Personality Disorders PDF

CHAPTER 19 Disorders of Personality The Building Blocks of Personality Disorders The Concept of Disorder What Is Abnormal? The Diagnostic and Statistical Manual of Mental Disorders Wha...

CHAPTER 19 Disorders of Personality The Building Blocks of Personality Disorders The Concept of Disorder What Is Abnormal? The Diagnostic and Statistical Manual of Mental Disorders What Is a Personality Disorder? Specific Personality Disorders Cluster A. The Eccentric Cluster: Ways of Being Different Cluster B. The Erratic Cluster: Ways of Being Unstable and Emotional Cluster C. The Anxious Cluster: Ways of Being Fearful and Distressed Prevalence of Personality Disorders Gender Differences in Personality Disorders Dimensional Model of Personality Disorders Causes of Personality Disorders Summary and Evaluation Key Terms The Adjustment Domain A shley Smith (January 29, 1988–October 19, 2007) grew up in New Brunswick where, by all accounts, she had a typical childhood, enjoying the outdoors and riding her bicycle often. In 2001, when Ashley was 13 years old, her parents noticed a change in her personality. Ashley became disruptive and defiant. She was suspended from school for bullying and then harassed a teacher from the school, making angry phone calls, following the teacher home, and repeatedly banging on the teacher’s door. By the age of 15, Ashley had com- mitted several assaults and was admitted to the Pierre Caissie Centre in Moncton, a facility that specializes in treating young people with behaviour problems. While there, Ashley was diagnosed with attention-deficit/ hyperactivity disorder (ADHD), a learning disorder, and borderline personality disorder. Although the original plan was for Ashley to spend 34 days at the centre, she was discharged after only 21 days because she had extreme difficulty interacting with staff and peers, was rude and intimidating, and was verbally aggressive. 602 lar65774_ch19_602-643.indd 602 1/17/20 7:15 PM  Chapter 19 Disorders of Personality Soon after this discharge Ashley was sentenced to one month at the New Brunswick Youth Centre (NBYC), a juvenile detention centre, for assault and trespassing. Ashley was so disruptive and aggressive that she was placed in restraints and was segregated from other inmates. She would spend the next several years in and out of NBYC; each time she was released she would commit a crime within a few days and be put back in custody. Despite a standing policy not to keep residents isolated for more than five days, Ashley was never released into the general population because of concern that she would harm other residents. Between 2002 and 2005, Ashley was involved in more than 800 incidents at NBYC related to defiance and aggression. In 2006, she turned 18 years old and was moved to an adult prison in St. John’s, Newfoundland. Ashley’s Ashley Smith was 19 years old when she died by self- aggressive and defiant behaviour continued, and inflicted strangulation in the Grand Valley Institution for she was moved from prison to prison frequently Women in Kitchener, Ontario, on October 19, 2007. A in an attempt to keep her in constant segregation psychiatrist who testified at the coroner’s inquest that from other prisoners. Between 2002 and 2007, followed her death reported that Ashley Smith met all 10 of Ashley made over 150 attempts to harm herself, the diagnostic criteria for antisocial personality disorder. and on October 19, 2007, she died by self- ©The Canadian Press/Geoff Robins strangulation. The jury presiding over a 2012 inquest into Ashley Smith’s death determined that she died by homicide, not suicide, because her guards saw her hanging in her cell on a video monitor and chose not to intervene. The jury also concluded that Corrections Canada needed to try to better serve female inmates with mental health problems and recommended a complete ban on solitary confinement. During the inquest, a psychiatrist testified that Ashley Smith met 10 out of 10 criteria for antisocial personality disorder. The criteria included having a conduct disorder before the age of 15, being at least 18 years of age, repeating behaviours that are grounds for an arrest, deceitfulness, impulsivity, irritability and aggressiveness, reckless disregard for the safety of others, consistent irresponsibility, lack of remorse, and not displaying schizophrenia or manic episodes. Ashley also met four out of eight criteria for borderline personality disorder. She had persistent instability in her interpersonal relationships, she had repeated suicidal behaviour, she was emotionally unstable, and she had inappropriate levels of anger that were uncontrollable. Ashley Smith’s antisocial and borderline personality disorders made it impossible for her to relate to others in a constructive way. As a result, Ashley had extremely low self-esteem, and this self-hatred led to self-harming behaviour that ultimately ended her life. Although Ashley Smith’s case is well known because of media interest surrounding the inquests that followed her death, her behaviours are not unusual for individuals who are incarcerated. The psychiatrist who assessed Ashley reported that none of her behaviours were unique or unusual and that many women currently incarcerated in Canada have mental illnesses that are similar to those observed in Ashley Smith. 603 lar65774_ch19_602-643.indd 603 1/17/20 7:15 PM  Part Six The Adjustment Domain The Building Blocks of Personality Disorders Many of the topics we have covered in previous chapters come together in helping to describe and understand the various personality disorders. The symptoms of personality disorders can be seen as maladaptive varia- tions within several of the domains we have covered. These include traits, emotions, cognitions, motives, interpersonal behaviour, and self-concepts. The 10 personality disorders we present in this chapter are built on the foundation of these broader concepts, and so we briefly will discuss the relevance of each to this chapter. Traits of personality describe consistencies in behaviour, thought, or action and represent meaningful differ- ences among people, as we described in Chapter 3. Personality disorders can be thought of as maladaptive variations or combinations of normal personality traits. Widiger and colleagues describe how extremes on either end of specific trait dimensions can be associated with personality disorders (Widiger, Costa, & McCrae, 2002a; Widiger et al., 2002b; Widiger & Costa, 2012). For example, a person with extremely low levels of trust and extremely high levels of hostility might be disposed to paranoid personality disorder. A person very low on sociability but very high on anxiety might be prone to avoidant personality disorder. A person with the oppo- site combination—extremely high on sociability and low on anxiety—might be prone to histrionic personality disorder. Thus, the concept of traits, such as the five-factor model of traits, can be especially useful for describ- ing personality disorders (Gore & Widiger, 2013; Trull & McCrae, 2002). Motivation is a second basic building block of personality that is important to understanding personality disorders. Motives describe what people want and why they behave in particular ways. In the intrapsychic domain, Chapters 9 to 11, we discussed several different kinds of motives, ranging from the sexual and aggressive basis of Freud’s theory to modern research on the need for intimacy, achievement, and power. A common theme in several personality disorders concerns maladaptive variations on these common motives, especially needs for power and intimacy. One important variation concerns an extreme lack of motivation for intimacy, which is seen in certain personality disorders. Another theme is an exaggerated need for power over others, which, at an extremely high level, can result in a maladaptive personality disorder. Other motives can be involved in personality disorders, such as the extreme need to be superior and receive the praise of others that is found in narcissistic personality disorder. People with obsessive-compulsive personality disorder might be seen as having an extremely high motivation for order and devotion to detail. Cognition also provides a basis for understanding personality disorders. As covered in Chapter 12, cognition consists of mental activity involved in perceiving, interpreting, and planning. These processes can become distorted in personality disorders. Some disorders involve routine and consistent misinterpretations of the intentions of others. Personality disorders typically involve an impairment of social judgment, such as when those with paranoid personality disorder think others are out to get them, or when those with histrionic personality disorder think others actually like being with them. People with borderline personality disorder may misinterpret innocent comments as signs of abandonment or criticism or rejection. In various ways, each of the personality disorders involves some distortion in the perception of other people and altered social cognition. Emotion is another area that is important to understanding personality disorders. We discussed normal range individual differences in emotion in Chapter 13. With several personality disorders there is extreme variation in experienced emotions. Some disorders involve extreme volatility in emotions (e.g., borderline), whereas other disorders involve extremes of specific emotions, such as anxiety (avoidant personality disorder), fear 604 lar65774_ch19_602-643.indd 604 1/17/20 7:15 PM  Chapter 19 Disorders of Personality (paranoid personality disorder), or rage (narcissistic personality disorder). Most personality disorders have an emotional core that is an important component to understanding that disorder. As described in Chapter 14, self-concept is a person’s own collection of self-knowledge—one’s understanding of oneself. In most personality disorders, there is some distortion in self-concept. Most of us are able to build and maintain a stable and realistic image of ourselves; we know our own opinions, we know what we value, and we know what we want out of life. With many of the disorders, there is a lack of stability in self-concept, such that individuals may feel they have no “core” or they have trouble making decisions or need constant reassurance from others. Self-esteem is also an important part of the self, and some disorders are associated with extremely high (e.g., narcissism) or extremely low (e.g., dependent personality disorder) levels of self- esteem. The self provides an important perspective on understanding personality disorders. Social relationships are frequently disturbed or maladaptive in personality disorders. Thus, the material we covered in the social and cultural domain, Chapters 15 through 17, is important for understanding and describing personality disorders. For example, a successful sexually intimate relationship with another person involves knowing when sexual behaviour is appropriate and expected and when it is inappropriate and unwanted. Problems with intimacy, either staying too distant from others or becoming too intimate too quickly, are frequent features of several personality disorders. An important element of interpersonal skill involves empathy, knowing how another person is feeling. Most personality disorders involve a deficit in empathy, such that the disordered person either misinterprets others or does not care about the feelings of others. Many disorders involve what might be called poor social skills. For instance, a person with schizoid personality disorder may stare at people without starting a conversation, while someone with histrionic personality disorder may behave in an inappropriately flirtatious manner. Biology can also form the building blocks of several of the personality disorders. The material covered in the biological domain, Chapters 6 through 8, is thus relevant. Some of the personality disorders have been found to have a genetic component. Others have been studied via physiological components, such as examining the brain functioning of antisocial individuals. There has even been an evolutionary theory proposed to explain the existence of personality disorders (Millon, 2000a). Most personality textbooks do not cover personality disorders. We feel, however, that understanding how something can become dysfunctional can tell us a lot about how it works normally. We also believe that the concept of personality disorders helps to tie together the various components and domains of personality. As such, it is a fitting topic with which to end this book. The Concept of Disorder Today, a psychological disorder is a pattern of behaviour 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 (American Psychiatric Association, 2013). The idea that something can go wrong with a person’s personality has a long history. Some of the earliest writings in medical psychiatry included classifications and descriptions of personality and mental disorders (e.g., Kraeplin, 1913; Kretschmer, 1925). 605 lar65774_ch19_602-643.indd 605 1/17/20 7:15 PM  Part Six The Adjustment Domain A very early concept derived by French psychiatrist Philippe Pinel was manie sans delire, or madness without loss of reason. This was applied to individuals who demonstrated disordered behaviour and emotions but who did not lose contact with reality (Morey, 1997). A related concept, popular in the early 1900s, was called “moral insanity,” to emphasize that the person did not suffer any impairment of intellect, but rather was impaired in terms of feelings, temperament, or habits. An influential psychiatrist named Kurt Schneider (1958) proposed the term psychopathic personality to refer to behaviour patterns that caused the person and the community to suffer. Schneider also emphasized statistical rarity, along with behaviours that have an adverse impact on the person and the community in which that person lives. This definition highlights the notion that all forms of personality disorder involve impaired social relationships; other people suffer as much as or more than the person with the disorder. A disorder is a conceptual entity that, although abstract, is nevertheless useful. It helps to guide thinking about the distinction between what is normal and what is abnormal, or pathological. The field of abnormal psychology is the study of the various mental disorders, including thought disorders, emotional disorders, and personality disorders. In this chapter, we focus on disorders of personality and the ways in which they affect functioning. What Is Abnormal? There are many ways to define abnormal. One simple definition is that whatever is different from normal is abnormal. This is a statistical definition in the sense that researchers can statistically determine how often something occurs and, if it is rare, call it abnormal. In this sense, colour blindness or polydactyly (having more than 10 fingers) is considered abnormal. Another definition of abnormal is a social definition based on what society tolerates (Shoben, 1957). If we define the term in this sense, behaviours that society deems unaccept- able are labelled as abnormal. In this sense, incest and child abuse are both considered abnormal. Both the statistical and the social definitions of abnormality suffer from changing times and changing social or cultural norms (Millon, 2000a, 2000b). Behaviours deemed offensive or socially inappropriate 20 years ago might be acceptable today. For example, 40 years ago, homosexuality was considered to be both rare and socially unacceptable, a form of abnormal behaviour, or even a mental illness. Today, being gay or lesbian is no longer considered abnormal (American Psychiatric Association, 2013) and is protected under civil rights laws in Canada. Thus, the statistical and social definitions of abnormality are always somewhat tentative as society evolves. Psychologists have consequently looked to other ways of identifying what is abnormal in behaviour and experience. They have looked within individuals, inquiring about subjective feelings, such as anxiety, depression, dissatisfaction, and feelings of loneliness. They have looked at how people think and experience themselves and their worlds. Psychologists have found that some people have disorganized thoughts, disruptive perceptions, or unusual beliefs and attitudes that do not match their circumstances. They have identified ways in which people fail to get along with one another and ways people have trouble living in the community. They have analyzed patterns of behaviour that represent ineffective efforts at coping or that put people at higher risk for other problems, behaviours that harm more than help. From a psychological perspective, any of these may be considered abnormal. 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 diagnosis of mental disorders is both a scientific discipline and an important part of the clinical work of many psychiatrists 606 lar65774_ch19_602-643.indd 606 1/17/20 7:15 PM  Chapter 19 Disorders of Personality and psychologists. Knowing how to define and how to identify a disorder is the first step in devising treatment or in designing research on that disorder. The Diagnostic and Statistical Manual of Mental Disorders The most widely used system for diagnosing mental disorders, including personality disorders, is the Diagnos- tic and Statistical Manual of Mental Disorders, published by the American Psychiatric Association (APA) and currently in its fifth edition (called the DSM-5). The DSM-5 sets the standard for diagnoses, and its system is the one taught by almost all psychiatry and psychology doctoral training programs, the one that appears in hospital records systems, and the one most insurance companies demand for reimbursement purposes in both the United States and Canada. Because society’s standards change over time and because new research accumulates, the DSM undergoes revision from time to time. The current version—the DSM-5—was published in 2013. The APA began working on this revision a decade earlier and appointed various working groups of experts to assist in each broad area of mental disorders. The personality disorders working group consisted of active personality psychologists and psychiatrists. During the decade they worked on the revision for DSM-5, the personality disorders working group considered several broad changes to personality disorders that might be incorporated into DSM-5. One change the personality disorders working group considered was to make diagnosis less categorical and more dimensional. 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. The categorical view held that there is a qualitative break between people who are, for example, antisocial and people who are not. And this concept was applied to all the personality disorders, viewing disorders as distinct and qualitatively different from normal extremes on each personality trait. 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. For example, part of being antisocial is disregarding the rights of others. But there are degrees to which this disregard can manifest in behaviour. For example, some people might simply be aloof and unconcerned about the feelings of others. Farther out on this dimension, a person might lack a desire to help others, being both aloof and uncaring. Even farther out on this dimension is the person who actively hurts or takes advantage of others. And finally, at the greatest extreme of disregard for others, is the person who takes pleasure in harming or terrorizing people. The dimensional view implies that certain patterns of behaviour, in various amounts, comprise each of the personality disorders. It is only at the extreme ends of the dimensions that the person becomes a problem to themselves and to others. Moreover, extremes of different personality traits can combine in ways that create unique forms of disorder. Modern personality theorists (e.g., Costa & Widiger, 1994, 2002; Widiger, 2000) have argued that the dimensional view provides a more reliable and meaningful way to describe the personality disorders. As the DSM-5 revision work progressed, the personality disorders working group considered this, and several other, changes to the way personality disorders are defined and diagnosed. The top personality psychologists and psychiatrists were involved, many meetings were held, data were collected, public input was solicited and 607 lar65774_ch19_602-643.indd 607 1/17/20 7:15 PM  Part Six The Adjustment Domain obtained, and many proposals were written and considered. However, to make a long story very short, the final outcome of the revision effort was the decision, on the part of the APA Board of Trustees, to make no changes to the way personality disorders are defined. The DSM-5 therefore maintains the categorical model of person- ality 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 issues in need further research. It is in this section, essentially an appendix to the DSM-5, where the dimensional model of personality disorders is detailed and a call for further research on the utility of viewing personality disorders as dimensions rather than distinct categories is issued. Later in this chapter we explore the 10 personality disorders included in the DSM-5, but first we consider the general notion of “personality disorder.” What Is a Personality Disorder? A personality disorder is an enduring pattern of experience and behaviour that differs greatly from the expectations of the individual’s culture (DSM-5). As discussed in Chapter 3, traits are patterns of experiencing, thinking about, and interacting with oneself and the world. Traits are observed in a wide range of social and personal situations. For example, a person who is high in conscientiousness is hardworking and persevering. If a trait becomes maladaptive and inflexible and causes significant impairment or distress, then it is consid- ered to be a personality disorder. For example, if conscientiousness were so high that one checked the locks on the door 10 times each night and checked every appliance in the house 5 times before leaving in the morning, then we might consider the possibility of a disorder. The essential features of a personality disorder, according to the DSM-5, are presented in Table 19.1. A person- ality 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 behaviour. The pattern is rigid Table 19.1 General Criteria for Personality Disorders 1. A personality disorder shows an enduring pattern of inner experience and behaviour that deviates markedly from the expectations of the individual’s culture. This pattern is manifest in two or more of the following areas: Cognition (i.e., ways of perceiving and interpreting the self, others, and events) Affectivity (i.e., the range, intensity, ability, and appropriateness of emotional responses) Interpersonal functioning Impulse control 2. The enduring pattern is inflexible and pervasive across a broad range of personal and social situations. 3. The enduring pattern leads to clinically significant distress or impairment in social, occupational, or other important areas of functioning. 4. The pattern is stable and of long duration, and its onset can be traced back to adolescence or early adulthood. 5. The enduring pattern is not better accounted for as a manifestation or consequence of another mental disorder. 6. The enduring pattern is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition, such as head trauma. Source: American Psychiatric Association, 2013. 608 lar65774_ch19_602-643.indd 608 1/17/20 7:15 PM  Chapter 19 Disorders of Personality and is displayed across a variety of situations, leading to distress or problems in important areas in life, such as at work or in relationships. For example, an overly conscientious man might drive his partner crazy with his constant checking of his household appliances. The pattern of behaviour that defines the personality disorder typically has a long history in the person’s life and can often be traced back to manifestations in adolescence or even childhood. 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. People 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. For example, North American culture is very individual- istic overall (as we reviewed in Chapter 17), and it values and rewards individuals for standing out from the crowd. To societies that are more collectivistic and value fitting in with the group, efforts to stand out from the crowd might be interpreted as self-centred and individualistic in an unwanted sense. Indeed, North America has been called a narcissistic culture; therefore, efforts to draw attention to the self are not socially abnormal in this society. Before judging that a behaviour 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. A study of immigrants to Norway found that many exhibited adjustment problems that might have appeared to be personality disorders (Sam, 1994). Many young male immigrants, for example, exhibited antisocial behaviours. These behaviours tended to diminish as the immigrants acculturated to their new social environment. 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 personal- ity disorder. For this reason, the American Psychiatric Association (2013) cautions against diagnosing person- ality disorders in persons under age 18. 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 behaviour that may look like a person- ality disorder. For example, a person who has experienced such a traumatic event may become violent or may impulsively enter into sexual relationships. A person’s age and life circumstances must therefore be considered to be sure that the person is not simply going through a developmental stage or reacting to a traumatic life event. Finally, 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. For example, in a study of more than 2,000 individuals, Huselid and Cooper (1994) found that males exhibit externalizing problems, such as fighting and vandalism, whereas females tend to exhibit relatively more internalizing problems, such as depression and self-harm. Similar findings were obtained by Kavanagh and Hops (1994). These differences in how men and women cope with problems most likely contribute to gender differences in the behaviours associated with the personality disorders. Psychologists need to be careful not to look for evidence of certain kinds of disorders just because of a person’s gender. 609 lar65774_ch19_602-643.indd 609 1/17/20 7:15 PM  Part Six The Adjustment Domain Exercise In this chapter, you will read about specific personality disorders. For each, try to think of exam- ples of how culture, gender, or age might influence whether a person’s behaviour is seen as evidence of a disorder. For example, are people from low socioeconomic groups likely to be seen by others as having particular disorders? How does this correspond to the topic of stereotypes and prejudice? How does this fit with the use of “profiles” by police and other law enforcement agencies? Concept Check What is the difference between a categorical view and a dimensional view of mental disorders? What is a personality disorder? List the key general criteria as outlined in the DSM-5. Specific Personality Disorders The following sections describe specific personality disorders, including the criteria for diagnosing someone as possessing each disorder. We focus this material on describing the characteristics of each personality disorder and by giving examples. We also organize the personality disorders according to the three clusters used in the DSM-5, which highlight some of the conceptual similarities among the disorders. Cluster A. The Eccentric Cluster: Ways of Being Different This cluster of personality disorders contains traits that combine to make people ill at ease socially and appear or act in highly abnormal ways. Most of the oddness in these disorders has to do with how the person interacts with others. 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 personality disorder and schizotypal personality disorder both take their root from schizo- phrenia 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 low-grade nonpsychotic symptoms of schizophrenia. For example, the person with schizotypal is eccentric and is interested in odd and unusual beliefs, whereas the person with schizoid displays social apathy. Individuals with schizophrenia display both of these characteristics plus delusions or hallucinations. Thus these personal- ity disorders have much in common with this more severe mental illness. In the case of schizotypal disorders, individuals are likely to possess the genotype that makes them vulnerable to schizophrenia. A large proportion of family members of those with schizophrenia exhibit odd and unusual behaviours that would contribute to a diagnosis of schizotypal personality disorder. 610 lar65774_ch19_602-643.indd 610 1/17/20 7:15 PM  Chapter 19 Disorders of Personality Schizoid Personality Disorder The schizoid personality is split off (schism), or detached, from normal social relations. The person with schizoid personality disorder 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 playing video games. 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 person with schizoid personality disorder 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 individual does not respond to social cues and so appears inept or socially clumsy. For example, such a person may walk into a room where there is another person and simply stare at that person, apparently not motivated to start a conversation. Sometimes the person with schizoid personality disorder is passive in the face of unpleasant happenings and does not respond effectively to important events. Such a person may appear directionless. Application The case of Roger, a research assistant with schizoid personality disorder. Roger was an undergradu- ate who had volunteered to help out in the laboratory of one of his psychology professors. He was responsible, showing up on time and doing the work he was given. However, he seemed detached from the work, never getting too excited or appearing to be even interested, though he volun- teered to work for several semesters. Roger often worked in the lab at night. On several occasions, some of the graduate students complained to the professor that Roger was “staring” at them. When pressed for details, these students said that, when they left their office doors open, they would sometimes turn around and find Roger standing in the doorway, looking at them. Several female graduate students complained that he was “spooky” and kept their office doors locked. Roger lived with his younger brother, who also went to the same university. The brother apparently handled all the daily chores, such as dealing with the landlord, buying groceries, and arranging for utilities. Roger thus had a protected life and spent most of his time studying, read- ing, or exploring the Internet. In class, he never talked or participated in discussion. Outside of class, he appeared to have no friends, nor did he participate in any extracurricular activities. The professor he worked for thought he might be on medication but, after inquiring, learned that Roger took no medication. After graduating with a degree in psychology, Roger returned to live with his parents. He remodelled the space above his parents’ garage and has been living there, rent-free, for the past 15 years. Every few years, he e-mails his professor with an update on his rather stable life, although the professor’s return e-mails bounce back with the message that “no such e-mail address exists.” Apparently, Roger has found a way to keep his e-mail address secret. People from some cultures react to stress in a way that looks like schizoid personality disorder. That is, without actually having the disorder, some people under stress may appear socially numb and passive. For example, people who move out of extremely rural environments into large cities may react in a schizoid fashion for several weeks or months. Such a person, overwhelmed by noise, lights, and overcrowding, may prefer to be 611 lar65774_ch19_602-643.indd 611 1/17/20 7:15 PM  Part Six The Adjustment Domain alone, have constricted emotions, and manifest other deficits in social skills. Also, people who emigrate from other countries are sometimes seen as cold, reserved, or aloof. For example, people who emigrated from South- eastern Asia during the 1970s and 1980s were sometimes seen as being hostile or cold by people in mainstream urban American culture. These are cultural differences and should not be interpreted as personality disorders. Schizotypal Personality Disorder Whereas the person with schizoid personality disorder is indifferent to social interaction, the person with schizo- typal personality disorder is acutely uncomfortable in social relationships. Those with schizotypal are anxious in social situations, especially if those situations involve strangers. They also feel that they are different from others or that they do not fit in with the group. Interestingly, when such individuals have to interact with a group, they do not necessarily become less anxious as they become more familiar with the group. For example, The famous surrealist painter Salvador Dali while attending a group function, those with schizotypal displayed many of the characteristics associated personality disorder will not become less anxious as time with the schizotypal personality disorder. wears on, but instead will become more and more tense. ©IanDagnall Computing/Alamy Stock Photo This is because they 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 un- usual for them to harbour 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, individuals with schizotypal personality disorder 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 person simply does not fit into the social group. Due to their similarity in terms of avoiding social relations, the characteristics of schizoid and schizotypal personality disorders are presented together in Table 19.2. Some beliefs and thoughts (mostly concerned with other people) which characterize individuals with these disorders are also listed. Mason, Claridge, and Jackson (1995) published a questionnaire for assessing schizotypal traits and validated it in several British samples. One of the scales contains items that get at the presence of unusual experiences: “Are your thoughts sometimes so strong you can almost hear them? Have you sometimes had the feeling of gaining or losing energy when certain people look at you or touch you? Are you so good at controlling others 612 lar65774_ch19_602-643.indd 612 1/17/20 7:16 PM  Chapter 19 Disorders of Personality Table 19.2 Characteristics of Schizoid and Schizotypal Personality Disorders Schizoid Detached from normal social relationships Pleasureless life Inept or socially clumsy Passive in the face of unpleasant events Schizotypal Anxious in social relations and avoids people “Different” and nonconforming Suspicious of others Eccentricity of beliefs, such as in ESP or magic Unusualness of perceptions and experiences Disorganized thoughts and speech Typical Thoughts or Beliefs Associated with the Schizoid and Schizotypal Personalities “I hate being tied to other people.” “My privacy is more important to me than being close to others.” “It’s best not to confide too much in others.” “Relationships are always messy.” “I manage best on my own and set my own standards.” “Intimate relations are unimportant to me.” that it sometimes scares you?” Another scale contains items that assess cognitive disorganization: “Do you ever feel that your speech is difficult to understand because the words are all mixed up and don’t make any sense? Do you frequently have difficulty starting to do things?” Another set of items measures the tendency to avoid people: “Are you much too independent to really get involved with people? Can you usually let yourself go and enjoy yourself at a party?” And, finally, there is a scale for assessing the nonconformity aspect of schizotypy: “Do you often feel like doing the opposite of what people suggest, even though you know they are right? Would you take drugs that might have strange or dangerous effects?” Exercise Many famous people have been odd or eccentric. Artists (e.g., Salvador Dali), writers (e.g., Tennessee Williams), musicians, film stars, and even politicians have exhibited some fairly eccentric behaviours. Can you think of examples of public figures who have displayed odd beliefs or actions recently? Would they fit the rest of the characteristics of the schizotypal personality? Paranoid Personality Disorder Whereas the personal with schizotypal personality disorder is uncomfortable with others, the person with paranoid personality disorder is extremely distrustful of others and sees others as a constant threat. Such individuals assume that others are out to exploit and deceive them, even though there is no good evidence to 613 lar65774_ch19_602-643.indd 613 1/17/20 7:16 PM  Part Six The Adjustment Domain support this assumption. Individuals feel that they have been injured by others and are preoccupied with doubts about the motivations of others. People with this personality typically do not reveal personal information to others, fearing that the informa- tion will be used against them. Their reaction to others is “Mind your own business.” The paranoid person often misinterprets social events. For example, someone makes an off-hand comment and the paranoid interprets it as a demeaning or threatening remark (e.g., wondering, “What did he mean by that?”). Those with this disorder are constantly on the lookout for hidden meanings and disguised motivations in the comments and behaviours of others. A person with paranoid personality disorder often holds resentments toward others for slights or perceived insults. Such a person is reluctant to forgive and forget even minor altercations. Individuals often become involved in legal disputes, suing others for the slightest reasons. Sometimes they plead with those in power to intervene on their behalf, such as writing to congresspersons or calling the local police chief day after day. Pathological jealousy is a common manifestation of paranoid personality disorder. For example, a pathologi- cally jealous woman suspects that her husband or partner is unfaithful, even though there is no objective evidence of infidelity. She may go to great lengths to find support for her jealous beliefs. She may restrict the activities of her partner or constantly question him as to his whereabouts. She may not believe her partner’s accounts of how he spent his time or believe his claims of faithfulness. 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. Their extreme suspiciousness and the unreasonableness of their beliefs make people with this disorder particularly difficult in social relations. Table 19.3 presents the main characteristics of the paranoid personality disorder, along with some examples of beliefs and thoughts commonly found among individuals with this disorder. Table 19.3 Characteristics of Paranoid Personality Disorder Is distrustful of others Misinterprets social events as threatening Harbours resentments toward others Is prone to pathological jealousy Is argumentative and hostile Typical Thoughts or Beliefs Associated with the Paranoid Personality “Get them before they get you.” “Other people always have ulterior motives.” “People will say one thing but do another.” “Don’t let them get away with anything.” “I have to be on guard all the time.” “When people act friendly toward you, it is probably because they want something. Watch out!” 614 lar65774_ch19_602-643.indd 614 1/17/20 7:16 PM  Chapter 19 Disorders of Personality Cluster B. The Erratic Cluster: Ways of Being Unstable and Emotional People 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, border- line, histrionic, and narcissistic personality disorders. Antisocial Personality Disorder Antisocial individuals show a general disregard for others and care very little about the rights, feelings, or happiness of other people. Antisocial people have also been referred to as sociopaths or psychopaths (Zuckerman, 1991a). Adults with this disorder typically had a childhood that was fraught with behavioural problems. Such early childhood behavioural 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 behavioural problems include behaving aggressively or cruelly to- ward animals, threatening and intimidating younger children, destroying property, lying, and breaking rules. Behavioural problems in childhood are often first noticed in school, but such children also come to the attention of the police and truant officers. Sometimes even very young children, during an argument with another child, use a weapon that can cause serious physical harm, such as a baseball bat or a knife. Once childhood behavioural problems become an established pattern, the possibility of antisocial personality disorder becomes more likely (American Psychiatric Association, 2013). As a child with behavioural 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 behavioural problems rapidly develop to a level of dangerous and even sadistic behaviour. For example, we sometimes hear in the news about preteen children (usually male) who murder other children in cold blood and without remorse. In one study, children who grew into severe delinquency as teenagers were already identifiable by kindergarten teachers’ ratings of impulsiveness and antisocial behaviour at age five (Tremblay et al., 1994). Studies of children ages 6–13 also find that some children exhibit a syndrome of antisocial behaviours, including impulsivity, behavioural problems, callous social attitudes, and lack of feelings for others (Douglas & Guy, 2008). If a child exhibits no signs of conduct problems by age 16, it is unlikely that they will develop antisocial personality as an adult. Moreover, even among children with conduct problems, the majority simply grow out of them by early adulthood (American Psychiatric Association, 2013). However, some children with conduct problems go on to develop full-blown antisocial personality disorder in adulthood. Children with earlier-onset conduct problems (e.g., by age six or seven) are much more likely to grow into antisocial personality disorder as an adult than are children who displayed a few conduct problems in high school (Laub & Lauritsen, 1994). The antisocial adult continues with the same sorts of conduct problems started in childhood, but on a much grander scale. The term antisocial implies that the person has a lack of concern for social norms. Individuals with antisocial personality disorder have very little respect for laws and may repeatedly engage in acts that are grounds for arrest, such as harassing others, fighting, destroying property, and stealing. “Cold-hearted” is a good description of their interactions with others. Individuals may manipulate and deceive others to gain rewards or pleasure (e.g., money, power, social advantage, or sex). 615 lar65774_ch19_602-643.indd 615 1/17/20 7:16 PM  Part Six The Adjustment Domain 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. Lying becomes a common part of social interac- tion for the antisocial personality. Some make a living conning others out of money. “Getting one over” on people, especially authorities, through deception may even be pleasurable to the antisocial person. Another common characteristic of the antisocial personality is impulsivity, which is often manifested as a failure to plan ahead. The antisocial person might start a chain of behaviour without a clear plan or sequence in mind; for example, the person might enter a gas station and decide on the spot to rob the attendant, even without a planned getaway. Prisoners with antisocial personalities often complain that their lack of planning led to their arrest, and they are often more remorseful about getting caught than about committing the crime. A more common form of impulsivity is to simply make everyday decisions without much forethought or without considering consequences. For example, an antisocial man might leave his wife and baby for several days without calling to say where he is. This often results in trouble in relationships and trouble in employment settings. Generally, antisocial individuals change jobs often, change relationships often, and move often. Those with antisocial personality disorder 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 individuals tend to be assaultive, particularly to those around them, such as spouses or children. Fights and physical attacks are common. Recklessness is another characteristic, such that individu- als show little regard for their own safety or that of others. Driving while intoxicated or speeding is indicative of recklessness, as is having unprotected sex with multiple partners. Individuals with antisocial personality disorder who are both highly irritable and highly impulsive are at heightened risk for engaging in suicide- related behaviours (Douglas et al., 2008). Irresponsibility is another key feature of the antisocial personality. Individuals with antisocial personality disorder get bored easily and find monotony or routine to be stressful. A person may, for example, decide on the spur of the moment to abandon their job, with no plan for getting another right away. Repeated unexplained absences from work are a common sign of the antisocial character. Irresponsibility in financial matters is also common, with the antisocial person often running up unpayable debts, or borrowing money from one person to pay a debt owed to another, staying one step ahead of the bill collector. Such a person may squander the money needed for groceries or gamble away the family savings. Lack of remorse and guilt feelings, as well as indifference to the suffering of others, are the hallmarks of the antisocial mind. The person with antisocial personality disorder can be ruthless, without the normal levels of human compassion, charity, or social concern. Table 19.4 summarizes the key characteristics of antisocial personality disorder. Also included are typical beliefs or thoughts that someone with this disorder might have. A concept related to antisocial personality disorder is psychopathy, which was a term coined toward the middle of the twentieth century (Cleckley, 1941) to describe people who are superficially charming and intelligent, but are also deceitful, unable to feel remorse or care for others, impulsive, and lacking in shame, guilt, and fear. Psychopathy and antisocial personality are similar notions but there are important distinc- tions, so they should not be used interchangeably. The antisocial personality designation places emphasis on observable behaviours, such as chronic lying, repeated criminal behaviour, and conflicts with authority. 616 lar65774_ch19_602-643.indd 616 1/17/20 7:16 PM  Chapter 19 Disorders of Personality Application A possible case of antisocial personality disorder. Conrad Black (b. 1944) was a Canadian citizen until 1999 and once controlled Hollinger International, the third-largest newspaper consortium in the world. Conrad Black is also well known for being convicted of fraud in 2007, for which he served 37 months in prison. Although he had many friends and an active social life, Conrad Black seems to meet seven of the ten criteria for antisocial personality disorder. As a Conrad Black exhibits several characteristics consistent child Black was expelled from three with antisocial personality disorder. He has repeatedly different private schools for academic misconduct and insubordination, sug- made unethical business decisions that have hurt other gesting a conduct disorder before the age people and refuses to accept responsibility for his own of 15. Over the course of his adult life, actions. When confronted with evidence of his crimes Black Black was charged with embezzling $80 invariably responds with angry words and typically mocks million from Hollinger International and insults his accusers while showing a lack of remorse. (for which he served prison time) and for ©Mug Shot/Alamy Stock Photo lesser crimes related to his financial dealings, including securities fraud. Black misled shareholders of his company and is thought to have coerced two elderly widows into selling him companies for much less than the companies were actually worth. When accused of inappropriate behaviour, Conrad Black has responded with aggression and anger, writing scathing newspaper articles directed at his accusers. Black has reportedly spent lavishly on company accounts and gone back on agreements made with businesses with which he worked. The case of Conrad Black demonstrates that even people who hold esteemed positions within society may show signs of antisocial personality disorder. The psychopathy designation places emphasis on more subjective characteristics, such as the incapacity to feel guilt, a high degree of superficial charm, or having callous social attitudes. The distinction can get blurred, because the DSM-5 also includes a subjective criterion, “lack of remorse,” in its definition of antiso- cial personality disorder. However, the concept of psychopathy is mainly a research construct, pioneered by the scientific work of Canadian psychologist Robert Hare. He developed a measure of the construct called the Psychopathy Checklist, which contains two major clusters of symptoms. One cluster refers to emotional and interpersonal traits, such as incapacity for fear, superficial charm, lack of empathy and care for others, being egocentric, and having callous social attitudes and shallow emotions. The second cluster assesses the social deviance associated with an antisocial lifestyle, such as being impulsive, displaying poor self-control, possessing a high need for excitement, and having early and chronic behavioural problems. The major distinction between psychopathy and antisocial personality disorder mainly lies in the first cluster of emotional and interpersonal traits that define psychopathy. Consequently, most extreme psychopaths would meet criteria for a diagnosis of antisocial personality disorder, but not all people with antisocial personality disorder are psychopaths (if they don’t have the subjective characteristics of superficial charm, egocentricity, lack of empathy, and shallow emotions). Two theories of the origins of psychopathy are discussed in A Closer Look: Theories of the Psychopathic Mind. 617 lar65774_ch19_602-643.indd 617 1/17/20 7:16 PM  Part Six The Adjustment Domain Table 19.4 Characteristics of Individuals with Antisocial Personality Disorder Fails to conform to social norms, e.g., breaks the law Repeated lying or conning others for pleasure or profit Impulsivity Irritable and aggressive, e.g., frequent fights Reckless disregard for safety of others and self Irresponsible, e.g., truant from school, cannot hold a job Lack of remorse, e.g., indifferent to pain of others, rationalizes having hurt or mistreated others Typical Thoughts Associated with the Antisocial Personality “Laws don’t apply to me.” “I’ll say whatever it takes to get what I want.” “I think I’ll skip work today and go to the racetrack.” “That guy I beat up deserved every bit of it.” “She had it coming, she asked for it...” “I’m the one you should feel sorry for here...” One interesting concept is the notion of the “successful” psychopath. Certainly there are some features of psy- chopathy 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 psychopa- thy may facilitate success in certain professions, such as financial consulting, politics, and contact sports. A recent review of research on the “successful” psychopath (Lilienfeld, Watts, & Smith, 2015) concluded that it is a controversial and elusive concept, fraught with alternative interpretations, and requires additional research to determine if a positive manifestation of psychopathy can exist without the truly maladaptive and negative elements. Nevertheless, various surveys of psychopathy in business and corporate settings have suggested that between 4 percent and 20 percent of individuals could be described as psychopaths (Brooks & Fritzon, 2016). Exercise For the next week, read through at least one online news outlet each day. Look for stories on peo- ple who might be good examples of antisocial personality disorder, such as murderers, white- collar criminals, and con artists. Look for evidence from the person’s life and actual behaviours that match the characteristics of antisocial personality listed in Table 19.4. When evaluating antisocial personality profile, it is good to keep in mind the social and environmental con- texts in which some people live. Psychologists have expressed concern that the antisocial label is sometimes applied to people who live in settings where socially undesirable behaviours (such as fighting) are viewed as protective. For example, in a high-crime area, some of the antisocial attitudes may safeguard people against being victimized. Thus, the term antisocial should be used only when the behaviour pattern is indicative of dysfunction and is not simply a response to the immediate social context. For example, youths who emigrate from war-ravaged countries, where aggressive behaviours are necessary to survive each day, should not be considered antisocial. The economic and social contexts must be taken into account when deciding whether undesirable behaviours are signs of dysfunction. 618 lar65774_ch19_602-643.indd 618 1/17/20 7:16 PM  Chapter 19 Disorders of Personality A Closer Look Theories of the Psychopathic Mind Here we compare two theories about the origins of psychopathy: a biological explanation and a social learning explanation. Many psychologists have argued that psychopathy is caused by a biological deficit or abnormality (e.g., Cleckley, 1988; Fowles, 1980; Gray, 1987a, 1987b). Research along these lines has focused on the idea that psychopaths are deficient in their ability to experience fear (Lykken, 1982). Being deficient in fear would help explain why psychopaths do not learn as well from punishment as from reward (Newman, 1987). Psychopaths may pursue a career in crime and lawlessness because, in part, they are simply not afraid of the punishment because they are insensitive to fear. The theory of Jeffrey Gray (1990) has been influential to a number of researchers looking for a biologi- cal explanation of psychopathy. Recall from Chapter 7 that Gray proposed a system in the brain that is responsible for inhibiting behaviour. The behavioural inhibition system (BIS) acts as a psychological brake, responsible for interrupting ongoing behaviour when cues of punishment are present. According to Gray, the BIS is the part of the brain that is especially sensitive to signals of punishment coming from the environment. People who sense that a punishment is likely to occur typically stop what they are doing and look for ways to avoid the punishment. Researchers are beginning to examine the emotional lives of psychopaths, especially with respect to their experience of anxiety and other negative emotions. Psychologist Chris Patrick and his colleagues are following an interesting line of research. One study examined a group of prisoners, all of whom were convicted of sexual offences (Patrick, Bradley, & Lang, 1993). Even in this group of severe offend- ers, some individuals were more psychopathic than others, as measured by Hare’s Psychopathy Check- list (Hare, Hart, & Harpur, 1991). Patrick and his colleagues had the prisoners look at unpleasant pictures (e.g., injured people, threatening animals) to try to bring about feelings of anxiety. While they were looking at the pictures, the prisoners were startled by random bursts of a loud noise. People typically blink their eyes when they are startled by a loud noise. Moreover, a person who is in an anxious or fearful state when startled will blink faster and harder than a person in a normal emotional state. This means that eye-blink speed when startled may be an objective physiological measure of how anxious or fearful a person is feeling. That is, the eye-blink startle method may allow researchers to measure how anxious individuals are without actually having to ask them. The results from this study of prisoners showed that the more psychopathic offenders displayed less of the eye-blink effect when startled, indicating that they were experiencing relatively less anxiety to the same unpleasant pictures. However, when asked about how distressing the pictures were, both the psychopaths and the nonpsychopaths reported that the pictures were distressing. Overall, these results suggest that psychopaths will say that they are feeling anxious or distressed, yet direct nervous system measures suggest that they are actually experiencing less anxiety than nonpsychopaths in the same situation. In another study, Patrick, Cuthbert, and Lang (1994) again used a group of prisoners who differed from each other in terms of antisocial behaviours. This time, the prisoners were asked to imagine fearful scenes such as having to undergo an operation. The low- and high-antisocial prisoners did not differ in terms of their self-reports of fear and anxiety—all reported more of these emotions in response to the fear images than in response to neutral images such as walking across the yard. Large differences, however, were found in their physiological responses to the fear images. The less antisocial prisoners were more aroused by the fear imagery than were the antisocial subjects. In other words, the antisocial prisoners displayed a deficit in fear responding when their fear responses were assessed with physio- logical measures, which are less susceptible to being faked than the self-report measures. These results are consistent with the idea that the psychopath is deficient in the ability to experience fear and 619 lar65774_ch19_602-643.indd 619 1/17/20 7:16 PM  Part Six The Adjustment Domain anxiety. In a review of the literature, Patrick (1994) argued that the core problem with psychopaths is a deficit in the fear response. As a consequence, the psychopath is not motivated to interrupt ongoing behaviour in order to avoid punishment or other unpleasant consequences. Other researchers have de-emphasized biological explanations for psychopathy and argue instead that the emotional unresponsiveness of the psychopath is learned This is the kind of photo used in the study by (Levenson, Kiehl, & Fitzpatrick, 1995). The observed psychologist Chris Patrick, who found that fearlessness of the psychopath may be the result of a psychopaths did not exhibit the normal fear desensitization process. If a person is repeatedly exposed to violence or other antisocial behaviour (such as child- response to such threatening stimuli. hood abuse or gang activities), they may become desen- ©Taras Verkhovynets/Shutterstock sitized to such behaviours. That is, the callous disregard for others—the hallmark of psychopathy—may result from desensitization, a well-known form of learn- ing. A prospective study of more than 400 victims of childhood abuse found that, compared with a control group, the abused children had significantly higher rates of psychopathy 20 years later (Luntz & Widom, 1994). By being victims of abuse, the argument goes, people learn that abusing others is a means of achieving power and control and obtaining what they want. Many psychopaths are motivated by interpersonal dominance and appear to enjoy having power over others. This can sometimes be seen in board meetings of corporations, in police stations, in politics, and wherever else one person has an opportunity to bully others. The point of this research, however, is that people who grow up to be bullies were themselves frequently bullied and abused as children. Levenson (1992) has used results such as these to argue for a social learning model of psychopathy. He holds that at some point people decide to engage in antisocial behaviour because they have learned from observing others that this is one way to get what they want. Psychologists are currently debating the relative merits of viewing psychopathy as biological or as learned. Whatever the cause of psychopathy, the frequency and severity of antisocial behaviours almost always decrease as a person ages. It has been said that the best therapy for the psychopath is to grow older while in prison. The incidence of antisocial behaviours dramatically decreases in individuals age 40 and older (DSM-5). It has been widely known that, among criminals, those who make it to their fourth decade are much less likely to be rearrested for antisocial acts than are those in their twenties or thirties. For example, a study of 809 male prison inmates aged 16–69 found that deviant social behaviours, im- pulsivity, and antisocial acts were much less prevalent in the older prisoners (Harpur & Hare, 1994). There was less of an age decline in antisocial beliefs and callous social attitudes. Thus, although older psychopaths still don’t care much about other people or their feelings, they nevertheless are less likely to impulsively act out these beliefs or to engage in actual antisocial behaviours. Borderline Personality Disorder The lives of people with borderline personality disorder are marked by instability. Their relationships are unstable, their behaviour is unstable, their emotions are unstable, and even their images of themselves are unstable. Let’s consider each of these, starting with relationships. The relationships of borderline individuals tend to be intense, emotional, and potentially violent. They suffer from strong fears of abandonment. If such individuals sense separation or rejection in an important relation- ship, profound changes in their self-image and in how they behave may result, such as becoming very angry at 620 lar65774_ch19_602-643.indd 620 1/17/20 7:16 PM  Chapter 19 Disorders of Personality 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 behaviour (burning or cutting themselves) or suicide attempts. A study of 84 hospital patients with a diagnosis of borderline personality disorder found that 72 percent had a history of attempting suicide (Soloff, Lis, Kelly, & Cornelius, 1994). In fact, among this sample, the average borderline patient had attempted suicide on at least three occasions. Recent research suggests that greater impairments in emotional perception in individuals with borderline personality disorder increase the risk for self-harm (Williams et al., 2015). We explore this further in Highlight on Canadian Research: Ambiguous Facial Expressions and Borderline Personality Disorder. Highlight on Canadian Research Ambiguous Facial Expressions and Borderline Personality Disorder Researchers have long suspected that the misinterpretation of emotional cues is central to borderline personality disorder (BPD) (Linehan, 1995). Alexander Daros, Amanda Uliaszek, and Anthony Ruocco of the University of Toronto tested this hypothesis by comparing performance on the Penn Emotional Acuity Test (PEAT) in females with BPD and IQ and age-matched nonpsychiatric controls. The PEAT involves presenting an individual with 40 pictures of faces conveying neutral, happy, or sad expressions and asking the individual to rate the emotional expression on each face. The pictures conveying happiness and sadness differ in the intensity of their emotional expression: some convey mild emotion, others moderate emotion, and some prototypical emotions. Faces must be rated as very sad, moderately sad, mildly sad, neutral, mildly happy, moderately happy, or very happy. Both response time and accuracy are recorded as individuals complete the PEAT. Daros, Uliaszek, and Ruocco (2014) found that both individuals with BPD and nonpsychiatric controls classified intense emotional expressions quickly and accurately. However individuals with BPD were less accurate than controls when asked to classify facial expressions that were neutral or mildly sad. When the facial expression was neutral, individuals with BPD tended to classify the face as conveying an emotion, although they were equally likely to classify the neutral face as happy or sad. When the facial expression was mildly sad, individuals with BPD were more likely to classify it as more intensely sad. Despite the difference in accuracy, response times to the faces were similar for individuals with BPD and controls. Daros and colleagues (2014) suggest that individuals with BPD may misperceive facial expres- sions conveying little or no emotional content as conveying an emotion, which may in turn contribute to the symptoms of the disorder. The researchers speculate that treatment that encourages individuals with BPD to be more mindful of their reactions to ambiguous facial expressions may be beneficial. The relationships of borderline individuals are unpredictable and intense. They may go from idealizing the other to ridiculing the other. They are prone to sudden shifts in their views of relationships, behaving at one time in a caring manner and at another time in a punishing and cruel manner. They may go from being submissive to being an avenger for past wrongs. The 1987 Oscar-nominated movie Fatal Attraction contains a character with several features of the borderline personality disorder. Borderline people 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 person with borderline personality disorder assume some new responsibilities. 621 lar65774_ch19_602-643.indd 621 1/17/20 7:16 PM  Part Six The Adjustment Domain 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 people 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 fin- ishing or destroying a caring relationship just when it starts going smoothly. People with borderline personality disorder are characterized by huge vacillations in both mood and feelings about the self and others. They can shift quickly from loving another to hating that same person. They are very demanding on their friends, relatives, lovers, and therapists because they are manipulative. For example, they may threaten or even try suicide when they don’t get their way. They are very sensitive to cues that others may abandon or leave them. In particular, people with borderline personality disorder tend to have difficulty correctly identifying neutral facial expressions, which may lead to inaccurate inferences about what others are thinking and feeling (Daros, Uliaszek, & Ruocco, 2014). Table 19.5 lists the major features of borderline personality disorder, along with examples of beliefs and thoughts that those with this disorder might commonly have. People with borderline personality disorder, compared with those without, have a higher incidence rate of childhood physical or sexual abuse, neglect, or early parental loss. Many researchers believe that borderline disorder is caused by an early loss of love from parents, as may happen in parental death, abuse, severe neglect, or parental drug or alcohol abuse (Kuo, Khoury, Metcalfe, Fitzpatrick, & Goodwill, 2015; Millon et al., 2000). Early loss may affect a child’s capacity to form relationships. Children in such circumstances may come to believe that others are not to be trusted. Individuals with borderline personality disorder have also been shown to have difficulty accurately recalling events from the past, which may contribute to their seemingly erratic behaviour (Ruocco & Bahl, 2014). We illustrate one example of how Hollywood explores this disorder in A Closer Look: Does Anakin Skywalker Suffer from Borderline Personality Disorder? Although individuals have difficulty with relationships, they may form stable relationships if given enough structure and support. If they find someone who is accepting and stable, who is diplomatic, who meets their expectations for commitment, and who is caring and can defuse trouble as it occurs, then the borderline personality may experience a satisfying relationship. Recent Table 19.5 Characteristics of Borderline Personality Disorder Instability of relationships, emotions, and self-image Fears of abandonment Aggressiveness Proneness to self-harm Strong emotions Typical Thoughts or Beliefs Associated with the Borderline Personality “I’m nothing without you.” “I’ll just die if you leave me.” “If you go, I’ll kill myself.” “I hate you, I hate you, I HATE YOU.” “I love you so much that I’ll do anything or be anything for you.” “I feel empty inside, as if I don’t know who I am.” 622 lar65774_ch19_602-643.indd 622 1/17/20 7:16 PM  Chapter 19 Disorders of Personality A Closer Look Does Anakin Skywalker Suffer from Borderline Personality Disorder? French researcher Eric Bui was working on his graduate degree around the time that two Star Wars prequels, Attack of the Clones (2002) and Revenge of the Sith (2005), were released. While watching these movies, Bui noticed that Anakin Skywalker (who eventually becomes Darth Vader) exhibited many of the traits typically associated with borderline personality disorder (BPD). Bui notes that Anakin’s life history was similar to many people with BPD: his father was absent and he was separated from his mother from an early age. In addition, Anakin’s omnipotent and impulsive behaviour as a child, combined with dysfunc- tional relationships, mirrors that of many people with BPD. Finally, Anakin fulfills six out of nine of the DSM criteria for BPD. First, he is impulsive and can’t control his anger. Second, he can’t decide if he idealizes his mentors or hates them. Third, he is so afraid of being abandoned by his wife that he betrays his friends to secure the relationship. Fourth, he experiences dissociative episodes following stressful events. Fifth, he acts out violently. And sixth, he clearly has an identity disturbance which culminate