in men with a prevalence rate of about 4.5 percent and in women at only about a 0.8 percent prevalence rate. As such, about 1 out of every 20 adult men has antisocial personality disorder, whereas it is less than 1 in 100 for women. Borderline and dependent personality disorders may be somewhat more prevalent in women than men, though the evidence is not strong. Paranoid and obsessive-compulsive personality disorder may be more common in men than women, but the difference is not large. One important issue concerns gender biases in diagnoses. **Dimensional Model of Personality Disorders Causes of Personality Disorders** it is clear that persons who suffer with borderline personality disorder experienced poor attachment relationships in childhood, and that many borderline persons were the target of sexual abuse in childhood. There is abundant evidence that most people with borderline personality disorder grew up in chaotic homes, with a lot of exposure to the impulsive behavior of adults. It appears that genetic factors play little role in borderline personality disorder. Instead, most of the evidence implicates loss of, or neglect by, the parents in early childhood. When it comes to schizotypal personality disorder, the evidence is more in line with genetic causes. A variety of family, twin, and adoption studies suggest that schizotypal disorder is genetically similar to schizophrenia. Moreover, the first-degree relatives of persons with schizophrenia are much more likely to exhibit features of schizotypal personality disorder than persons in the general population. However, prevalence rates for paranoid and avoidant personality disorders were also elevated among the relatives of the schizophrenia patients, suggesting that these disorders may be genetically related to schizophrenia. Antisocial personality disorder also has several explanatory theories. For example, many antisocial persons were themselves abused and victimized as children, leading to social learning and psychoanalytic theories of the cause of this disorder. A high proportion of antisocial persons also abuse multiple illegal drugs or alcohol, leading some researchers to propose that biological changes associated with drug abuse are responsible for antisocial behavior. There are also clear familial trends suggesting that antisocial personality disorder is due, in part, to genetic causes. Others have proposed learning theories of antisocial personality disorder, due mainly to research showing that such persons are deficient in learning through punishment. The neurological underpinnings of antisocial and psychopathic traits are also being investigated. **A useful model here is the triarchic model, which characterizes psychopaths in terms of three distinguishable components: boldness, meanness, and lack of inhibition.** A new measure of this triarchic model provides better coverage of these three components than previous inventories. Moreover, this new measure correlates with neuroscience findings in quite sensible ways. For example, "boldness" is related to an under- reactivity in the brain's defensive motivational system. The "lack of inhibition" component is related to deficits in the frontal cortical regions involved in self-regulation, cognitive control, and moral reasoning. Both of these components---boldness and lack of inhibition---are also associated with brain circuits that process rewards. The third component---"meanness"---is thought to be related to dysfunction in brain systems important to empathy, perspective taking, and perhaps even to lower levels of oxytocin, and neurochemical related to social bonding. Explanations of the other personality disorders also follow this pattern. There are biological explanations, learning explanations, psychodynamic explanations, and cultural explanations. There may be some truth to each of these views, that personality disorders, like normal-range personality variables, have multiple causes. Moreover, it is very difficult to separate biology from learning, to separate nature from nurture. For example, an individual's early experiences---such as with an abusive parent---may lead to neurological changes in certain brain centers, such as the abnormalities in the hypothalamus and pituitary functioning. Consequently, it does not make sense to speak of early childhood abuse as a strictly experiential or learning factor when biological changes can follow from such abusive experiences. Most of the research on personality disorders is descriptive or correlational. True experiments, where people would be randomly assigned to either have or not have a disorder, are impossible. Because the research is mostly correlational, it cannot pin down the causal direction of relationships that are identified.