Nicohwilliam

Assignment 1: at least 250 words, APA format; cite relevant sources and textbook; Textbook chapter 13 and 14 content and video below

After reviewing the textbook chapters as well as the posted videos, respond meaningfully to each of the following questions.  

1.  Describe the criteria used to assess personality disorders.

2.  List what personality traits are important in determining pathology.

3.  Discuss what causes sexual dysfunctions and what types of treatment are available for them.

4.  Discuss the causes of gender dysphoria, and how it is treated

Youtube video:

Transgender at 11: Listening to Jazz Jennings | 20/20 | ABC News

https://www.youtube.com/watch?v=bJw3s85EcxM

Textbook:

Sue, D., Sue, D. W., Sue, D., & Sue, S. (2014). Essentials of understanding abnormal behavior (2nd ed.). Belmont, CA: Wadsworth Cengage Learning.

Chapter 13

13-1What Is “Normal” Sexual Behavior?

Despite the quantity of research on the topic, distinguishing between abnormal behavior and harmless variations in sexual preferences is often challenging (McManus, Hargreaves, Rainbow, & Alison, 2013). Definitions of normal sexual behavior vary widely and are influenced by both moral and legal judgments (Potter, 2013). For example, until 2003 some states had laws that defined oral-genital sex as a “perversion” and a “crime against nature,” punishable by imprisonment.

Since it is not easy to delineate “normal” sexual behavior, it is not surprising that definitions of sexual disorders are also inexact. In fact, over the past century, psychiatrists in the United States and Europe have pathologized and depathologized a variety of sexual preferences, desires, and behaviors. Revised definitions of what constitutes pathological behaviors or normative sexual practices often occur during the periodic updating of psychiatric classification systems such as the DSM (De Block & Adriaens, 2013).

Did You Know?

More than 150,000 girls in the United States are at risk of female circumcision, the forced cutting of their clitoris and labia. Common in many African countries to control a woman’s sexuality, genital mutilation continues among some African immigrants despite U.S. laws banning the practice.

Source: Roberts & Smith, 2014

Cultural norms and values also influence definitions of “normal” sexual behavior. In some cultures or cultural groups, sexual activity is considered appropriate only for procreative purposes (Bhugra, Popelyuk, & McMullen, 2010). Determining normal and abnormal behavior becomes especially difficult when comparing Western and non-Western cultures. Adults in Japan, for example, have 70 percent less sexual intercourse compared to adults in the United States, a pattern also seen in other Asian countries (Durex, 2005). Thus, it is important to take into account cultural variations when considering normative sexual behaviors and constructing definitions of sexual disorders. There is even greater controversy as to whether gender dysphoria should be considered a psychiatric disorder, because much of the suffering associated with this condition stems from discrimination and negative societal reactions. In short, the ambiguities and controversies surrounding all classification systems are particularly relevant to the three groups of sexual disorders discussed in this chapter.

Cultural Influences and Sexuality

Sexuality is influenced by how it is viewed in different cultures. Some societies have very rigid social, cultural, and religious taboos associated with exposure of the human body, whereas other societies are more open. Note the dress and behavioral differences between the two groups of young women shown here.

Enlarge Image

Amr Abdallah Dalsh/Reuters Glowimages/Getty Images

13-1aThe Sexual Response Cycle

Did You Know?

Data from U.S. surveys indicate that:

· 2.2 percent of women have a bisexual orientation and 1.1 percent report a lesbian orientation;

· 1.4 percent of men have a bisexual orientation and 2.2 percent have a gay orientation;

· 8.2 percent of adults have engaged in same-sex sexual activities; and

· 11 percent of adults acknowledge some degree of same-sex attraction.

Source: Gates, 2011

Understanding and treating sexual dysfunctions requires consideration of the normal sexual response cycle, which traditionally consists of four stages: appetitive (interest and desire), arousal, orgasm, and resolution (Figure 13.1). Empirical findings suggest that it is difficult to distinguish between the desire of the appetitive and arousal stages, because they seem to overlap. Desire and interest, for example, may precede or follow arousal. Although we use a four-stage description, it is best to view the appetitive and arousal stages as intertwined and interactive.

1. The appetitive phase is characterized by a person’s interest in sexual activity. The person begins to have thoughts or fantasies about sex, feels attracted to another person, or daydreams about sex.

2. The arousal phase involves heightened and intensified arousal resulting from specific and direct sexual stimulation. In a male, blood flow increases in the penis, resulting in an erection. In a female, the breasts swell, nipples become erect, blood engorges the genital region, and the clitoris expands.

3. The orgasm phase is characterized by involuntary muscular contractions throughout the body and the eventual release of sexual tension. In males, muscles at the base of the penis contract, propelling semen through the penis. In females, the outer third of the vagina contracts rhythmically.

4. The resolution phase is characterized by relaxation of the body after orgasm. Males enter a refractory period during which they are unresponsive to sexual stimulation. However, females are capable of multiple orgasms with continued stimulation.

Figure 13.1Human Sexual Response Cycle

The studies of Masters and Johnson reveal similar normal sexual response cycles for men and women. Note that women may experience more than one orgasm. Sexual disorders may occur at any of the phases, but seldom at the resolution phase.

© Cengage Learning®

Problems may occur in any of the phases of the sexual response cycle, although they are rare in the resolution phase.

13-2Sexual Dysfunctions

A  sexual dysfunction  is a recurrent and persistent disruption of any part of the normal sexual response cycle involving sexual interest, arousal, or response. The DSM-5 requires that the symptoms associated with a sexual dysfunction be present for at least 6 months and be accompanied by significant distress. According to the DSM-5, a diagnosis of sexual dysfunction is not appropriate when “severe relationship distress, partner violence, or significant stressors better explain the sexual difficulties” . In addition, people who have no interest in sexual activity or who are unconcerned about an inability to experience an orgasm would not receive a sexual dysfunction diagnosis. The 12-month prevalence of sexual problems in adults is summarized in Table 13.1.

Table 13.1

​Past Year Prevalence of Sexual Disorders in U.S. Men and Women in the 40–80 Age Range

Condition	Women (%)	Men (%)
Lack of interest in sex	33.2	18.1
Inability to reach orgasm	20.7	12.4
Orgasm reached too quickly	N/A	26.2
Pain during sex	12.7	3.1
Sex not pleasurable	19.7	11.2
Trouble lubricating	21.5	N/A
Erectile Difficulties	N/A	22.5

Source: Laumann, Glasser, Neves, & Moreira (2009).

Sexual dysfunctions can be lifelong (evident during initial sexual experiences), acquired (developed after successful sexual experiences), generalized (occurring in nearly all situations), or situational (occurring with certain partners, situations, or types of stimulation). As indicated in Table 13.2, the DSM-5 includes dysfunctions associated with sexual interest and arousal, orgasm, and sexual pain.

Table 13.2

DSM-5 Disorders Chart
Dysfunction	DSM-5 Definition	Prevalence	Associated Features
Male Hypoactive Sexual Desire	Recurrent lack of sexual interest	Up to 15% of men have transient episodes; Less than 2% have chronic symptoms	Increasing prevalence with age
Erectile Dysfunction	Inability to attain or maintain erection sufficient for sexual activity	13%–21% have occasional episodes	Low self-esteem or lack of confidence; fear of failure
Premature Ejaculation	Ejaculation prior to or within 1 minute after vaginal penetration	Up to 30% indicate concern	Fear of not satisfying partner; but only 1%–3% meet the criteria
Delayed Ejaculation	Persistent delay or absence of ejaculation nearly all the time during partnered sex activity	Less than 1% of men	Partner may feel less attractive, feelings of frustration
Female Sexual Interest/Arousal Disorder	Little or no sexual interest or arousal for sexual activity	30% with symptoms but many do not experience distress	Problems with arousal, pain, orgasm; relationship problem
Female Orgasmic Disorder	Persistent delay or inability to attain an orgasm in nearly all sexual encounters	10%–42% from surveys; nearly 10% never achieve an orgasm in their lifetime	Only mildly related to women’s sexual satisfaction
Genito-Pelvic Pain/Penetration Disorder	Difficulty with vaginal penetration, fear of pain, tightening of pelvic muscles	15%–21% of women report painful intercourse	Fear of penetration, avoidance of sexual activities

​Sexual Dysfunctions

Source: APA, 2013; Carvalheira, Træen, Štulhofer (2014); Pazmany, Bergeron, Van Oudenhove, Verhaeghe, & Enzlin (2013).

13-2aSexual Interest/Arousal Disorders

Sexual interest/arousal disorders involve problems with sexual excitement, including difficulties with feelings of sexual pleasure or the physiological changes associated with the appetitive and arousal phases. They include:

· male hypoactive sexual desire disorder , characterized by little or no interest in sexual activities, either actual or fantasized; and

· female sexual interest/arousal disorder , characterized by little or no interest in sexual activities, either actual or fantasized, and/or a lack of or diminished arousal to sexual cues during nearly all sexual activities.

Some clinicians estimate that 40–50 percent of all sexual difficulties involve deficits in interest; this is one of the most common complaints of couples seeking sex therapy (Laumann, Glasser, Neves, & Moreira, 2009). In a sample of men between the ages of 18 and 75, a distressing lack of sexual interest was reported by 14.5 percent of the participants, and was most common in men in long-term relationships. Stress involving work or professional activities was a common explanation for lack of interest in sex (Carvalheira, Traeen, & Stulhofer, 2014).

Did You Know?

Men think about sex significantly more often than women do.

Adapted from Michael, Gagnon, Laumann, & Kolata (1994)

Among a group of women, 31 percent reported experiencing a lack of sexual interest (McCabe & Goldhammer, 2013). For women, difficulties with sexual interest or arousal often result from negative attitudes about sex or early sexual experiences. For example, receiving inaccurate or disturbing sexual information, having been sexually assaulted or molested, or having conflicts with a sexual partner may contribute to limited sexual interest or arousal (Perlman et al., 2007). Although people with sexual interest/arousal disorders are often capable of experiencing orgasm, they have little interest in, or derive minimal pleasure from, sexual activity.

Erectile Disorder

Case Study

A 20-year-old college student was experiencing acquired erectile dysfunction. His first episode of erectile difficulty occurred when he attempted sexual intercourse after drinking heavily. Although he knew that his sexual performance was affected by alcohol, he began to have doubts about his sexual ability. During a subsequent sexual encounter, his anxiety and worry increased. When he failed in this next coital encounter, even though he had not been drinking, his anxiety level rose even more. When his erectile difficulties continued, he decided to seek therapy.

Did You Know?

Vascular disease, which can limit blood flow to the penis, is common in males with erectile dysfunction. As a group, men with erectile disorder have a 65 percent increased risk of developing coronary heart disease and a 43 percent increased risk of stroke within 10 years.

Source: Moore et al., 2014

In men, inhibited sexual excitement takes the form of an  erectile disorder , an inability to attain or maintain an erection sufficient for sexual intercourse or other sexual activity on almost all occasions (Yuan et al., 2014). As was the case of the student seeking therapy, the man may feel fully aroused, yet be unable to engage in intercourse. In the past, people often attributed erectile dysfunction to psychological causes (“It’s all in the head”). However, studies indicate that a large percentage of erectile dysfunction is due to limited blood flow caused by vascular insufficiency, a condition associated with physiological influences such as diabetes or arteriosclerosis (hardening of the arteries) (R. W. Lewis, Yuan, & Wang, 2008). Complaints regarding erectile dysfunction are common among older men, but are also prevalent in younger individuals. In one study, 26 percent of men seeking treatment for erectile dysfunction were between the ages of 17 and 40 (Capogrosso et al., 2013).

Erectile Dysfunction: Clark

Listen to an interview with Clark, an older patient who has had changes in his sex life.

Volume 41%

 

Copyright © Cengage Learning.

Controversy

Is Hypersexual Behavior a Sexual Disorder?

Can a person be “oversexed” and have a sexual appetite that requires frequent sex in order to be satisfied? More than 4 percent of people claim to have sex every day; 2 percent of married men and 1 percent of married women report having intercourse more than once a day (Durex, 2001, 2005). Are these people statistically abnormal?

Most therapists agree that some individuals seem obsessed with sex, feel compelled to engage in frequent sexual activity, and experience personal distress due to their behavior. In fact, it is estimated that between 3 and 6 percent of U.S. adults exhibit compulsive, impulsive, or addictive sexual behavior (Karila et al., 2013). Terms such as hypersexuality, erotomania, nymphomania (in women), and satyriasis (in men) refer to this phenomenon. Golfer Tiger Woods, actors Charlie Sheen and David Duchovny (The X-Files, Californication), and TV reality star Jesse James (ex-husband of Sandra Bullock) all admitted to “sex addiction” and entered rehabilitation centers for treatment (Thompson, 2014). In these cases, their “compulsions” to have sex with multiple partners resulted in negative personal or professional consequences. Is sexual addiction a real disorder or simply an excuse?

Clinical and research evidence suggests that hypersexuality can result in impairment and distress, so those revising the DSM considered the inclusion of a hypersexual disorder. Although there was a decision not to incorporate this disorder in the DSM-5, most clinicians and researchers agree that some people do have sexual behavior that resembles an addiction. They have recurrent sexual fantasies and urges or they engage in compulsive sexual behavior in response to depression, anxiety, boredom, irritability, or stressful life events. Additionally, they have considerable difficulty reducing or controlling their sexual urges, activities, and fantasies, even when the behaviors cause physical or emotional harm to themselves or others (Weiss, 2012).

In addition to personal psychological distress (guilt, shame, anxiety, or depression), the consequences of hypersexual behavior may include relationship problems, divorce or separation, an increased rate of sexually transmitted disease, unintended pregnancies, excessive spending on sexual services, and school or employment dysfunction (Kafka, 2009). Do you know anyone who demonstrates hypersexuality? If so, what do you see as the pros and cons of having their behavior recognized as a psychiatric disorder?

13-2bOrgasmic Disorders

Orgasmic disorders affect both men and women. Those with this condition experience difficulty or an inability to achieve a satisfactory orgasm after entering the excitement phase and receiving adequate sexual stimulation. Female orgasmic disorder is quite different from orgasmic difficulties experienced by men. In men, the symptoms of orgasmic dysfunction are subsumed under the diagnostic categories of delayed ejaculation and premature ejaculation.

Female Orgasmic Disorder

A woman with  female orgasmic disorder  experiences persistent delay, or inability to achieve an orgasm or a “markedly reduced intensity of orgasmic sensations” (APA, 2013) on nearly all occasions of sexual activity despite receiving “adequate” stimulation. Most women require clitoral stimulation to achieve an orgasm; this may be one of the reasons that only a small percentage of women report consistently experiencing orgasm during sexual intercourse.

The diagnosis of female orgasmic disorder is given only if the woman has difficulty achieving an orgasm through clitoral stimulation. Female orgasmic disorder is a frequently reported sexual problem for women (Buster, 2013). In fact, approximately 10 percent of all women have never achieved an orgasm during their life (APA, 2013).

Delayed Ejaculation

Delayed ejaculation  is the persistent delay or absence of ejaculation after the excitement phase has been reached and sexual activity has been adequate in focus, intensity, and duration. The term is usually restricted to a delay or inability to ejaculate during partnered sexual activity, even with full arousal. For a disorder to be diagnosed, delayed ejaculation must have occurred 75–100 percent of the time for at least 6 months. Due to a lack of consensus in the research, the diagnostic criteria do not address what constitutes a “delay” (APA, 2013).

Premature (Early) Ejaculation

In contrast to delayed ejaculation,  premature (early) ejaculation  involves a distressing and recurrent pattern of having an orgasm with minimal sexual stimulation before, during, or shortly after vaginal penetration; the diagnostic criterion specifies that ejaculation must occur within approximately 1 minute of penetration or attempted penetration (APA, 2013).

Did You Know?

Aphrodisiacs—including powdered animal genitals, herbs, secret concoctions, and even drugs like Viagra—are a multibillion-dollar industry. Is this because our society associates a strong libido with potency, power, attractiveness, sensual pleasure, and health?

Premature ejaculation is the most common male sexual dysfunction, affecting approximately 21–33 percent of men (Morales, 2012). However, because DSM-5 added the duration of 1 minute after vaginal penetration to the diagnostic criteria, only 1–3 percent will now meet the criteria for a premature ejaculation diagnosis. Table 13.3 compares responses regarding sexual functioning and satisfaction from men with and without problems with premature ejaculation.

Table 13.3

​Mean Responses of Men with and without Premature Ejaculation

Item	With	Without
· 1. Over the past month, how was your control over ejaculation during sexual intercourse? (0 = very poor; 4 = good)	0.9	3.0
5. 2. Over the past month, how was your satisfaction with sexual intercourse? (0 = very poor; 4 = very good)	1.9	3.3
1. 3. How distressed are you by how fast you ejaculate during intercourse? (4 = extremely distressed; 0 = not at all)	2.9	0.7
1. 4. To what extent does how fast you ejaculate cause difficulty in your relationship with your partner? (4 = extremely; 0 = not at all)	1.9	0.3

Source: Rowland, Tai, & Brummett (2007).

13-2cGenito-Pelvic Pain/Penetration Disorder

According to DSM-5, genito-pelvic pain/penetration disorder may be diagnosed when a woman experiences distress and difficulty associated with: vaginal penetration during intercourse; pain in the genital or pelvic region during intercourse ( dyspareunia ); fear of pain or vaginal penetration; or tension in the pelvic muscles (APA, 2013). The pain and distress associated with genito-pelvic pain/penetration disorder is not caused exclusively by lack of lubrication or by the rare condition,  vaginismus , which results when involuntary spasms of the outer third of the vaginal wall prevent or interfere with sexual intercourse.

Painful intercourse is relatively common in women under age 40 and is estimated to affect between 15 and 21 percent of women in this age group. As compared to a control group of pain-free women, a sample of women with dyspareunia reported significantly higher levels of distress over their body image and genitals (Pazmany, Bergeron, Van Oudenhove, Verhaeghe, & Enzlin, 2013). As you might expect, many women with genito-pelvic pain/penetration disorder also experience reduced sexual arousal.

13-2dAging and Sexual Dysfunctions

Changes in sexual functioning (decreases in sexual interest, arousal, and activity) are common as we age. It is, therefore, important for clinicians to consider ways in which the aging process affects sexuality. When women reach menopause, estrogen levels drop, and women may experience painful intercourse due to vaginal dryness and thinning of the vaginal wall (Nappi, Kingsberg, Maamari, & Simon, 2013). Older men are at increased risk for prostate problems and cardiovascular difficulties that may increase the risk of erectile disorder (Gooren, 2008).

Sexual Flirtation Common among Teens

Direct expressions of sexual interest are discouraged in some cultures. Flirting, however, allows for indirect, playful, and romantic sexual overtures toward others. It may occur through verbal communication (tone of voice, pace, and intonation) or body language (eye contact, open stances, hair flicking, or brief touching).

Brand X Pictures/Jupiter Images

Other illnesses associated with aging such as diabetes, high blood pressure, or heart disease can also affect sexual performance and interest. Hormone replacement therapy, drugs for erectile disorder (Cialis, Levitra, and Viagra), and other medical procedures may help minimize the effects of these biological problems. Additionally, lifestyle modifications such as weight loss, increasing exercise, or decreasing smoking or alcohol consumption can improve sexual functioning in older adults (Glina, Sharlip, & Hellstrom, 2013).

13-2eEtiology of Sexual Dysfunctions

Sexual dysfunctions clearly demonstrate the complex interaction of various etiological factors (Bitzer, Giraldi, & Pfaus, 2013). Let’s return to the case of Jeremiah and Christina from the chapter opening to illustrate how various etiological factors can contribute to sexual dysfunction. You may wish to reread the case in order to follow this multipath analysis. The following multipath explanation of the couple’s sexual difficulties might be operative.

Case Study Analysis

Christina and Jerimiah sought sex therapy because Christina did not seem to desire or enjoy sex. Additionally, Jeremiah was experiencing erectile difficulties for the first time in his life. The therapist concluded that these problems were not primarily the result of severe relationship distress. Christina was diagnosed as having a sexual interest/arousal disorder and Jeremiah an erectile disorder.

Their sexual difficulties involved a variety of interacting factors. Christina’s limited interest in sex increasingly strained their sexual relationship and caused Jeremiah, who felt anger, guilt, and humiliation, to experience difficulty maintaining an erection. After a while, Jerimiah began to drink before initiating sex; although drinking decreased his inhibition and gave him the courage to initiate sex with a reluctant partner, alcohol is a central nervous system depressant, a factor that made it more difficult for him to achieve an erection.

When Jeremiah was able to become erect, he quickly entered Christina for fear of losing the erection, and in turn appeared “brief” and “perfunctory” in lovemaking. This caused Christina to feel hurt and rejected. Additionally, the brevity of the sexual encounter did not allow Christina to become sexually aroused; this resulted in insufficient lubrication, painful intercourse, and an inability to achieve an orgasm. Christina then began to fake orgasms in order to please Jeremiah, who was further humiliated because he realized she was faking.

As a man, Jeremiah was also affected by cultural scripts—social and cultural beliefs that guide attitudes and behaviors—that associate masculinity with sexual potency. Thus, he began to equate his inability to satisfy Christina with “not being a real man.” Given all of these influences, they both found their sexual encounters increasingly unpleasant, a factor that added stress to their relationship and further decreased Christina’s interest in sex.

As you can see, Jeremiah and Christina’s sexual disorders are intertwined and cannot be viewed in isolation. Although the problems began with Christina’s low sexual interest, they escalated as Jeremiah began experiencing difficulties achieving and maintaining an erection. Consistent with our case example, research suggests that difficulties with sexual interest, desire, and performance are due to interactions among biological, psychological, social, and sociocultural factors as reflected in our multipath model (Figure 13.2).

Figure 13.2Multipath Model of Sexual Dysfunctions

The dimensions interact with one another and combine in different ways to result in a specific sexual dysfunction.

© Cengage Learning®

Biological Dimension

Environmental and relationship variables influence sexual dysfunction to a greater degree than biological factors (Burri, 2013). However, lower levels of testosterone have been associated with lower sexual interest in both men and women and with erectile difficulties in men (van Lankveld, 2008). Conversely, the administration of androgens (hormones such as testosterone, which promotes male sexual characteristics) is associated with reports of increased sexual desire in both men and women. The relationship between hormones and sexual behavior, however, is complex and difficult to understand. Many people with reduced sexual desire have normal testosterone levels (Hyde, 2005).

Medications that treat medical conditions such as hypertension, ulcers, glaucoma, allergies, and seizures can also affect sex drive. Use of recreational drugs, alcohol, and antidepressant medications are also associated with sexual dysfunctions, as are certain medical conditions (Ben-Sheetrit, Aizenberg, Csoka, Weizman & Hermesh, 2015; Ramsey et al., 2013). Indeed, some researchers believe that alcohol abuse is the leading cause of both erectile disorder and premature ejaculation (Arackal & Benegal, 2007).

A complete physical workup—including a medical history, physical exam, and laboratory evaluation—is a necessary first step in assessment. For example, genito-pelvic pain/penetration disorder is often caused by gynecological conditions such as endometriosis (Buster, 2013). Penile hypersensitivity to physical stimulation may also influence sexual functioning in men. In other words, for some men, premature ejaculation may be physiological. Men who ejaculate early may be “hardwired” to have a sensitive and more easily triggered sensory and response system (Rowland & McMahon, 2008).

Psychological Dimension

Sexual dysfunctions may result from psychological factors alone or from a combination of psychological and biological factors. Psychological causes for sexual dysfunctions include predisposing or historical factors, as well as more current problems and concerns. Stressful situations and the presence of anxiety disorders tend to inhibit sexual responding and functioning in both women and men (Carvalheira, Traeen, & Stulhofer, 2014). For example, Iraqi and Afghanistan war veterans with post-traumatic stress disorder (PTSD) were over 3 times more likely to have a sexual dysfunction compared to veterans without the disorder (Breyer et al., 2014). Guilt, anger, or resentment toward a partner can also interfere with sexual performance (Westheimer & Lopater, 2005). As was the case for Jeremiah and Christina, having a partner with a sexual dysfunction further increases risk of sexual difficulties in the other partner (Jiann, Su, & Tsai, 2013).

Apprehension about sexual functioning plays a key role in erectile disorder, especially for men who report that sex is very important to them or to their partner (Rowland, Lechner, & Burnett, 2012). Men with psychological erectile dysfunction often report anxiety over sexual overtures, including a fear of failing sexually or being judged as sexually inferior, as well as anxiety over the size of their genitals. Performance anxiety and taking on a “spectator role” can exacerbate erectile dysfunction. For example, if a man experiences a problem achieving or maintaining an erection, he may then begin to worry that it will happen again. Instead of enjoying the next sexual encounter and becoming aroused, he monitors or observes his own reactions (“Am I getting an erection?”) and becomes a spectator who is anxious and detached from the situation. This can result in sexual failure and increased anxiety during future sexual encounters.

Previous and current sexual experiences may influence a man’s sexual expectations and responses in other ways. Men with early ejaculation, for example, report having less frequent sexual intercourse than those without this condition (Rowland & McMahon, 2008). This is significant because even in men without sexual dysfunction, longer intervals between sex results in greater excitement when intercourse occurs. For men with early ejaculation, having fewer sexual experiences may predispose them to greater excitement and arousal. In addition, they may have fewer opportunities to learn how to delay an ejaculatory response.

Situational anxiety or emotional factors resulting from sexual abuse or other negative childhood sexual experiences often interfere with sexual functioning in women. Other factors include: having a sexually inexperienced or dysfunctional partner; fear of being an undesirable sexual partner; worry that they will never be able to attain orgasm; concern about pregnancy or sexually transmitted disease; an inability to accept the partner, either emotionally or physically; and misinformation or ignorance about sexuality or sexual techniques (Westheimer & Lopater, 2005).

Did You Know?

A survey of X-rated film actresses revealed that they were more likely to be bisexual, enjoy sex, have more sexual partners, use more drugs, and have higher self-esteem than a matched sample of women. They were also less likely to have experienced childhood abuse.

Source: Griffith, Mitchell, Hart, Adams, & Gu, 2013

Negative thoughts (“my partner doesn’t really care about me”) and dysfunctional beliefs (“sexual desire is sinful”) also play a role in female sexual dysfunction. Such thoughts and beliefs are associated with sexual interest/arousal and orgasmic difficulties, as well as painful intercourse (Carvalho, VerÍssimo, & Nobre, 2013). Focusing on one’s body may influence the sexual responsiveness of women. Women who are self-conscious about their attractiveness or who focus excessively on their bodies experience more difficulty with sexual arousal (Woertman & van den Brink, 2012). Thirty percent of women indicated that a negative body image affected their sex lives and 52 percent reported hiding one or more aspects of their body during sex (Peplau et al., 2008).

Social Dimension

Social upbringing and current relationships both influence sexual functioning. The attitudes parents display toward sex and their expression of affection toward each other can affect their children’s attitudes. A strict religious upbringing is associated with sexual dysfunction in both men and women (Carvalho et al., 2013). Traumatic sexual experiences involving rape or sexual abuse during childhood or adolescence are also factors to consider. Women who have been raped or who were subjected to molestation as children may find it difficult to trust and establish intimacy and exhibit various sexual dysfunctions (Buster, 2013).

Relationship issues are often at the forefront of sexual disorders. Marital satisfaction, for example, is associated with greater levels of sexual arousal and sexual frequency between partners, whereas relationship dissatisfaction can lead to sexual interest and arousal disorders (C. A. Graham et al., 2004). Specifically, sexual satisfaction is increased when relationships are caring, warm, and affectionate and when couples communicate openly about sex and sexual activities (Meston et al., 2008). It is important to note that men and women may define sexual satisfaction differently. For many women, closeness to a partner is more important than the frequency of orgasms or the intensity of sexual arousal.

Sociocultural Dimension

A variety of sociocultural factors can influence sexual attitudes, behavior, and functioning. Although the human sexual response cycle is similar for women and men, gender differences are clearly present: Women have different sexual fantasies than men, are more attuned to relationships in the sexual encounter, and take longer than men to become aroused (Safarinejad, 2006). Likewise, gender differences and biological factors may interact and cause sexual dysfunction. Not surprisingly, women are much more likely to experience sexual interest/arousal difficulties. It is important to note that sex researchers and clinicians who do not take into account these biological differences may unfairly portray women as having a sexual dysfunction.

Through the process of gender role socialization we learn cultural scripts about sex—social and cultural beliefs and expectations regarding sexual behavior. In U.S. society, men are taught to be sexually assertive whereas women are socialized to avoid initiating sex directly. Cultural scripts for men in the United States may include “sexual potency in men is a sign of masculinity”; “the bigger the sex organ, the better”; and “strong and virile men do not show feelings.” For women, scripts include “nice women don’t initiate sex”; “women should be restrained and proper in lovemaking”; “men are only after one thing”; and “it is the woman’s responsibility to take care of contraception.” Because these scripts often guide our sexual attitudes and behaviors, they can exert a major influence on sexual functioning.

Cultural scripts also exist in other nations. For example, people in Asian countries consistently report the lowest frequency of sexual intercourse. Guilt regarding sex may be a contributing factor. In a study of European-Canadian and Chinese-Canadian women, the former group reported less sexual guilt and greater sexual desire. Further, Chinese-Canadian women who showed greater acculturation to Western standards reported less guilt and greater sexual desire than their less acculturated counterparts. Cultural differences in sex guilt may be a means by which ethnicity affects reported sexual desire (Woo, Brotto, & Gorzalka, 2012).

Did You Know?

A female version of Viagra (flibanserin), developed to increase sexual interest in women, was blocked by the FDA due to concern about the drug’s limited effectiveness and negative side effects such as dizziness, fatigue, and nausea. Why has the 15-year search for a female sexual stimulant been unsuccessful? Is it because women’s sexual interests are more psychological or relational than physical?

Source: Perrone, 2013

Sexual orientation is also a sociocultural influence that may affect sexual responsiveness and sexual dysfunction in gay men and lesbians. Although there are no physiological differences in sexual arousal and response between lesbians and gay men and their heterosexual counterparts, their sexual issues and dysfunctions may differ quite dramatically. For example, problems among heterosexuals most often involve issues with sexual intercourse, whereas sexual concerns among lesbians and gay men may focus on other behaviors (e.g., aversion toward anal eroticism or cunnilingus). Lesbians and gay men must also deal with societal or internalized homophobia, which may inhibit openly expressing affection toward sexual partners (M. S. Schneider, Brown, & Glassgold, 2002).

13-2fTreatment of Sexual Dysfunctions

Many approaches are used to treat sexual dysfunctions, including biological interventions and psychological treatment approaches.

Biological Interventions

Discovering underlying biological issues is an important first step in treating sexual dysfunction (Buster, 2013). Biological interventions may include hormone replacement, special medications, or mechanical means to improve sexual functioning. For example, men with physiologically-based erectile dysfunction are sometimes treated with penile implants. The penile implant is an inflatable device that, once expanded, produces an erection sufficient for intercourse and ejaculation (see Table 13.4). Approximately 89 percent of men with penile implants and 70 percent of their partners expressed satisfaction with the implants (Center for Male Reproductive Medicine and Microsurgery, 2005), and most said that they would choose the treatment again.

Table 13.4

​Treating Erectile Disorder: Medical Interventions

Treatment	Primary Agent	Effects	Drawbacks
Oral medication	Viagra, Levitra, or Cialis	Taken as a pill. Enhances blood flow to the penis and allows many users to achieve normal erections. The drugs are taken before sex, and stimulation is needed for an erection.	Medication side effects including head or stomach pain or nasal congestion.
Surgery	Vascular surgery	Corrects venous leak from a groin injury by repairing arteries to boost blood supply in the penis. Restores the ability to have a normal erection.	Minimal problems when used appropriately with diagnosed condition.
Suppository	Muse (alprotadil)	A tiny pellet is inserted into the penis by means of an applicator 5 to 10 minutes before sex. Erections can last an hour.	Penile aching, minor urethral bleeding or spotting, dizziness, and leg-vein swelling.
Injection therapy	Vasodilating drugs, including Caverject (alprotadil), Edex (alprostadil), and Invicorp (VIP and phentolamine)	Drug is injected directly into the base of the penis 10 minutes to 2 hours before sex, depending on the drug. The drug helps relax smooth-muscle tissues and creates an erection in up to 90% of patients. Erection lasts about an hour.	Pain, bleeding, and scar tissue formation. Erections may not readily subside.
Devices	Vacuum pump	Creates negative air pressure around the penis to induce the flow of blood, which is then trapped by an elastic band encircling the shaft. Pump is used just before sex. Erection lasts until band is removed.	Some difficulty in ejaculation. Penis can become cool and appear constricted in color. Apparatus can be clumsy to use.
	Penile implants	Considered a last resort. A penile prosthesis is implanted in the penis, enabling men to literally “pump themselves up” by pulling blood into it.	Destruction of spongy tissue inside the penis.

© Cengage Learning®

Medications are also used to treat erectile disorder. One form of medical treatment for erectile dysfunction involves injecting medication (Alprostadil) into the penis or inserting a suppository with the medication into the opening at the tip of the penis (R. W. Lewis et al., 2008). Within a very short time, blood flow to the area is increased and the man gets an erection, which may last from 1 to 4 hours. These methods do have some side effects, including prolonged erections and bruising of the penis.

Oral medications such as Viagra, Levitra, and Cialis are frequently used to treat erectile disorder. In fact, Viagra made headlines in 1998 as a “miracle cure” for men with erectile dysfunction (Read & Mati, 2013). Unlike injectables, Viagra and its competitors do not produce an erection in the absence of sexual stimuli. If a man becomes aroused, the drugs enable the body to follow through the sexual response cycle to completion. The medications do not improve sexual functioning in normally functioning men, nor do they lead to a stiffer erection. However, it is possible that these drugs may act as a placebo in men without erectile dysfunction and thereby improve sexual arousal and performance. Viagra has, in fact, been found to increase the level of confidence of men engaging in sexual activity (Seftel et al., 2014).

Although biological treatments are increasingly important in treating sexual dysfunctions, these treatments deemphasize the role of psychological and social factors. Because relationship, sociocultural, and psychological factors are often involved, treatment needs to include more than medications or other biological means to boost sexual interest or desire (Berry, 2013). For example, group therapy plus Viagra is more effective than Viagra alone for treating erectile dysfunction, according to a review by Read and Mati (2013). In fact, group therapy alone produced better results than Viagra alone, which again emphasizes the need for comprehensive treatment.

Psychological Treatment Approaches

Psychological treatment is recommended when relationship or psychological issues, including prior traumatic experiences, play a role in sexual dysfunction. General psychological treatment approaches include the following components (Frühauf, Gerger, Schmidt, Munder, & Barth, 2013):

· Education. The therapist replaces sexual myths and misconceptions with accurate information about sexual anatomy and functioning.

· Anxiety reduction. The therapist uses procedures such as desensitization or gradual approaches to keep anxiety at a minimum. The therapist explains that constantly observing and evaluating one’s performance can interfere with sexual functioning.

· Maladaptive thoughts and beliefs. The therapist helps the client identify and change negative thoughts and beliefs that interfere with sexual enjoyment.

· Structured behavioral exercises. The therapist gives a series of graded tasks that gradually increase the amount of sexual interaction between the partners. Each partner takes turns touching and being touched over different parts of the body except for the genital regions. Later the partners fondle the body and genital regions without making demands for sexual arousal or orgasm. Successful sexual intercourse and orgasm are the final stage of the structured exercises.

· Communication training. The therapist teaches the partners appropriate ways of communicating their sexual wishes to each other and strategies for effectively resolving relationship conflicts.

In addition to these general psychological treatments, sex therapists can also focus on specific aspects of sexual dysfunction. Some specific nonmedical treatments for other dysfunctions include:

6. Female orgasmic dysfunction. Both structured behavioral exercises and communication training have been successful in treating sexual arousal disorders in women. Masturbation appears to be the most effective way for women with orgasmic dysfunction to achieve an orgasm. High success rates are reported with this procedure, especially for women who have never experienced an orgasm. However, this approach does not necessarily lead to a woman’s ability to achieve orgasm during sexual intercourse (Both & Laan, 2009).

7. Early ejaculation. In one technique, the partner stimulates the penis until the man feels the sensation of impending ejaculation. At this point, the partner momentarily stops the stimulation and then continues it again. This pattern is repeated until the man can tolerate increasingly greater periods of stimulation before ejaculation (Carufel & Trudel, 2006).

8. Vaginismus. The results of treatment for vaginismus have been uniformly positive. The involuntary spasms or closure of the vaginal muscle can be deconditioned by first training the woman to relax and then inserting successively larger dilators while she is relaxed (Vorvick, 2012).

Myth vs Reality

Myth

Sex is unimportant to older adults. They are averse to being sexually active and are conservative in sexual behavior.

Reality

Although sexual activity declines with age, a major survey of adults ages 57 to 85 found that many older people are sexually active well into their 60s, 70s, and 80s. Fifty-four percent reported having sex at least twice a month, and 23 percent reported having sex at least once weekly. Approximately 50 percent of the respondents younger than age 75 had engaged in oral sex in the previous 2 months (Lindau et al., 2007).

13-3Gender Dysphoria

Case Study

Coy Mathis, born a male triplet, has behaved like a girl since she was 18 months old. While her brother Max was consumed with dinosaurs, she was playing with Barbie dolls. By 4, she was telling her mother that something was wrong with her body. Since enrolling in elementary school in Fountain, Colorado, the 6-year-old has presented as female and wears girls’ clothing. Her classmates and teachers use female pronouns when referring to her (S.D. James, 2013).

Gender dysphoria  —previously called gender identity disorder—is characterized by distress and impairment in functioning that results from a marked incongruence (mismatch) between one’s experienced or expressed gender and one’s  assigned gender  as a boy or girl. In other words, individuals who experience gender dysphoria have distress associated with their  transgender identity —their innate emotional and psychological identity as male or female is opposite from their biological sex. In the case of Coy Mathis, she was born a boy but has identified as a girl since early childhood.

Life as a Transgender Girl

Coy Mathis, left, plays with her sister at their home in Colorado. Biologically, Coy is a boy, but she has self-identified as a girl since early childhood. Her family, friends, and classmates all consider her a girl.

AP Images/Brennan Linsley

It is important to note that gender identity and  sexual orientation  are not the same thing—the sexual orientation of someone with a transgender identity can be heterosexual, gay, lesbian, bisexual, or asexual (Zucker & Cohen-Ketteris, 2008). For example, when television personality and Olympic gold medal winner Bruce Jenner first publicly spoke about his transgender identity and decision to transition to a woman, he pointed out the difference between gender identity and sexual orientation. “Sexuality is who you’re attracted to, who turns you on — gender identity is who you are, what is in your soul.” (Donnelly, 2015). As was the case with Jenner, individuals with a transgender identity are often aware of the mismatch between their assigned gender and experienced gender early in life, long before sexual interests develop during puberty.

Gender dysphoria is diagnosed only when there is significant distress or impairment in functioning resulting from the individual’s transgender identity and experiences. Individuals with gender dysphoria may display a strong dislike of their sexual anatomy, a desire for sexual characteristics of their experienced gender, and rejection of objects or activities associated with their assigned gender. In rare cases, the experienced gender may be an alternative gender, distinct from the traditional two genders common across cultures (APA, 2013).

Estimates suggest that between 0.25 and 1 percent of the U.S. population have a transgender identity (National Center for Transgender Equality, 2009). However, gender dysphoria is relatively rare because many transgender individuals do not experience significant distress or impairment in functioning. The prevalence of gender dysphoria ranges from 0.005% to 0.014% in men and from 0.002% to 0.003% in women (APA, 2013).

Gender incongruence is experienced differently at different ages. People with gender dysphoria often begin to report gender-role conflicts early in childhood (Zucker, 2009). A boy may claim that he will grow up to be a woman, demonstrate disgust with his penis, and be interested in toys and activities considered “feminine.” He may prefer playing with girls and avoid the aggressive activities commonly enjoyed by boys. Male peers or others frequently label boys with a transgender identity as “sissies.” Girls with gender dysphoria may insist that they have a penis or will grow one and may exhibit an avid interest in rough-and-tumble play. Nonconformity with stereotypical gender role behavior should not, however, be confused with the pervasive gender incongruence experienced by those with a transgender identity. The strength, pervasiveness, and persistence of gender-incongruent behaviors are a key feature of gender dysphoria.

As physiological maturation progresses during puberty, dislike for and desire to be rid of their sexual anatomy may strengthen, thus increasing their distress (Lawrence, 2008). As puberty sets in, transgender boys may begin to shave their legs or bind their genitals, whereas transgender adolescent girls may attempt to make their breasts less visible. As their personal identity develops during adolescence, their emotions and reactions may increasingly resemble those of their experienced gender, a factor that further increases gender incongruence. During adolescence and early adulthood, transgender people find it increasingly important to be treated and accepted as a member of their experienced gender. It is often under these circumstances that the extent of distress associated with gender incongruence is recognized, treatment is sought, and gender dysphoria is diagnosed.

13-3aEtiology of Gender Dysphoria

The etiology of gender dysphoria is unclear. Because it is quite rare, investigators have focused more attention on other disorders. Gender dysphoria appears to be more common in males than in females and occurs in both children and adults (Lawrence, 2008). In all likelihood, a number of variables interact to produce gender dysphoria.

Biological Influences

Biological research suggests that neurohormonal factors and genetics may be involved in the development of a transgender identity (Ghosh & Pataki, 2012). In animal studies, for example, the presence or absence of testosterone early in life appears to influence the organization of brain centers that govern sexual behavior. In human females, early exposure to male hormones has resulted in a more masculine behavior pattern. Thus, it does appear that gender orientation can be influenced by a lack or excess of sex hormones.

Interestingly, a study involving physiological indicators of prenatal testosterone exposure found that boys with an early-onset transgender identity appeared to have had less exposure to testosterone compared to matched controls; in fact, their physiological responses were similar to girls in the control group. The transgender girls in the study, however, did not differ significantly from the comparison girls in indicators of prenatal testosterone exposure (Burke, Menks, Cohen-Kettenis, Klink, & Bakker, 2014).

It is important to note, however, that the limited research in this area makes conclusions about hormonal influences very tentative. Some researchers believe that gender identity is malleable. For example, most transgender children have normal hormone levels, raising doubt that biology alone determines masculine and feminine behaviors. Although neurohormonal levels are important, their degree of influence on gender identity in human beings may be minor.

Continuum

Video Project

Dean:© Cengage Learning®

Gender Dysphoria

“The more I tried to be a girl, it just wasn’t right.”

Access the Continuum Video Project in MindTap at www.cengagebrain.com.

Researchers are also looking into any specific neurological characteristics associated with a transgender identity. Neuroimaging using functional magnetic resonance imaging (fMRI) to compare transgendered individuals with matched controls revealed differences in brain connectivity between the groups; however, the neurological differences observed in participants with a transgender identity did not provide insight into etiology. Instead, the findings suggested that transgender individuals may detach bodily emotion from body image, a possible mechanism for coping with their lifelong gender incongruence (Lin et al., 2014).

Psychological and Social Influences

Psychological and social explanations for gender dysphoria must also be viewed with caution. Some researchers have hypothesized that childhood experiences influence the development of a transgender identity and gender dysphoria. Factors proposed to contribute to the disorder in boys include parental encouragement of feminine behavior, discouragement of the development of autonomy, excessive attention and overprotection by the mother, the absence of male role models, a relatively powerless or absent father figure, a lack of exposure to male playmates, and encouragement to cross-dress (Zucker & Cohen-Ketteris, 2008).

Of course, psychosocial stressors such as stigma, lack of societal acceptance, or difficulty obtaining adequate health care may play a role in the distress and impairment associated with gender dysphoria. In fact, the transgender community has been described as the “most marginalized and underserved population in medicine” (Roberts & Fantz, 2014).

Midlife Gender Transition

Bruce Jenner, pictured above winning an Olympic gold medal, made a midlife transition to a woman with support from his family and friends. Soon after Jenner publicly disclosed his decision to finalize the transition, he announced his new name (Caitlyn) in a cover story in Vanity Fair magazine. The photo below was taken while Jenner was in the process of gender reassignment.

Walter Iooss Jr./Getty Images Ethan Miller/Getty Images

13-3bTreatment of Gender Dysphoria

Case Study

“I am a woman.” This declaration has been frequently voiced by Lana Lawless since her sex reassignment surgery in 2005. Before that date, she had worked for 18 years as a “male” police officer for Rialto, California, in their “gang unit,” where Lawless achieved a reputation for being a burly, mean, 245-pound tough cop. “People didn’t want to mess with me,” she stated. Lawless indicates that beneath her callous exterior, she was always compassionate and sensitive on the inside: “I was always hiding in a straight world. . . . I wanted to be a normal girl.” Lawless is notable for another reason as well: She won a lawsuit forcing the Ladies Professional Golf Association (LPGA) to allow her and other transgender persons to compete in their tours (Thomas, 2010).

Transgender people, including those with gender dysphoria, often decide to pursue gender reassignment therapies, which involve changing their physical characteristics through medical procedures such as hormone treatment or surgery. Hormone therapy (taking hormones associated with the perceived gender) as part of gender reassignment has decreased the distress and psychological reactions associated with gender dysphoria, and has improved the quality of life and sexual functioning in many transgendered individuals (Murad et al., 2010).

In addition to hormone therapy, some transgender individuals, such as Lana Lawless, choose to have gender reassignment surgeries that change their existing external genitalia to those of the other gender. For men, the genital surgeries involve altering the penis and scrotum and constructing female genitalia. The skin of the penis is used in this construction because the nerve endings that are preserved enable the experience of orgasm. Sexual reassignment for those who are biologically female involves removal of the breasts, and, in some cases, individuals choose to have surgery to construct an artificial penis (Wroblewski, Gustafsson, & Selvaggi, 2013). This procedure is much more complicated and expensive than the male-to-female reassignment. Although just beginning, some health plans now include coverage of hormone therapy or gender-reassignment therapy for transgender individuals (Glicksman, 2013).

Some studies of transgender people indicate positive outcomes for gender reassignment. Many individuals who undergo a female-to-male transition express satisfaction over the outcome of their surgeries, including their sexual functioning (Wierckx et al., 2011). Those who transition to female feel satisfied on an emotional, psychological, and social level but report difficulties with sexual arousal, lubrication, and pain during sex (Weyers et al., 2009). Some research, however, has revealed that transgender individuals who have undergone gender reassignment surgery remain at risk for psychiatric difficulties, including suicidality; these findings suggest that follow-up monitoring of psychological well-being of individuals undergoing this procedure is important (Dhejne et al., 2011).

Is transitioning easier when the process is started earlier in life? Some experts believe that providing an understanding and accepting environment for children who are “consistent, persistent, and insistent” in expressing a cross-gender identity will lead to a more positive transitional experience and reduce the likelihood of gender dysphoria later in life (Snow, 2015).

13-4Paraphilic Disorders

A  paraphilia  is a condition in which a person’s sexual arousal and gratification depends on fantasies or behavior involving socially unacceptable objects, situations, or individuals. According to DSM-5, paraphilias involve sexual interest in non-normative targets or “distorted components of human courtship behavior.” The intense and persistent sexual interest associated with a paraphilia can involve unusual erotic behaviors (such as spanking or whipping) or socially unacceptable erotic targets (such as children, animals, or inanimate objects).

Did You Know?

Sweden removed transvestism, fetishism, and sadomasochism from its official list of mental illnesses. “These diagnoses are rooted in a time when everything other than the heterosexual missionary position were seen as sexual perversions,” according to the National Board of Welfare in Sweden.

Source: TT/The Local, 2008.

A  paraphilic disorder  is diagnosed only when the paraphilia harms, or risks harming, others (and is acted on) or causes the individual to experience distress or impairment in social or other areas of functioning. Thus, the DSM-5 makes a clear distinction between paraphilias and paraphilic disorders. Such a distinction prevents labeling behavior as pathological just because it is not common behavior. Therefore, a paraphilic disorder is not diagnosed if a paraphilia:

· involves only urges or fantasies, but has not been acted on;

· has not harmed others or created the potential to harm others;

· does not impair the person’s social, occupational, or other areas of functioning; or

· does not create anxiety, shame, guilt, loneliness, or sexual frustration or in other ways distress the person.

When the fantasies, urges, or behaviors associated with a paraphilia do not cause personal distress or have the potential to harm others, a psychiatric diagnosis and intervention is not warranted. Additionally, for a paraphilic disorder diagnosis, the dysfunctional paraphilic behaviors must have persisted for at least 6 months.

In some cases, diagnosis occurs because the person is severely distressed by or has experienced impairment in social or occupational functioning due to the paraphilia. In other situations, paraphilic disorder is diagnosed when there is evidence or disclosure confirming that the person has acted on paraphilic urges that caused harm, or created risk of harm, to others. In many cases, paraphilias that harm or interfere with the well-being of others result in arrest.

In all cases, paraphilic disorders are associated with recurrent urges, behaviors, or fantasies involving any of the following three categories (see Table 13.5):

9. nonhuman objects, as in fetishistic and transvestic disorders;

10. nonconsenting others, as in exhibitionistic, voyeuristic, frotteuristic (rubbing against others for sexual arousal), and pedophilic disorders; or

11. real or simulated suffering or humiliation, as in sexual sadism and sexual masochism disorders.

Table 13.5

​Paraphilic Disorders

DSM-5 Disorders Chart
Paraphilia Category	DSM-5 Definition	Prevalence	Associated Features
Nonhuman objects	Fetishistic disorder 3. Sexual attraction and fantasies involving objects or nongenital body parts	Disorder is uncommon but fetishistic behavior is not; occurs almost exclusively in males	May rub or smell object, and use it in sexual activities 1. Some collect fetish items
	Transvestic disorder 1. Intense sexual arousal from cross-dressing	Fewer than 3% of males report cross-dressing; extremely rare in females	May be aroused by fantasies of being a woman; may masturbate when wearing female clothes
Nonconsenting people	Exhibitionistic disorder 1. Urges, acts, or fantasies that involve exposing the genitals to a stranger	Mostly males; best estimates are 2%–4% of men	May expose to prepubertal children, adults, or both; in general, sexual contact is not sought
	Voyeuristic disorder 1. Urges, acts, or fantasies that involve observing an unsuspecting person disrobing or engaging in sexual activity	Behavior may occur in up to 39% of males 1. 12% of men and 4% of women may have this disorder	Most common of unlawful sexual behaviors
	Frotteuristic disorder 1. Urges, acts, or fantasies that involve touching or rubbing against a nonconsenting person	Primarily in men; exact figures not available; up to 30% of men may have engaged in frotteuristic acts	Some freely admit behavior but feel no distress or impairment
	Pedophilic disorder 1. Urges, acts, or fantasies that involve sexual contact with a prepubescent child	May occur in up to 3%–5% of males; rare in females	May access child pornography repeatedly; appears to be chronic condition
Pain or humiliation	Sexual sadism disorder 1. Urges, fantasies, or acts that involve inflicting physical or psychological suffering	Prevalence estimates of sexual sadism range from 2% to 30%; common in sexually motivated homicides	Extensive use of pornography with themes of pain and suffering; sadism may be a chronic condition
	Sexual masochism disorder 1. Sexual urges, fantasies, or acts that involve being humiliated, bound, or made to suffer	Unknown 1. Up to 18.5% report masochistic fantasies	May extensively use pornography with themes of bondage, being humiliated, or being beaten; may be part of sadomasochistic group

Enlarge Table

Based on data from Ahlers et al. (2011); APA (2013); Krueger (2010a, 2010b); Långström (2010); Seto (2009).

© Cengage Learning®

It is not unusual for people with paraphilic disorders to have multiple paraphilias (Langstrom & Zucker, 2005). In one study of sex offenders, almost 50 percent had engaged in a variety of sexually deviant behaviors, averaging between three and four paraphilic disorders and committing more than 500 deviant acts (Rosenfield, 1985). Men who had committed incest, for example, had also molested nonrelatives, exposed themselves, raped adult women, and engaged in voyeurism. In most cultures, paraphilias seem to be much more prevalent in males than in females (Gijs, 2008). This finding has led some to speculate that biological factors may account for the unequal distribution.

Although paraphilic disorders are relatively rare, the prevalence of paraphilias among the general population is more common. In a community sample of German men, 62.4 percent reported at least one paraphilia. The most common were voyeuristic (38.7 percent), fetishistic (35.7 percent), sadistic (24.8 percent), masochistic (18.5 percent), and frotteuristic (15 percent). Less common paraphilias were pedophilic (10.4 percent), transvestic (7.4 percent), and exhibitionistic (4.1 percent). Most of the men who reported paraphilias found them to be intensely sexually arousing. In only 1.7 percent of cases did the respondents report distress over their paraphilias (Ahlers et al., 2011).

In addition to the paraphilic disorders we will be discussing, the DSM-5 lists “other specified paraphilic disorders” including intense sexual arousal associated with behaviors such as making obscene telephone calls (telephone scatalogia) and sexual urges involving corpses (necrophilia), animals (zoophilia), urine (urophilia), or feces (coprophilia).

13-4aParaphilic Disorders Involving Nonhuman Objects

This category includes two forms of paraphilic disorders: fetishistic disorder, which involves attraction or arousal related to a nonliving object (the fetish), and transvestic disorder, which involves cross-dressing for sexual arousal.

Fetishistic Disorder

Case Study

Mr. D. met his wife at a local church and was strongly attracted to her because of her strong religious convictions. Although he loved his wife very much, he was unable to have sexual intercourse with her after their marriage because he could not obtain an erection. However, he had fantasies involving an apron and was able to get an erection and engage in intercourse while wearing an apron. Mrs. D. was upset over this discovery but accepted it because she wanted children. Although using the apron allowed them to consummate their marriage, Mrs. D. was upset about what she considered to be a sexual perversion.

Fetishistic disorder  occurs when there is an extremely strong sexual attraction to or fantasies involving inanimate objects, such as shoes or undergarments, or a specific focus on nongenital body parts such as the feet or toes. As you saw in the case of Mr. D., the fetish is often used as a sexual stimulus during masturbation or sexual intercourse. Many individuals who report having a sexual fetish do not report impairment or distress, and thus do not qualify as having a fetishistic disorder (APA, 2013).

To qualify as a fetishistic disorder, the behavior must cause the individual significant distress or cause harm to others. In many cases the fetish item is enough by itself for complete sexual satisfaction through masturbation, and the person does not seek contact with a partner. Common fetishes include aprons, shoes, undergarments, and leather or latex items. Sexual arousal to fetish items was reported in 35.7 percent of the previously mentioned sample of German men (Ahlers et al., 2011).

Transvestic Disorder

Case Study

A 26-year-old graduate student referred himself for treatment after he failed an exam in one of his courses. He had been cross-dressing since he was 10 and attributed his exam failure to the excessive amount of time that he spent doing so (four times a week). When he was younger, his cross-dressing had taken the form of masturbating while wearing his mother’s high-heeled shoes, but it had gradually expanded to the present stage, in which he dressed completely as a woman, masturbating in front of a mirror (Lambley, 1974, p. 101).

Transvestic disorder  occurs when intense sexual arousal is associated with fantasies, urges, or behaviors involving cross-dressing (wearing clothes appropriate to a different gender). This disorder should not be confused with having a transgender identity, whereby the individual psychologically identifies with and dresses in accordance with cultural norms for the opposite gender. Although some transgender people and some lesbians and gay men cross-dress, most people who cross-dress are exclusively heterosexual. For a diagnosis of transvestic disorder, the cross-dressing must cause significant distress or impairment in important areas of functioning.

The prevalence of transvestic disorder is not known. However, transvestic behavior was reported in 7.4% of the sample of German men (Ahlers et al., 2011). Men who cross-dress often report using pornography, being easily sexually aroused, and engaging in frequent masturbation (Langstrom & Zucker, 2005).

Cross-Dressing Behavior or Transvestic Disorder?

Not all transvestites have a transvestic disorder. Some simply enjoy the activity of cross-dressing and do not experience the intense sexual fantasies, urges, or behaviors associated with transvestic disorder. Here men are participating in the Hartjesdag (Day of Hearts), an annual cross-dressing carnival held in the Netherlands.

Gertan/Shutterstock.com

Men with a transvestic paraphilia often wear feminine garments or undergarments during masturbation or sexual intercourse with their partners. For some individuals, the arousal through cross-dressing may diminish over time and is replaced by feelings of contentment or comfort when cross-dressing (APA, 2013).

13-4bParaphilic Disorders Involving Nonconsenting Persons

This category of disorders involves persistent and powerful sexual fantasies about unsuspecting strangers or acquaintances. The targets are nonconsenting in that they do not choose to be the objects of the attention or sexual behavior.

Exhibitionistic Disorder

Case Study

A 19-year-old college student reported that he had daily fantasies of exposing himself and had actually done so on three occasions. The first occurred when he masturbated in front of the window of his dormitory room when women passed by. The other two acts occurred in his car; in each case he asked young women for directions and then exposed his penis and masturbated when they approached. (S. C. Hayes, Brownell, & Barlow, 1983)

Exhibitionistic disorder  is characterized by urges, acts, or fantasies that involve recurrent episodes of exposing one’s genitals to a stranger, often with the intent of shocking or impressing the unsuspecting target (Hunter, 2015). In some cases, exhibitionistic disorder is diagnosed when a person acts on exhibitionistic urges, and thereby harms an unconsenting person. In other situations, the person seeks treatment because the urges are emotionally distressing or result in impairment in important areas of life functioning (APA, 2013). In studies, the prevalence of the disorder ranges from 3.1 percent to 4.1 percent (Ahlers et al., 2011; Långström & Seto, 2006).

Exhibitionistic disorder most commonly occurs in men. The main goal seems to be the sexual arousal that comes from exposing oneself. The act may involve exposing a limp penis or masturbating an erect penis. Exhibitionists desire no further contact with their victims, but hope to produce a reaction such as surprise or sexual arousal. Most individuals with the disorder are in their 20s—far from being the “dirty old men” of popular myth. Individuals with this paraphilia report lower satisfaction in life, a high level of sexual arousability, and pornography use (Ahlers et al., 2011).

Voyeuristic Disorder

Voyeuristic disorder  is characterized by urges, acts, or fantasies that involve observing an unsuspecting person who is naked, disrobing, or engaging in sexual activity. The disorder is diagnosed only in those who are age 18 or older and only when the individual has acted on voyeuristic urges or is distressed by or has experienced impairment in life functioning due to voyeuristic behavior (APA, 2013). “Peeping,” as voyeurism is sometimes termed, is considered aberrant when it violates the rights of others, is done in socially unacceptable circumstances, or is preferred to coitus.

Did You Know?

The United States is considered an exhibitionistic and voyeuristic society. Reality television, Facebook, and other social media normalize the sharing of sexual pictures and intimate information with strangers and casual acquaintances.

Voyeurism is like exhibitionism in that sexual contact is not the goal; viewing an undressed body is the primary motive. Most people who engage in voyeurism are not interested in looking at their spouses or partners; an overwhelming number of voyeuristic acts involve strangers. Observation alone produces sexual arousal and excitement, and the individual often masturbates during this surreptitious activity. Because the act is repetitive and violates the privacy rights of unsuspecting victims, arrest is predictable when a witness or a victim notifies the police. It is estimated that the lifetime prevalence of voyeuristic disorder may be as high as 12 percent in males and 4 percent in females (APA, 2013). Voyeuristic behavior, including adolescent sexual curiosity, is much more common. For example, 38.7 percent of the sample of German men reported engaging in voyeuristic behavior (Ahlers et al., 2011).

Frotteuristic Disorder

Case Study

The 25-year-old man would board trains, stand near unsuspecting women, select a target, and rub his genitals against her body. If no resistance was encountered, he would take this as a positive sign and continue rubbing until orgasm and ejaculation occurred. On weekends, he would begin by watching pornographic movies and then spend the entire day riding trains and engaging in genital rubbing. He was distressed by this behavior but felt unable to control his urges (Kalra, 2013).

Physical contact is the primary motive in frotteuristic disorder, which is characterized by recurrent and intense sexual urges, acts, or fantasies that involve touching or rubbing against a nonconsenting person. The inappropriate behaviors of the young man in the case study are consistent with the behaviors exhibited by those with this disorder. The touching, not the coercive nature of the act, is the sexually exciting feature. Similar to other paraphilic disorders, to be diagnosed, the person has acted on or is markedly distressed by the frotteuristic urges.

Although up to 30 percent of males in the general population may have engaged in some form of frotteuristic behavior, the prevalence of frotteuristic disorder is difficult to determine (Brannon & Bienenfeld, 2013; Långström, 2010). It may be more common than thought because the behavior may go unnoticed, be ignored, or be overlooked because it is presumed to be accidental (Patra et al., 2013). In a recent study involving undergraduate students attending an urban university, a high number reported being victims of acts of frotteurism; these incidents were most frequently associated with using public transportation. The affected students reported feelings of being violated and, in some cases, ongoing psychological distress (Clark, Jeglic, Calkins, & Tatar, 2014).

Pedophilic Disorder

Pedophilic disorder  involves an adult obtaining erotic gratification through urges, acts, or fantasies that involve prepubescent or early pubescent children, generally children under age 13. For the diagnosis, the individual must have acted on or be clinically distressed by these urges. In addition, a person must be at least 16 years of age to be diagnosed with this disorder and at least 5 years older than the child (APA, 2013). People with this disorder may victimize children within or outside of their families and may be attracted only to children, or to both children and adults. Additionally, they may be attracted only to boys, only to girls, or to children of both genders.

Individuals with pedophilia frequently use child pornography for sexual gratification. In fact, some men with pedophilic urges report accessing child pornography but claim they have never attempted to approach a child in a sexual manner (Berlin & Sawyer, 2012). The actual prevalence of pedophilic disorder is not known, but it is estimated that up to 3–5 percent of men may have pedophilic urges; it is rare in women (Brannon & Bienenfeld, 2013; Seto, 2012). Pedophilia is usually considered a lifelong condition, although the intensity of urges may decrease with age (Seto 2009).

The effects of childhood sexual abuse can be lifelong. Although some young victims of sexual abuse show no overt symptoms, many do experience physical effects such as poor appetite, headaches, or urinary tract infections; additionally, psychological symptoms including nightmares, difficulty sleeping, decline in school performance, acting-out, or sexually focused behavior may occur. Some child victims show symptoms of post-traumatic stress disorder. One study of women who were survivors of childhood sexual abuse revealed that they experienced ongoing consequences of the abuse including a “contaminated identity” characterized by self-loathing, shame, and powerlessness (A. Phillips & Daniluk, 2004).

Pedophilia can also involve  incest —sexual contact between individuals who are too closely related to marry legally. The cases of incest most frequently reported to law enforcement agencies involve sexual contact between a father and daughter or stepdaughter. Mother–son incest seems to be rare. Although brother–sister incest is more common, most research has focused on father–daughter incest. This type of incestuous relationship generally begins when the daughter is between 6 and 11 years old. Unlike sex between siblings (which may or may not be exploitive), father–daughter incest is always exploitive. The girl is especially vulnerable because she depends on her father for emotional support. As a result, victims often feel guilty and powerless.

Psychological symptoms associated with father–daughter incest, such as feeling damaged and ashamed, often continue into adulthood and are reflected in high rates of depression and difficulties with adult sexuality and interpersonal relationships (Stroebel et al., 2012). Research comparing survivors of father–daughter and brother–sister incest found that although there were long-term psychosocial effects for both groups, father–daughter incest produced the most pervasive damage to self-esteem and psychological functioning (Stroebel et al., 2013a). Similarly, women who experienced sister–sister incest reported ongoing psychological distress and strained family relationships (Stroebel et al., 2013b).

13-4cParaphilic Disorders Involving Pain or Humiliation

Case Study

From early adolescence, Peter F., a 41-year-old man, had fantasies of being mistreated, humiliated, and beaten. He recalls becoming sexually excited when envisioning such actions. As he grew older, he experienced difficulty achieving an orgasm unless his sexual partners inflicted pain during sexual activities. He had been married and divorced three times because of his proclivity for demanding that his wives engage in “sex games” that involved having them hurt him. These games included binding him spread-eagled on his bed and whipping or biting his upper thighs, sticking pins into his legs, and other forms of torture.

Did You Know?

Sadism is named after the Marquis de Sade (1740–1814), a French nobleman who wrote extensively about the sexual pleasure he received from inflicting pain on women. The word masochism is derived from the name of a 19th-century Austrian novelist, Leopold von Sacher-Masoch, whose fictional characters obtained sexual satisfaction only when pain was inflicted on them.

Sexual masochism disorder  is characterized by sexual urges, fantasies, or acts that involve being humiliated, bound, or made to suffer. People who engage in sexual masochism report that they do not seek harm or injury but that they find the sensation of utter helplessness appealing. Because of their passive role, masochists are not considered dangerous to others. A sexual masochism disorder diagnosis occurs only if the paraphilia causes distress or impairment in functioning. The prevalence of sexual masochism is unknown (Krueger, 2010a).

Sexual sadism disorder  is characterized by sexual arousal associated with urges, fantasies, or acts that involve inflicting physical or psychological suffering on others. Sadistic sexual behavior may include pretend or fantasized infliction of pain; mild to severe cruelty toward partners; or an extremely dangerous, pathological form of sadism that involves mutilation or murder. Estimates regarding the prevalence of sexual sadism range from 2 percent to 30 percent, depending on the definition of sadism employed by the researchers (Krueger, 2010b). As with other paraphilic disorders, the DSM-5 specifies that to receive this diagnosis, a person must have acted on the urges with a nonconsenting person or feel markedly distressed by the behavior.

For some people who participate in sexual sadism or masochism, coitus becomes unnecessary; pain or humiliation alone is sufficient to produce sexual pleasure. Some participants engage in both submissive and dominant roles. Their sexual activities may be carefully scripted and involve mutually agreed upon role-playing (Lussier et al., 2008). In one survey of respondents who participate in sadomasochistic activities involving spanking, whipping, and bondage, only 16 percent were exclusively dominant or submissive. Approximately 40 percent had engaged in behaviors that caused minor pain using ice, hot wax, biting, or face slapping. Fewer than 18 percent had engaged in more harmful procedures, such as burning or piercing (Brewslow, Evans, & Langley, 1986).

Many individuals who practice sadomasochism are aware of the tremendous stigma attached to this practice and are secretive about their sexual behavior. They continue with the practices, however, because they find sadomasochistic sexual activities to be more satisfying than “straight” sex (Stiles & Clark, 2011).

13-4dEtiology and Treatment of Paraphilic Disorders

Although it is likely that multiple factors contribute to the development of paraphilic disorders, we still have much to learn about paraphilias. Investigators have attempted to find genetic, neurohormonal, and brain anomalies that might be associated with paraphilic disorders. Some men may be biologically predisposed to some paraphilias such as pedophilic disorder, as pedophiles have been found to have neurological abnormalities, including less white matter (Centre for Addiction and Mental Health, 2007). Even if biological factors are found to play a role in the development of paraphilias, psychological factors also contribute in important ways.

Among early attempts to explain paraphilic disorders, psychodynamic theorists proposed that these sexual behaviors represent unconscious conflicts that began in early childhood (Schrut, 2005). Castration anxiety in men, for example, is hypothesized to underlie transvestic disorder, fetishistic disorder, exhibitionistic disorder, sexual sadism disorder, and sexual masochism disorder. A man with exhibitionistic disorder, for example, exposes himself to reassure himself that castration has not occurred. The shock that registers on the faces of others assures him that he still has a penis.

Research looking into the characteristics of sex offenders has provided insight into early psychosocial variables that may influence their behavior. For example, juvenile sex offenders are more likely to have unusual sexual interests, low self-esteem, and anxiety. Additionally, they are more likely to have early exposure to sex, sexual violence, pornography, or a history of being sexually victimized (Seto & Lalumière, 2010). In a confidential study involving self-reported pedophiles and users of child pornography who had not yet been detected or arrested for their actions, participants reported long-standing sexual self-regulation difficulties, including high rates of sexual preoccupation and arousal involving a variety of other paraphilias, most commonly voyeurism, sadism, frotteurism, or exhibitionism (Neutze, Grundmann, Scherner, & Beier, 2012).

Learning theorists stress the importance of early conditioning experiences in the etiology of paraphilias (Brannon & Bienenfeld, 2013). In other words, paraphilias may result from accidental associations between sexual arousal and exposure to certain situations, events, acts, or objects. A young boy may develop a fetish for women’s panties after he becomes sexually excited watching girls come down a slide with their underpants exposed. He begins to masturbate to fantasies of girls with their panties showing; this behavior could lead to an underwear fetish. Paraphilias often develop during adolescence when sexual interest and arousal are particularly susceptible to conditioning. Additionally, if an adolescent masturbates while engaged in sexually deviant fantasies, the conditioning may hamper the development of normal sexual patterns.

Behavioral approaches to treating sexual deviations have generally involved one or more of the following elements (Kaplan & Krueger, 2012): (a) weakening or eliminating the sexually inappropriate behaviors through processes such as extinction or aversive conditioning; (b) acquiring or strengthening sexually appropriate behaviors; and (c) developing appropriate social skills.

One of the more unique treatments for exhibitionism involves aversive behavior rehearsal (MacKenzie, O’Neil, Povitsky & Acevedo, 2010), in which shame or humiliation is the aversive stimulus. The technique requires that the person exhibit himself in his usual manner to a preselected audience of women. During the exhibiting act, the person must verbalize a conversation between himself and his penis. He must talk about what he is feeling emotionally and physically and must explain his fantasies regarding what he supposes the female observers are thinking about him. One premise of this technique is that exhibitionism often occurs during a state similar to hypnosis, when the exhibitionist’s fantasies are extremely active and his judgment is impaired. This method forces him to experience and examine his actions while being fully aware of what he is doing.

The results of behavioral treatments are generally positive, although the majority of research involves single participants rather than group experimental designs. Additionally, many studies incorporate several different behavioral methods, making it difficult to evaluate specific techniques. In a recent review of research involving treatment for those who sexually abuse children, the results were discouraging—neither psychological nor pharmacological interventions had much effect on reoffending (Långström et al., 2013).

Chapter 14

14-1Personality Psychopathology

Most of us are fairly consistent and predictable in our outlook on life and in how we approach people and situations. Additionally, most of us are able to be flexible in how we respond to people and life circumstances. Those of us who are shy, for example, are not necessarily shy in all situations. Individuals with  personality psychopathology,  however, possess rigid patterns of responding that are inflexible, long-standing, and enduring; these dysfunctional personality characteristics are present in nearly all situations.

As we shall see in this chapter, when maladaptive personality characteristics are quite pronounced and the cause of problems for the person or for others, the person may be diagnosed with a personality disorder. Specifically, a diagnosis of a  personality disorder  is characterized by enduring personality patterns (involving behavior, thoughts, emotions, and interpersonal functioning) that are (a) extreme and deviate markedly from cultural expectations, (b) inflexible and pervasive across situations, (c) evident in adolescence or early adulthood and stable over time, and (d) associated with distress and impairment (APA, 2013). Although there are often telltale signs of personality psychopathology in childhood, clinicians do not usually consider a personality disorder diagnosis until late adolescence or adulthood when personality development is more complete.

Did You Know?

Phrenology—the study of the shape and size of a person’s skull—was based on the belief that different regions of the brain are associated with personality traits. Instruments that measured the skull, including bumps and indentations, were used to provide information about psychological attributes. The scientific community eventually abandoned this practice.

People with personality psychopathology often function well enough to get along without aid from others and may not see themselves as having a problem. Although they might be described as odd, peculiar, dramatic, or unusual, they often do not seek help or come to the attention of mental health professionals. As a result, the incidence of personality disorders is difficult to ascertain. The overall lifetime prevalence of personality disorders is estimated to be 9–13 percent, which suggests that these disorders are relatively common in the general population; similarly, personality disorders account for approximately 5–15 percent of those seeking treatment at hospitals and outpatient clinics (Lenzenweger, Lane, Loranger, & Kessler, 2007; Sansone & Sansone, 2011).

DSM-5 delineates two distinct methods of diagnosing and classifying personality psychopathology:

1. a categorical diagnostic model, involving 10 specific personality disorder types, which are each qualitatively distinct clinical syndromes; and

2. an alternative model, including components of both dimensional and categorical assessment.

We will review the 10 traditional personality disorders and discuss diagnostic issues associated with personality disorders rather than focusing on the alternative system for personality diagnosis recently included in the DSM-5.

Checkpoint Review

4-2Personality Disorders

The 10 specific personality disorders in the DSM-5 are grouped into three behavior clusters: (1) odd or eccentric behaviors; (2) dramatic, emotional, or erratic behaviors; or (3) anxious or fearful behaviors (see Table 14.1). To diagnose a personality disorder, clinicians use the DSM-5 descriptions of the disorder and determine the degree of match with the individual. We will discuss each of the 10 personality disorders rather briefly. We then provide a multipath analysis of the personality disorder that has the greatest impact on society—antisocial personality disorder.

Table 14.1

​Personality Disorders

Disorders Chart
Disorder	DSM-5 Descriptors	Gender Differences	Prevalence
Disorders Characterized by Odd or Eccentric Behaviors
Paranoid personality disorder	· Pervasive pattern of mistrust and suspiciousness regarding others’ motives	Somewhat more common in males	2.3%–4.4%
Schizoid personality disorder	· Socially isolated, emotionally cold, indifferent to others	Somewhat more common in males	3.1%–4.9%
Schizotypal personality disorder	· Peculiar thoughts and behaviors; poor interpersonal relationships	Slightly more common in males	Up to 3.9%
Disorders Characterized by Dramatic, Emotional, or Erratic Behaviors
Antisocial personality disorder	· Failure to conform to social or legal codes; lack of anxiety and guilt; irresponsible behaviors	Much more common in males	0.6%–4.5%
Borderline personality disorder	· Intense fluctuations in mood, self-image, and interpersonal relationships	Predominantly diagnosed in females	1.6%–5.9%
Histrionic personality disorder	· Self-dramatization, exaggerated emotional expression, and seductive, provocative, or attention-seeking behaviors	Mixed findings, but more prevalent in females in clinic settings	0.4%–1.8%
Narcissistic personality disorder	· Exaggerated sense of self-importance; exploitative behavior; lack of empathy	More common in males	0%–6.2%
Disorders Characterized by Anxious or Fearful Behaviors
Avoidant personality disorder	· Pervasive social inhibition; fear of rejection and humiliation	Equal frequency in men and women	1.4%–5.2%
Dependent personality disorder	· Excessive dependence on others; inability to assume responsibilities; submissive	Unclear, but more frequently diagnosed in women in clinic settings	About 0.5%
Obsessive-compulsive personality disorder	· Perfectionism; controlling interpersonal behavior; devotion to details; rigidity	Twice as common in males	2.1%–7.9%

Note: Symptoms of personality disorders appear early in life. Personality disorders tend to be stable and to endure over time, although symptoms sometimes remit with age. Prevalence figures and gender differences have varied from study to study.

Source: Based on APA (2013); Bollini & Walker (2007); J. R. Kuo & Linehan (2009); Sansone & Sansone (2011).

14-2aCluster A—Disorders Characterized by Odd or Eccentric Behaviors

Three personality disorders are included in Cluster A: paranoid personality, schizoid personality, and schizotypal personality. These personality disorders share characteristics, including overlapping environmental and genetic risk factors, which are similar to those found in the schizophrenia spectrum disorders (Esterberg, Goulding, & Walker, 2010). There is some evidence that individuals with disorders in this grouping have a greater likelihood of having biological relatives with schizophrenia or other psychotic disorders (APA, 2013).

Paranoid Personality Disorder

Case Study

Ralph and Ann married after a brief, intense courtship. The first year of their marriage was relatively happy, although Ralph was very domineering, opinionated, and overprotective. Ann had always known that Ralph was a jealous person who demanded a great deal of attention. She was initially flattered that Ralph would become upset when other men flirted with her because it indicated he cared. It soon became clear, however, that his jealousy was excessive. For example, when Ann came home from shopping later than usual, Ralph became very hostile and agitated and would demand an accounting of her activities. He often doubted her explanations, and embarrassed Ann by calling her friends or co-workers to confirm her stories.

The primary characteristic of  paranoid personality disorder  is a “pervasive distrust and suspiciousness of others such that their motives are interpreted as malevolent” (APA, 2013, p. 649). People with paranoid personality disorder exhibit unwarranted suspiciousness, hypersensitivity, and reluctance to trust others because they expect to be exploited or mistreated. As was the case with Ralph, they tend to be rigid in their thinking and preoccupied with unfounded beliefs, such as suspicions about the fidelity of their partners. They may seem aloof and lacking in emotion. People with paranoid personality disorder often interpret others’ motives negatively, question people’s loyalty or trustworthiness, and bear grudges. These beliefs are extremely resistant to change and result in social isolation, difficulties in working with others, and hostility. The prevalence of paranoid personality disorder ranges from 2.3 to 4.4 percent in U.S. samples (Sansone & Sansone, 2011). As you might expect, many people with this disorder fail to seek treatment because of their suspiciousness and mistrust.

Certain groups, such as refugees and members of minority groups, may display guarded or defensive behaviors not because of a disorder but because of their minority group status, experiences with discrimination, or lack of familiarity with the majority society. To avoid misinterpreting the significance of mistrustful behavior, clinicians assessing members of these groups are careful to clarify the origins of feelings of wariness or suspiciousness.

Eluding Capture: Aided by a Personality Disorder?

It took many years for authorities to track down and arrest Ted Kaczynski, the Unabomber, who killed many people over an 18-year period. Formerly a math professor at the University of California, Berkeley, Kaczynski is believed to have had a schizoid personality disorder and to have eluded capture because of his hermit-like existence. He was a loner and did not seem interested in socializing with people. He was finally arrested in his isolated cabin, where he had lived alone for many years.

AP Images/Elaine Thompson

Causes and Treatment

Paranoid personality traits result from the use of projection—a defense mechanism in which unacceptable impulses are denied and attributed to others—according to psychodynamic theorists. In other words, someone with paranoid personality disorder may believe “I am not hostile; they are.” From a cognitive-behavioral perspective, individuals with this disorder may filter and interpret the responses of others through an untrusting mental schema such as “Other people have hidden motives,” which accounts for their suspiciousness (Bhar, Beck, & Butler, 2012). In terms of treatment, psychotherapy focuses on helping clients reduce their paranoia so they can function better in daily living. However, it may be difficult for therapists to develop rapport due to the client’s suspiciousness and difficulty trusting others.

Schizoid Personality Disorder

The most prominent characteristics of  schizoid personality disorder  are “pervasive detachment from social relationships and a restricted range of expression of emotions in interpersonal settings” (APA, 2013, p. 652). People with this disorder have a long history of impairment in social functioning, including social isolation, emotional coldness, and indifference to others. They tend to neither desire nor enjoy close relationships. Many live alone, engage in solitary recreational activities, and are described as withdrawn and reclusive.

People with schizoid disorder are perceived by others as peculiar and aloof because of their lack of desire for social relationships. They may interact with others in the workplace and similar situations, but their relationships are superficial and frequently awkward. They prefer a hermit-like existence (Esterberg, Goulding, & Walker, 2010). In general, individuals with this disorder prefer social isolation and the single life rather than marriage. When they do marry, their spouses are often unhappy due to their lack of affection and reluctance to participate in family activities. Members of different cultures vary in their social behaviors, and diagnosticians must consider the cultural background of individuals who show schizoid symptoms. The prevalence of this disorder ranges from 3.1 to 4.9 percent in the United States (Sansone & Sansone, 2011).

Causes and Treatment

The relationship between schizoid personality disorder and schizophrenia spectrum disorders (described in Chapter 11) is unclear. One view is that schizoid personality is genetically associated with schizophrenia (APA, 2013). Some studies have shown that schizoid personality disorder is associated with a cold and emotionally impoverished childhood lacking in empathy (Marmar, 1988). Little is known about psychotherapy with individuals with schizoid personality disorder since few seek treatment (Blais, Smallwood, Groves, & Rivas-Vazquez, 2008). They are most likely to seek therapy if they are experiencing stress or a crisis, but even then they can be challenging to treat (Thylstrup & Hesse, 2009).

Schizotypal Personality Disorder

Case Study

A 41-year-old man was referred to a community mental health clinic for help in improving his social skills. He had a lifelong pattern of social isolation, had no real friends, and spent long hours worrying that his angry thoughts about his older brother would cause his brother harm. During one interview, he was distant and distrustful, but described in elaborate and often irrelevant detail his rather uneventful and routine daily life. . . . For 2 days he had studied the washing instructions on a new pair of jeans—Did “wash before wearing” mean that the jeans were to be washed before wearing the first time, or did they need, for some reason, to be washed each time before they were worn? . . . He asked the interviewer whether, if he joined the program, he would be required to participate in groups. He said that groups made him very nervous because he felt that if he revealed too much personal information, such as the amount of money that he had in the bank, people would take advantage of him or manipulate him for their own benefit. (Spitzer et al., 1994, pp. 289–290)

People with  schizotypal personality disorder  have odd, eccentric, paranoid, or peculiar thoughts and behaviors and a high degree of discomfort with and reduced capacity for interpersonal relationships (APA, 2013). Many believe they possess magical abilities or special powers (e.g., “I can predict what people will say before they say it”), and some are subject to recurrent illusions (e.g., “I feel that my dead father is watching me”). Speech oddities, such as frequent elaboration, digression, or vagueness in conversation, are often present (Minor & Cohen, 2012). The man in the case study has symptoms that are typical of schizotypal personality disorder: absence of close friends, magical thinking (worrying that his thoughts might harm his brother), conversational oddities, and social anxiety. Up to 3.9 percent of individuals in U.S. community samples have a schizotypal personality disorder (Sansone & Sansone, 2011). Again, the evaluation of individuals must take into account their cultural milieu. For example, superstitious beliefs and hallucinations are common in certain cultures or religions.

Causes and Treatment

Research shows that people with schizotypal personality disorder have abnormalities in cognitive processing that may explain many of their symptoms (Bollini & Walker, 2007). That is, they seem to have problems in thinking and perceiving, which may lead to symptoms of social isolation, hypersensitivity, inappropriate emotional responding, and lack of pleasure from social interactions. In fact, many characteristics of schizotypal personality disorder resemble those of schizophrenia, although in less serious form. For example, people with schizophrenia exhibit problems in social functioning and information processing—deficits seen in people with schizotypal personality disorder. Some research has suggested a genetic link between the two disorders (Bollini & Walker, 2007).

Crime Bosses and Antisocial Personality Disorders

Vito Corleone (played by Marlon Brando) in The Godfather and Tony Soprano (played by James Gandolfini) in the TV series The Sopranos both exhibit antisocial personality disorder traits. Both show a callous disregard for the rights of others and little regret or remorse for cheating, lying, breaking the law, or even killing. However, they also reveal characteristics that are at odds with the diagnosis. Both have deep family relationships, reveal intense loyalty and emotional commitment to their families, and occasionally experience guilt; Tony Soprano even seeks psychiatric help for his anxiety attacks.

Enlarge Image

Paramount Pictures/Moviepix/Getty Images Anthony Neste/The LIFE Images Collection/Getty Images

Various psychotherapies are used to treat schizotypal personality disorder, such as interpersonal psychotherapy and cognitive-behavioral approaches, as well as group psychotherapy. However, few individuals with schizotypal personality disorder seek therapy.

14-2bCluster B—Disorders Characterized by Dramatic, Emotional, or Erratic Behaviors

The group of disorders in Cluster B, characterized by dramatic, emotional, or erratic behaviors, includes four personality disorders: antisocial, borderline, histrionic, and narcissistic.

Antisocial Personality Disorder

The primary characteristic of  antisocial personality disorder (APD) , is a “pervasive pattern of disregard for and violation of the rights of others” that has occurred since age 15 (APA, 2013). This diagnosis only applies to individuals 18 and older. Chronic antisocial behavioral patterns, such as a failure to conform to social or legal codes, a lack of anxiety and guilt, and irresponsible behaviors, are common with APD. People with this disorder may show little concern about their wrongdoing, which may include lying, using other people, and perpetrating aggressive sexual acts. Relationships with others are superficial and fleeting and involve little loyalty. Those with this disorder seek power over others and often manipulate, deceive, exploit, and con others for their own needs and purposes (Dolan & Fullam, 2010). Clinicians sometimes use the term psychopath or sociopath to describe individuals with APD, especially those with a pattern of emotional detachment, low levels of anxiety or fear, a bold interpersonal style, and high levels of attention seeking (APA, 2013).

Did You Know?

There are differences between those with antisocial personality disorder who are caught breaking the law (criminals) and those who break the law without detection. Those in the latter group have higher cognitive functioning, have greater cardiovascular reactivity to stress, are less likely to come from economically disadvantaged backgrounds, and are more likely to work in white- collar jobs. These attributes may make them less susceptible to arrest.

Source: J. R. Hall & Benning, 2006

People with APD are prone to engage in unlawful and criminal behavior and have no qualms about violating moral, ethical, or legal codes of conduct. The following case study of Robert T. exemplifies many of these characteristics.

Case Study

The epitome of a hard-driven, successful businessman, Robert T. seemed to have it all: enormous financial wealth, an apparently healthy marriage, and, despite his reputation as a ruthless corporate raider, high regard from associates for his business acumen. Then, in less than a year, he lost everything. Auditors raised questions about nonstandard accounting practices and inappropriate personal use of funds. Robert’s financial world collapsed. Lawsuits against him and his company followed, with the trustees finally demanding his resignation. Robert refused to resign and launched a campaign against his own board of directors, accusing them of pursuing a personal vendetta and of conspiring against him. He hired a private detective to dig up dirt on certain trustees and their families, and tried to use that information to intimidate and discredit them. In cases where embarrassing information was lacking, he had no qualms about spreading false rumors. These attempts, however, failed, and Robert was eventually removed from his post. His wife filed for divorce.

It was only after his downfall that the extent of Robert’s dishonesty become known. He did not graduate from the Wharton School of Business, as his resume had indicated. He told people that he had been divorced once, but he had been married four times (two of the marriages ended in divorce before age 20); and his fortune did not come from “old money,” but from a series of questionable real estate schemes that left investors holding bad debts, which he referred to as “collateral damage.” People who knew him in the past described him as arrogant, deceitful, cunning, and calculating. He showed a disregard for the rights of others, manipulated them, and then discarded them when they served no further use to him. He never expressed regret or remorse for any of his actions.

School records revealed a pattern of juvenile alcohol use, poor grades, frequent lying, and petty theft. At age 14, he was diagnosed with a conduct disorder when school officials became concerned with his fascination for setting fires in the restroom toilets. Nevertheless, the school psychologist described Robert as “very bright, charming, and persuasive.”

Robert T. typifies an individual with APD. He exhibits little empathy for others, views them as objects to be manipulated, and has difficulty establishing meaningful and intimate relationships. Robert pushes the boundaries of social convention and often violates moral, legal, and ethical rules for his own personal gain, with little regard for the feelings of others. This characteristic way of handling things is long-standing, and was evident early in life. Similar to others with APD, Robert often blames others, is inflexible in his manner of dealing with life problems, has a callous orientation toward people and appears to feel no remorse when he deceives others through lying, exaggeration, and manipulation.

Did You Know?

“Internet trolls”—individuals who appear to enjoy hurling insults and inciting arguments and discord in online comment sections—have many characteristics associated with personality disorders, such as glee over the distress of others, willingness to manipulate others, and lack of empathy for others.

Source: Buckels, Trapnell, & Paulhus, 2014

In the United States, estimates regarding the prevalence of APD range from 0.6–4.5 percent; more men than women are diagnosed with the disorder (APA, 2013; Sansone & Sansone, 2011). Estimates of prevalence vary from study to study; this may be due to differences in sampling or diagnostic and methodological procedures. People with APD are a difficult population to study because they do not voluntarily seek treatment. Consequently, investigators often locate research participants in prisons, which presumably contain a relatively large proportion of people with the disorder.

Antisocial Personality Disorder in Criminal Populations

Not all individuals who are incarcerated have an antisocial personality disorder, but many people who break the law display many antisocial personality traits. Prisoners who have an antisocial personality disorder have a high risk of re-offending once they are released.

AP Images/Spencer Weiner, Pool

The behavior patterns associated with APD are different and distinct from impulse control problems such as pyromania, kleptomania, and intermittent explosive disorder (see Table 14.2) and from behaviors involving social protest or criminal lifestyles. Individuals who violate societal laws or conventions by engaging in civil disobedience are not, as a rule, people with APD because they are usually quite capable of forming meaningful interpersonal relationships and experiencing guilt. They may perceive their violations of rules and norms as acts performed for the greater good. Similarly, engaging in criminal behavior does not necessarily reflect a personality disorder. Although many convicted criminals do have antisocial characteristics, many others do not. Instead, they may come from a subculture that encourages and reinforces criminal activity; hence, in perpetrating such acts, they are adhering to group norms and codes of conduct.

Table 14.2

​​Impulse Control Disorders

Definitions of some personality disorders include the characteristic of impulsivity. However, there are other mental disorders in which impulse control is a primary characteristic.

· 1. People with intermittent explosive disorder · experience periodic aggressive episodes that result in physical injury or property damage or frequent episodes of lower intensity verbal or physical aggression; · display an impulsive aggressiveness that is grossly out of proportion to any precipitating stressor or event that may have occurred; and · show no signs of general aggressiveness between episodes and may genuinely feel remorse for their actions.

· 2. People with kleptomania · chronically fail to resist impulses to steal; · do not need the stolen objects for personal use or monetary value, since they usually have enough money to buy the objects and typically discard them, give them away, or surreptitiously return them; and · feel irresistible urges and tension before stealing, followed by an intense feeling of relief or gratification after stealing.

· 3. People with pyromania · deliberately set fires; · are fascinated by and get intense pleasure or relief from setting the fires, watching things burn, or observing firefighters and their efforts to put out fires; and · have fire-setting impulses driven by this fascination rather than by motives involving revenge, sabotage, or financial gains.

© Cengage Learning ®

Borderline Personality Disorder

Individuals with  borderline personality disorder (BPD)  show an enduring pattern of volatile emotional reactions, instability in interpersonal relationships, poor self-image, and impulsive responding (APA, 2013). They lack a strong sense of self-identity and have a fragile self-concept that is easily disrupted by stress. BPD is also characterized by intense fluctuations in mood; hypersensitivity to social threat; and volatile interactions with family, friends, and sometimes even strangers (Herpertz & Bertsch, 2014). People with BPD are impulsive, have chronic feelings of emptiness, and form unstable and intense interpersonal relationships. They may engage in behaviors with negative consequences such as binge eating, substance abuse, self-injury, verbal aggression, or impulsive shopping (Selby & Joiner, Jr., 2013). They may be quite friendly one day and quite hostile the next. Some of the characteristics of BPD can be seen in the following case.

Case Study

Dal is an attractive young woman but seems to be unable to maintain a stable sense of self-worth and self-esteem. Her confidence in her ability to “hold on to men” is at a low ebb, having just parted ways with “the love of her life.” In the last year alone she confesses to having six “serious relationships” . . . “No one f***s with me. I stand my ground, you get my meaning?” She admits that she physically assaulted three of her last six boyfriends, hurled things at them, and, amidst uncontrollable rage attacks and temper tantrums, even threatened to kill them. . . . As she recounts these sad exploits, she alternates between boastful swagger and self-chastising, biting criticism of her own traits and conduct. Her mood swings wildly, in the confines of a single therapy session, between exuberant optimism and unbridled gloom. She sought therapy because she is having intrusive thoughts about killing herself. Her suicidal ideation also manifests in acts of self-injury (Vaknin, 2012).

Individuals with BPD are more likely to show dysfunctional moods, interpersonal problems, poor coping skills, and cognitive distortions than are people without BPD features (J. C. Franklin, Heilbron, Guerry, Bowker, & Blumenthal, 2009). As with Dal, many individuals with BPD exhibit recurrent suicidal behaviors; the number of suicide attempts and completions are higher than average among those who have this disorder. Self-destructive behaviors, such as suicidal actions and nonsuicidal self-injury (cutting and self-mutilation), frequently occur during periods of high stress and are often triggered by interpersonal conflicts and events (Reitz et al., 2015; Sansone & Sansone, 2012). Sexual difficulties, such as sexual preoccupation and dissatisfaction, are also common (Zanarini, Parachini, Frankenburg, & Holman, 2003). Because of their behavioral excesses, those with BPD have increased risk of chronic illnesses such as cardiovascular disease, diabetes, and obesity (Iacovino, Powers, & Oltmanns, 2014). People who have BPD sometimes exhibit psychotic symptoms, such as auditory hallucinations (e.g., hearing imaginary voices that tell them to commit suicide); these symptoms are recognized as unacceptable and are usually transient (Sieswerda & Arntz, 2007). In contrast, most people with schizophrenia spectrum disorders do not realize that their symptoms are abnormal.

Did Princess Diana Have Borderline Personality Disorder?

Princess Diana, smiling happily in this picture, was known to experience rapid mood swings. Her impulsiveness, marked fluctuations in mood, chronic feelings of emptiness, and unstable and intense interpersonal relationships, are consistent with a diagnosis of borderline personality disorder. Why do women receive this diagnosis far more frequently than men?

Chris Smith/PhotoEdit

BPD is the most commonly diagnosed personality disorder in both inpatient and outpatient settings (Oldham, 2006). The prevalence of BPD in U.S. community samples ranges from 1.6 to 5.9 percent, and is more common in women (Sansone & Sansone, 2011). Although up to 10 percent of individuals with BPD die by suicide, long-term outcome studies show progressive remission of symptoms over the course of 6 or more years for many individuals with this disorder (Soloff & Chiappetta, 2012). However, remission or recovery is slow, and individuals with BPD often have high rates of symptom recurrence (Zanarini, Frankenburg, Reich, & Fitzmaurice, 2012).

Did You Know?

Mothers with borderline personality disorder have more difficulty recognizing the emotions of their infants and are more likely to label neutral expressions as sad compared to control group mothers.

Source: Elliot et al., 2014

Causes and Treatment

Difficulty with mood regulation is a central feature of BPD (J. R. Kuo & Linehan, 2009). A biologically based vulnerability to emotional dysregulation may underlie the intense emotional reactivity seen in BPD; in addition, an inability to modulate this hyperreactivity may slow emotional recovery following stressful events (Scott, Levy, & Granger, 2013). In fact, magnetic resonance imaging (MRI) and positron emission tomography (PET) imaging have revealed structural abnormalities in the brain regions associated with mood regulation among individuals with BPD (Richter et al., 2014).

Unstable and intense interpersonal relationships often accompany the difficulties in regulating emotions seen in BPD (J. C. Franklin et al., 2009). According to the cognitive-behavioral perspective, these characteristics are affected by distorted or inaccurate explanations for others’ behaviors or attitudes. Cognitive theorists argue that an individual’s basic assumptions about the world play a central role in influencing perceptions, interpretations, and behavioral and emotional responses. Individuals with BPD seem to have three basic assumptions: (1) “The world is dangerous,” (2) “I am powerless and vulnerable,” and (3) “I am inherently unacceptable.” Believing in these assumptions, individuals with BPD become fearful, vigilant, guarded, defensive, and reactive (Bhar et al., 2012).

Continuum

Video Project

Tina© Cengage Learning ®

Borderline Personality Disorder

“I kinda get high off of making people as uncomfortable as they make me. It’s almost my way of really connecting with myself.”

Access the Continuum Video Project in MindTap at www.cengagebrain.com

Similarly, Young, Klosko, and Weishaar (2003) believe that early experiences of neglect or abuse play a role in BPD; unmet childhood needs may result in negative mental frameworks such as concern about being abandoned by loved ones. Viewing relationships through this mental filter leaves the individual hypersensitive and prone to emotional overreactivity in interpersonal situations. Not surprisingly, BPD is associated with maladaptive family functioning and childhood trauma such as sexual abuse (Newnham & Janca, 2014).

Cognitive-behavioral therapy can help individuals with BPD identify negative thoughts and replace them with more adaptive cognitions; this approach has been effective in reducing suicidal acts, dysfunctional beliefs, anxiety, and emotional distress (Davidson, Norrie, & Palmer, 2008). Another form of psychotherapy, schema therapy, combines cognitive-behavioral therapy with psychodynamic techniques; this approach teaches clients to identify and modify maladaptive interpersonal schemas and behaviors. Schema therapy has produced promising results with BPD (Sempértegui, Karreman, Arntz, & Bekker, 2013).

Dialectical behavior therapy (DBT), developed by Linehan (1993) specifically for clients with BPD, was a major breakthrough in the treatment of BPD and is increasingly viewed as the therapy of choice for this challenging disorder (Neacsiu, Lungu, Harned, Rizvi, & Linehan, 2014). Averting possible suicidal behaviors in clients and strengthening the therapist–client relationship are priorities in DBT. Clients are taught skills that address BPD symptoms, including emotional regulation, distress tolerance, and interpersonal effectiveness (Rizvi, Steffel, & Carson-Wong, 2013). The goals of DBT, in descending order of priority, are to address (1) suicidal behaviors, (2) behaviors that interfere with therapy, (3) behaviors that interfere with quality of life, (4) reactive behaviors, (5) post-traumatic stress behavior, and (6) self-respect behaviors. DBT has proven effective in treating symptoms of BPD, including decreasing suicidal behaviors (Fox, Krawczyk, Staniford, & Dickens, 2014).

Histrionic Personality Disorder

People with  histrionic personality disorder  show a “pervasive pattern of excessive emotionality and attention-seeking” (APA, 2013, p. 667). The term histrionic refers to intensely dramatic emotions and behaviors used to draw attention to oneself. Individuals with histrionic personality disorder engage in self-dramatization, exaggerated expression of emotions, and attention-seeking behaviors. The desire for attention may lead to flamboyant acts or flirtatious behaviors (Blais et al., 2008).

Despite superficial warmth and charm, the histrionic person is typically shallow and self-centered. Individuals from different cultures vary in the extent to which they display their emotions, but the histrionic person goes well beyond cultural norms. In the United States, about 0.4 to 1.8 percent of the population may have this disorder (Sansone & Sansone, 2011). Gender differences are not evident, although in clinical settings this disorder is diagnosed more frequently in females (APA, 2013). Histrionic behaviors were apparent in a female client seen by one of the authors, as shown in the following case.

Focus on Resilience

Dr. Marsha Linehan: Portrait of Resilience

A 17-year-old girl was institutionalized at a psychiatric facility in Connecticut. Doctors considered her among the most seriously disturbed patients they had ever seen (B. Carey, 2011). She habitually cut and burned herself, and would use any sharp object to slash her arms, legs, and midsection. She expressed a desire to die and made attempts at suicide (Grohol, 2011). Because of these constant attempts at self-harm, she was locked in a seclusion room free of any object that she could possibly use to hurt herself. However, this did not prevent her from injuring herself, since she constantly and violently banged her head against the floor or walls.

She was given hours of Freudian analysis, large doses of psychiatric drugs, and, as a last resort, electroconvulsive shock treatments. When discharged 2 years later, doctors gave her little chance of survival outside the hospital.

Dr. Marsha Linehan

Peter Yates/New York Times/Redux

This is the true story of Dr. Marsha Linehan, a world- renowned psychologist who developed a groundbreaking form of psychotherapy called dialectical behavior therapy (DBT)—a therapeutic approach that successfully treats people with borderline personality disorder and suicidal tendencies. Despite her difficult years and diagnosis of borderline personality disorder, Linehan managed to find the answers to the problems that haunted her and drove her to thoughts of suicide. She went on to receive her PhD in psychology and is a professor of psychology and director of the Behavioral Research and Therapy Clinics at the University of Washington. The psychological community has embraced her unique and highly successful therapeutic approach. Her self-healing journey is truly inspirational and speaks to the courage, inner fortitude, and resilience of the human condition. In her own recovery, Linehan has outlined lessons she learned that involve components of a resilient and peaceful life (Emel, 2011):

1. Real change is possible. According to conventional wisdom, people with personality disorders have great difficulty changing; some people even go so far as to say that very little can be done, especially for those with borderline personality disorder. Yet Linehan is a prime example that change is possible, and her DBT incorporates the notion that learning new skills and changing behavior ultimately changes perceptions and emotions.

2. Accept life as it is, not as it is supposed to be. Linehan calls this “radical acceptance” and uses her own recovery as an example. The gulf between who she was and what she wanted to be made her hopeless, desperate, and depressed. She despised herself, and her self-harm behaviors symbolized this hatred. Linehan believes that accepting oneself as one truly is represents the first step in combating feelings of self-loathing because it eliminates the discrepancy between an unrealistic ideal and the current state of the person and allows realistic and positive views of the self to develop.

3. A diagnosis of borderline personality disorder or any disorder is not a life sentence. According to Linehan, receiving a psychiatric diagnosis often fosters a victim mentality that produces helplessness, dependency, and hopelessness. The person begins to believe that little can be done to overcome the disorder. Linehan teaches her clients to think of themselves as survivors, or people who can control their destiny in life and are capable of overcoming challenges. Such a fundamental change in thinking moves clients from a passive to an active stance.

4. Find faith and meaning in life. Linehan’s religion and faith in God played an important role in her recovery. Her Catholic faith gave her hope and allowed her to experience an epiphany in 1967 that ultimately led her to develop the core principles of DBT. Since then, Linehan’s mission in life has been to help others through the challenges of mental illness.

Case Study

A 33-year-old real estate agent entered treatment for problems involving severe depression. Her boyfriend had recently told her that she was a self-centered and phony person. He found out that she had been dating other men, despite their understanding that neither would go out with others. Once their relationship ended, her boyfriend refused to communicate with her. The woman then angrily called the boyfriend’s employer and told him that unless the boyfriend contacted her, she would commit suicide. He never did call, but instead of attempting suicide, she decided to seek psychotherapy.

The woman dressed in a tight and clinging sweater for her first therapy session. Several times during the session she raised her arms, supposedly to fix her hair, in a very seductive manner. Her conversation was animated and intense. When she was describing the breakup with her boyfriend, she was tearful. Later, she raged over the boyfriend’s failure to call her. Near the end of the session, she seemed upbeat and cheerful, commenting that the best therapy might be for the therapist to arrange a date for her.

None of the behaviors exhibited by this client, in isolation, warrants a diagnosis of histrionic personality disorder. In combination, however, her self-dramatization, incessantly drawing attention to herself via seductive behaviors, angry outbursts, manipulative suicidal threats, and lack of genuineness suggest this disorder.

Causes and Treatment

Both biological factors, such as autonomic or emotional excitability, and environmental factors, such as parental reinforcement of a child’s attention-seeking behaviors or histrionic parental models, may be important influences in the development of histrionic personality disorder (Millon et al., 2004). There is little research on treatment for this disorder (Weston & Riolo, 2007). Psychodynamic therapies focus on establishing a therapeutic alliance with the client and determining why the client craves attention (Horowitz, 2001). Cognitive-behavioral therapy focus on changing irrational cognitions such as: “I should be the center of attention” (Bhar et al., 2012).

Narcissistic Personality Disorder

Case Study

Roberto J. was a well-known sociologist at the local community college. He was flamboyant, always seeking attention, and well known for bragging about himself to anyone who would listen. Most people found him superficial and so self-centered that any type of meaningful conversation was nearly impossible. His expertise was in critical race theory, and he had published a few minor articles on topics of racism in professional journals. He saw himself as a great scholar and would often talk about his “accomplishments” to colleagues; Roberto had nominated himself for numerous awards, and asked colleagues to write letters on his behalf. Because his accomplishments were considered mediocre by academic standards, Roberto seldom received any of the awards. Nevertheless, he continued to present himself as a renowned pioneer in the field of race relations.

Roberto came for couples counseling at the request of his wife, who was tired of his self-centered behavior. After nearly a year of therapy without significant change in Roberto, his wife filed for divorce.

Narcissistic Behavior

Miranda Priestly (Meryl Streep) in the movie The Devil Wears Prada illustrates some of the symptoms of narcissistic personality disorder, including an exaggerated sense of self-importance, an excessive need for admiration, and an inability to accept criticism or rejection. Do you think that narcissistic personality disorder is increasing among young people?

Enlarge Image

Twentieth Century Fox/Topham/The Image Works

Similar to many people with  narcissistic personality disorder , Roberto has a sense of entitlement, exaggerated self-importance, and superiority. He also seems unconcerned with the feelings of others. The characteristics associated with narcissistic personality disorder include a “pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy” (APA, 2013, p. 669). People with this disorder require constant attention and approval, and have difficulty accepting personal criticism. They talk mainly about themselves and show a lack of interest in others. Many fantasize about having power or influence, and they frequently overestimate their talents and importance. For example, they may be impatient or irate if others arrive late for a meeting but may frequently be late themselves and think nothing of it. Although lack of empathy is a primary characteristic of narcissistic personality disorder, the degree of empathic functioning varies among individuals with this disorder (Baskin-Sommers, Krusemark, & Ronningstam, 2014).

Narcissistic traits are common among adolescents and do not necessarily imply that a teenager has a narcissistic personality (APA, 2013). It has been found, however, that people later diagnosed with narcissistic personality disorder were more likely to experience feelings of invulnerability, display risk-taking behavior, and have strong feelings of uniqueness as adolescents (Weston & Riolo, 2007). The prevalence of narcissistic personality disorder varies greatly across studies of U.S. community samples and ranges from 0 to 6.2 percent (Sansone & Sansone, 2011).

Causes and Treatment

Little research exists on the etiology of narcissistic personality disorder. Psychodynamic theorists have hypothesized that the extreme self-focus and lack of empathy shown by individuals with this disorder is due to a lack of parental modeling of empathy during childhood (Kohut, 1977). According to cognitive-behavioral theorists, cognitive schemas such as “Other people should satisfy my needs” are thought to underlie narcissistic characteristics (Bhar et al., 2012).

As with most personality disorders, controlled treatment studies for narcissistic personality disorder are rare; therefore, treatment recommendations are frequently based on clinical experience (Blais et al., 2008). Individuals with narcissistic personality are most likely to seek treatment when in a vulnerable state of depression, anxiety, or suicidality (Pincus, Cain, & Wright, 2014). Unfortunately, narcissistic personality disorder is considered very difficult to treat; therapists usually attempt to help clients increase empathy skills, understand the needs of others, and decrease self-involvement (R. L. Leahy, Beck, & Beck, 2005). None of these treatments has met with much success. However, some remission of symptoms does occur. Over a 2-year period, about 53 percent of one sample of individuals with narcissistic personality disorder showed symptom improvement (Vater et al., 2014).

14-2cCluster C—Disorders Characterized by Anxious or Fearful Behaviors

The remaining cluster of personality disorders is characterized by anxious or fearful behaviors. This category includes the avoidant, dependent, and obsessive-compulsive personality disorders.

Avoidant Personality Disorder

Case Study

My name is Deb, and I have moderate to severe avoidant personality disorder. . . . I feel like I’ve had this condition my whole life; there just wasn’t a name for it yet. I was considered a very shy, sensitive, overly emotional child. My road to diagnosis began a few years ago when I didn’t eat for 4 days because I was afraid someone at the grocery store would talk to me. . . . The fear of being disliked or unwanted is so overwhelming that I’d rather be alone. My daily life involves watching TV or being on the Internet. . . . I hope to be well enough to go watch a parade, see a movie, or attend a carnival and chat with people whom I know (Cooper, 2013).

The essential features of  avoidant personality disorder  are a “pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation” (APA, 2013, p. 672). As in Deb’s situation, fear of rejection and humiliation produce a reluctance to enter into social relationships. People with this disorder tend to have a negative sense of self, low self-esteem, and a strong sense of inadequacy. They tend to avoid social situations and relationships and are often socially inept, shy, and withdrawn. They fear humiliation, are overly sensitive to criticism, blame themselves for things that go wrong, and seem to find little pleasure in life.

Unlike some individuals who avoid others because they lack interest, individuals with avoidant personality disorder crave affection and an active social life. They want—but fear—social contact, and this ambivalence is reflected in different ways. For example, many people with this disorder engage in intellectual pursuits or are active in the artistic community. Thus, their need for contact and relationships is woven into their activities. A person with avoidant personality disorder may write poems expressing a need for human intimacy or emphasizing the plight of people who are lonely.

In U.S. community samples, the prevalence of avoidant personality disorder ranges from 1.4 to 5.2 percent (Sansone & Sansone, 2011), and no gender differences are apparent (APA, 2013). People with avoidant personality disorder often have a lifelong pattern of feeling inferior, inadequate, depressed, or anxious (Mahgoub & Hossain, 2007). As with other personality disorders, avoidant personality disorder is considered to be a chronic and enduring condition. However, studies indicate that the symptoms of the disorder change markedly over time and, in cases where symptoms decrease, individuals become more assertive, less submissive, and more self-assured in social situations (Wright, Pincus, & Lenzenweger, 2013).

Causes and Treatment

Some researchers believe that avoidant personality disorder is on a continuum with social anxiety disorder, whereas others see it as a distinct disorder that happens to include the trait of social anxiety. It may be that an avoidant personality results from a complex interaction between early childhood environmental experiences and innate  temperament . For example, parental rejection and censure, reinforced by rejecting peers, may lead to the development of mental schema such as “I should avoid unpleasant situations at all costs” (Bhar et al., 2012). Additionally, people with this disorder are caught in a vicious cycle: Because they are preoccupied with rejection, they are constantly alert for signs of negativity or ridicule. This concern leads to many perceived instances of rejection, which cause them to avoid others. Their social skills may then become deficient, resulting in criticism from others.

Because of the fear of rejection and scrutiny, clients may be reluctant to disclose personal thoughts and feelings during therapy. If the therapist is unable to establish rapport and build a strong therapeutic alliance, the client may discontinue treatment. A number of different therapies, such as cognitive-behavioral, psychodynamic, interpersonal, and pharmacological treatments, are used with avoidant personality disorder. In a preliminary investigation, cognitive-behavioral therapy effectively reduced symptoms and improved the quality of life for clients with this disorder (Rees & Pritchard, 2014).

Dependent Personality Disorder

Case Study

Jim was 56, a single man who was living with his 78-year-old widowed mother. When his mother was hospitalized for cancer, Jim decided to see a therapist. He was distraught and depressed over his mother’s condition and his future. His mother had always taken care of him, and, in his view, she always knew best. Even when he was young, his mother had “worn the pants” in the family. The only time that he was away from his family was during his 6 years of military service. After he was wounded, he spent several months in a Veterans Administration hospital and then went to live with his mother. Because of his service-connected injury, Jim was unable to work full time. His mother welcomed him home, and she structured all his activities.

At one point, Jim met and fell in love with a woman, but his mother disapproved of her. During a confrontation between the mother and the woman, each demanded that Jim make a commitment to her. This was quite traumatic for Jim. His mother finally grabbed him and yelled that he must tell the other woman to go. Jim tearfully told the woman that he was sorry, but she must go, and the woman angrily left.

While Jim was relating his story, it was clear to the therapist that Jim harbored some anger toward his mother, although he overtly denied any feelings of hostility. His life had always been structured, first by his mother and then by the military. His mother’s illness meant that his structured world might crumble.

Dependent personality disorder  is a condition in which an individual shows a “pervasive and excessive need to be taken care of that leads to submissive and clinging behavior and fear of separation” (APA, 2013, p. 675). As with Jim’s situation, his dependency and inability to take responsibility interfered with important life decisions, and resulted in depression, helplessness, and suppressed anger. Individuals with dependent personality disorder lack self-confidence and often subordinate their needs to those of the people on whom they depend. Nevertheless, casual observers may fail to recognize or may misinterpret their dependency and inability to make decisions. Friends may perceive those with dependent personalities as understanding and tolerant, without realizing that they are fearful of doing anything that might disrupt the friendship. Similarly, they may allow their domestic partner to be dominant or abusive for fear that the partner will otherwise leave. Thus, individuals with dependent personality disorder are at high risk of becoming victims of relationship violence (Loas, Cormier, & Perez-Diaz, 2011).

Did You Know?

Beck, Freeman, and their associates (1990) summarized the life strategies (behavioral approaches to life) and beliefs that characterize various personality disorders:

Disorder	Strategy	Example Belief
Antisocial personality disorder	Predatory	“Others are patsies.”
Avoidant personality disorder	Withdrawal	“People will reject the real me.”
Obsessive-compulsive personality disorder	Ritualistic	“Details are crucial.”

Source: Sgobba, 2011

Dependent personality disorder is relatively rare and occurs in about 0.5 percent of the population (Sansone & Sansone, 2011). The prevalence by gender is unclear. In clinical samples, dependent personality disorder is diagnosed more frequently in women. However, other surveys have found similar prevalence rates for men and women (APA, 2013). The individual’s environment must be considered before rendering a diagnosis of dependent personality disorder. The socialization process that teaches people to be independent, assertive, and individual rather than group oriented does not occur in all cultures (Sue & Sue, 2016).

Causes and Treatment

Explanations for dependent personality disorder vary according to theoretical perspective. From the psychodynamic perspective, the disorder is a result of maternal deprivation, which causes fixation at the oral stage of development (Marmar, 1988). Behavioral learning theorists believe dependency develops when a family or social environment rewards dependent behaviors and punishes independence. Research findings show that dependency is associated with overprotective or authoritarian parenting (Bornstein, 1997). Presumably, these parenting styles prevent the child from developing a sense of autonomy and self-efficacy.

Cognitive theorists attribute dependent personality disorder to the development of distorted beliefs that discourage independence (Loas et al., 2011). Dependency is not simply a matter of being passive and unassertive. Rather, those with dependent personalities have deeply ingrained assumptions that affect their thoughts, perceptions, and behaviors. First, they see themselves as inherently inadequate and unable to cope. Second, they conclude that their course of action should be to find someone who can take care of them. Their schema or cognitive framework involves thoughts such as “I need others to help me make decisions or tell me what to do” (Bhar et al., 2012). Different individual and group treatments are used with dependent personality disorder, and, in general, there is more success than with other personality disorders (Perry, 2001).

Obsessive-Compulsive Personality Disorder

Case Study

Cecil, a third-year medical student, was referred by his graduate adviser for therapy. The adviser said Cecil was in danger of being expelled from medical school because of his inability to get along with patients and other students. Cecil often berated patients for failing to follow his advice. On one occasion, he told a patient with a lung condition to stop smoking. When the patient indicated he was unable to stop, Cecil angrily told the patient to go for medical treatment elsewhere—that the medical center had no place for a “weak-willed fool.” Cecil’s relationships with others were similarly strained. He considered many members of the faculty to be “incompetent old deadwood,” and he characterized fellow graduate students as “partygoers.”

The graduate adviser said that the only reason that Cecil had not been expelled was because several faculty members thought that he was brilliant. Cecil studied and worked 16 hours a day. He was extremely well read and had an extensive knowledge of medical disorders. Although he was always able to provide a careful and detailed analysis of a patient’s condition, it took him a great deal of time to do so. His diagnoses tended to cover every disorder that each patient could conceivably have, with a detailed focus on all possible combinations of symptoms.

Obsessive-compulsive personality disorder (OCPD)  involves a “pervasive pattern of preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness, and efficiency” (APA, 2013, p. 676). The person’s preoccupation with details and rules leads to an inability to see the big picture. There is a heightened focus on being in control over aspects of one’s own life and one’s emotions; additionally, there is a strong devotion to minor details and a need to control other people. Individuals with OCPD lack flexibility and their rigid behaviors can significantly impair their occupational and social functioning and affect their quality of life (Pinto, Steinglass, Greene, Weber, & Simpson, 2013). As we saw with Cecil, co-workers may find those with OCPD to be demanding, inflexible, and perfectionistic. In many cases, individuals with OCPD are ineffective on the job, despite devoting long hours to their work.

Did You Know?

There are both differences and similarities between obsessive-compulsive personality disorder (OCPD) and obsessive-compulsive disorder (OCD):

Characteristics	OCPD	OCD
Rigidity in personality	Yes	Not usual
Preoccupation in thinking	Yes	Yes
Orderliness in general	Yes	Not usual
Need for control	Yes	Not usual
Perfectionism	Yes	Not usual
Intrusive thoughts/behaviors	Not usual	Yes
Need to perform rituals	Not usual	Yes

Source: Sgobba, 2011

OCPD is distinct from obsessive-compulsive disorder (OCD), discussed in Chapter 4. The two disorders have similar names, but their clinical manifestations are quite different. Individuals with OCD experience unwanted intrusive thoughts or urges that cause significant distress. On the other hand, OCPD is a pervasive personality disturbance. People with OCPD genuinely see their way of functioning as the correct way. They relate to the world though a lens incorporating their own strict standards. In two studies, the prevalence of OCPD ranged from 2.1 to 7.9 percent in U.S. community samples (Sansone & Sansone, 2011). It is diagnosed twice as frequently in males (APA, 2013).

Causes and Treatment

Little research has been done regarding the etiology of OCPD. The disorder appears to occur more frequently among family members, which may be due to genetic or early childhood environmental factors (Blais et al., 2008). Cognitive-behavioral therapy, as well as supportive forms of psychotherapy, has helped some clients (Barber, Morse, Krakauer, Chittams, & Crits-Cristoph, 1997).

The diversity of personality disorders makes it difficult to extensively discuss the etiology and treatment of each. In many cases, we do not have enough information about the disorder to engage in a comprehensive etiological explanation. Yet it is clear that biological, psychological, social, and sociocultural forces influence the development of personality disorders. In the next section, we use our multipath model to discuss one of the better-researched personality disorders: antisocial personality disorder.

Compulsive Behavior

TV detective Adrian Monk, played by Tony Shalhoub in the once popular TV series Monk, has some characteristics of obsessive-compulsive personality disorder, including rigidity in thinking and preoccupation with orderliness and cleanliness. However, he also has symptoms of obsessive-compulsive disorder such as fears of contamination and compulsions to perform repetitive behaviors.

Enlarge Image

Hopper Stone /USA Network/Everett Collection

Checkpoint Review

1. Describe and compare the ten personality disorders.

2. Give a brief etiological explanation for each of the disorders.

14-3Analysis of One Personality Disorder: Antisocial Personality

Although research on most personality disorders has been quite limited, there is more information about antisocial personality disorder (APD) because those with the disorder are often involved with the legal and criminal justice systems. We use our multipath model to explain how biological, psychological, social, and sociocultural dimensions may interact and contribute to the development of APD, as shown in Figure 14.1. In this way, we hope to provide a prototype for understanding the multidimensional development of other personality disorders.

Figure 14.1Multipath Model of Antisocial Personality Disorder

The dimensions interact with one another and combine in different ways to result in antisocial personality disorder.

© Cengage Learning®

Myth vs Reality

Myth

Antisocial personality disorder is primarily caused by genetic factors.

Reality

Although genetic factors may influence the development of antisocial personality disorder, family characteristics are also associated with the disorder. For example, severe parental discord, a parent’s maladjustment or criminality, overcrowding, and even large family size, can predispose children to antisocial behaviors, especially if they do not have a loving relationship with at least one parent.

14-3aBiological Dimension

The development of APD appears to involve interactions between biological vulnerabilities and environmental adversity (Fairchild, van Goozen, Calder, & Goodyer, 2013). Thus, considerable research has been devoted to trying to uncover the biological basis of APD.

Genetic Influences

It is not uncommon for casual observers to remark that people with antisocial personalities appear to have an inborn tendency toward sensation seeking, impulsivity, aggressiveness, and disregard for others. These speculations are difficult to test, because it is often difficult to distinguish between environmental and hereditary influences on behavior (Sterzer, 2010). Nevertheless, genetic factors are implicated in the development of APD, including behavioral characteristics evident during childhood and adolescence (Van Hulle et al., 2009).

Support for genetic influences on antisocial behavior comes from research comparing concordance rates for identical or monozygotic twins with those for fraternal or dizygotic twins. Most studies show that monozygotic twins have a higher concordance rate for antisocial tendencies, delinquency, and criminality. Further, some children born to biological parents with antisocial personalities but raised by adoptive parents without such a diagnosis still exhibit higher rates of antisocial characteristics (Eley, Lichtenstein, & Moffitt, 2003).

Although this body of evidence seems to show a strong causal pattern, it must be viewed cautiously for several reasons. First, many of the studies on APD have drawn research participants from criminal populations; thus, we know less about those with APD in the general population. Second, studies indicating that genetic factors are important do not provide much insight into exactly how hereditary factors influence APD. Genetic factors do not appear to directly affect antisocial behavior, but may instead influence characteristics, such as risk taking and impulsivity, that increase the probability that such behavior will occur (Moffitt, 2005). Genetic predisposition also affects people’s levels of fearlessness. Antisocial behavior may develop when individuals are fearless or display low levels of anxiety (J. P. Newman, Curtin, et al., 2010). While people who have normal levels of fear avoid risks and extreme stress, those with limited fear may seek thrill and adventure. Fearlessness may explain why individuals with APD engage in risky criminal activities or impulsively violate societal norms and rules (Sterzer, 2010).

Lack of Fear Conditioning and Emotional Responsiveness

One line of research involves the hypothesis that biological abnormalities make people with APD less susceptible to fear and anxiety and therefore less likely to learn from their experiences in situations in which punishment or other negative outcomes are involved (Glenn et al., 2009). Because they have less fear about the consequences of their actions, they are less likely to learn to distinguish between appropriate and inappropriate behaviors. Research supports the hypothesis that people with APD have atypical patterns of emotional processing. For example, neuroimaging studies using MRI and PET scans have revealed that individuals with APD have neurological differences in the prefrontal cortex and the limbic amygdala circuitry, regions known to underlie emotional processing (Gao et al., 2010; Schiffer et al., 2014). These differences may help explain why those with APD have difficulty learning from experience and from punishment.

In a major longitudinal study based on data collected some 20 years ago, Gao and colleagues (2010) reasoned that fear conditioning in response to stimuli such as punishment or other negative consequences helps us learn to inhibit antisocial behavior when we are young. They hypothesized that deficient functioning of the amygdala, the part of the brain involved in fear conditioning, may make it difficult for some people to recognize cues that signal threats, making them appear fearless and unconcerned about consequences. Poor fear conditioning would thus predispose individuals to antisocial behavior. Recognizing that this should be detectable early in life, the researchers tested fear conditioning (physiological responses to an unpleasant noise) in children at age 3 using skin conductance measures of fear and arousal. They then probed the association between these findings and adult criminal behavior at age 23. They found that those with criminal records in early adulthood had failed to show fear conditioning in early childhood. It is possible that people with APD do not become conditioned to aversive stimuli; thus, they fail to acquire avoidance behaviors, experience little anticipatory anxiety, and consequently have fewer inhibitions about engaging in antisocial behavior.

Similarly, youth exhibiting antisocial behaviors showed diminished reactivity in the amygdala when shown pictures depicting fearful facial expressions, a finding that may partially explain their lack of compassion and limited emotional responsiveness to others (Brouns et al., 2013). In another study using MRI scans, youth scoring high on psychopathic traits were compared with matched controls in their reactions to photos of painful injuries; participants were asked to imagine that the body in the photograph was theirs and, in another condition, that it belonged to someone else. As compared to the healthy controls, the youth with psychopathic traits showed less activity in the anterior cingulate cortex and amygdala when they were imagining the injury involved another person. Thus, they appeared to demonstrate lower levels of emotional empathy to the plight of others (Marsh et al., 2013).

Arousal and Sensation Seeking

Another line of research proposes that people with APD have lower levels of physiological reactivity and are generally underaroused (Glenn et al., 2009). According to this view, some people have high and some have low levels of arousal. Thus, those who are underaroused may require more stimulation to reach an optimal level of arousal. People with APD may seek excitement and thrills without concern for conventional behavioral standards. Additionally, if those with APD are underaroused, it may take a more intense stimulus to elicit a reaction in them compared to those without this characteristic (J. P. Newman, Curtin, et al., 2010). The lowered levels of reactivity may result in impulsive, stimulus-seeking behaviors in response to boredom.

Risk-Taking and Thrill-Seeking Behaviors

People with low anxiety levels are often thrill seekers. The difference between a risk-taking psychopath and an adventurer may largely be a matter of whether the thrill-seeking behaviors are channeled into destructive or constructive acts.

Enlarge Image

Greg Epperson/Shutterstock.com

14-3bPsychological Dimension

Psychological explanations of APD fall into three camps: psychodynamic, cognitive, and social learning.

Psychodynamic Perspectives

According to psychodynamic approaches, faulty superego development may cause those with APD to experience little guilt; they are, therefore, more prone to frequent violation of moral and ethical standards. Thus, the personalities of people with APD are dominated by id impulses that operate primarily from the pleasure principle; they impulsively seek immediate gratification and show minimal regard for others (Millon et al., 2004). People exhibiting antisocial behavior patterns presumably did not adequately identify with their parents and thus did not internalize the morals and values of society. Additionally, frustration, rejection, or inconsistent discipline may have resulted in fixation at an early stage of development.

Cognitive Perspectives

Certain core beliefs, and the ways they influence behavior, are emphasized in cognitive explanations of APD (Bhar et al., 2012). These core beliefs operate on an unconscious level, occur automatically, and influence emotions and behaviors. Beck and colleagues summarized typical cognitions associated with APD (Beck, Freeman, & Associates, 1990, p. 361):

· I have to look out for myself.

· Force or cunning is the best way to get things done.

· Lying and cheating are OK as long as you don’t get caught.

· I have been unfairly treated and am entitled to get my fair share by whatever means I can.

· Other people are weak and deserve to be taken.

· I can get away with things, so I don’t need to worry about bad consequences.

These thoughts arise from what Beck and colleagues refer to as a “predatory strategy.” Thus, the worldview of those with APD revolves around a need to perceive themselves as strong and independent so they can survive in a competitive, hostile, and unforgiving world.

Learning Perspectives

Learning theories suggest that people with APD (1) have inherent neurobiological characteristics that impede their learning, and (2) lack positive role models that would help them develop prosocial behaviors. Thus, biology and environmental factors combine in unique ways to influence the development of APD.

Did You Know?

Support for the death penalty increases when a defendant is described as having characteristics of antisocial personality disorder such as lack of remorse or a manipulative interpersonal style.

Source: Edens, Davis, Fernandez Smith, & Guy, 2013

As we have seen, some researchers believe that learning deficiencies among individuals with APD are caused by the absence of fear or anxiety and by lowered autonomic reactivity. If so, is it possible to improve their learning by increasing their anxiety or arousal ability? In a now classic study, researchers designed two conditions in which those with APD and control participants performed an avoidance-learning task, with electric shock as the unconditioned stimulus (Schachter & Latané, 1964). Under one condition, participants were injected with adrenaline, which presumably increases arousal; under the other, they were injected with a placebo. Those with APD receiving the placebo made more errors in avoiding the shocks than did controls; however, after receiving adrenaline, they tended to perform better than controls. These findings imply that those with APD are more able to learn from negative consequences when their anxiety or arousal is increased.

14-3cSocial Dimension

Among the many factors that are implicated in ASD, relationships within the family—the primary agent of socialization—are paramount in the development of antisocial patterns. A number of social factors are associated with increased antisocial behavior and limited prosocial behavior among children (J. C. Franklin et al., 2009). First, poor parental supervision and limited parental involvement can increase antisocial behaviors (Loeber, 1990). Additionally, rejection or neglect by one or both parents reduces the opportunity for children to learn socially appropriate behaviors or the value of people as socially reinforcing agents. Both parental separation or absence and inconsistent parenting are associated with APD (K. A. Phillips & Gunderson, 1999). Such situations may lead children to believe that there is little satisfaction in close or meaningful relationships with others and may explain why individuals with APD often misperceive the motives and behaviors of others and have difficulty being empathetic (Benjamin, 1996).

Children’s risk of personality dysfunction increases when the adults they live with exhibit antisocial behavior or when they are subjected to neglect, hostility, maltreatment, or abuse (Jaffee, Moffitt, Caspi, Taylor, & Arsenault, 2002). Children from such environments learn that the world is cold, unforgiving, and punitive. Struggle and survival become part of their outlook on life, and they may respond in an aggressive fashion in an effort to control and manipulate the world. Additionally, children living in poverty are twice as likely to develop APD compared to those with a higher socioeconomic status (Lahey, Loeber, et al., 2005).

14-3dSociocultural Dimension

A variety of sociodemographic variables, including social class, race, and gender, are important in both normal and abnormal development (Sue & Sue, 2016). Determining the relative impact of sociocultural factors on APD, however, is complicated.

Gender

Men are more likely to exhibit characteristics of APD compared to women. Thus, there may be different pathways to developing APD that exist along gender lines. For example, women with APD are more likely to report childhood emotional neglect, sexual abuse, and parental use of substances compared to men with APD. Gender also influences the way APD is expressed. Traditional gender-role training by parents may influence antisocial behaviors in children. Traditionally, aggression in males is accepted or even encouraged, whereas aggression in females is discouraged; this may explain why antisocial patterns involving aggression are more prevalent among men than among women (Alegria et al., 2013).

A Successful Psychopath?

Bernard L. Madoff exhibits all the traits of antisocial personality disorder and has often been labeled “a successful psychopath.” He lied to family, friends, and investors, manipulated people, experienced feelings of grandiosity, and had a callous disregard for his victims. A seemingly respected power broker on Wall Street, he is reported to have bilked investors out of some $50 billion. In 2009, he was sentenced to 150 years in prison.

Enlarge Image

DON EMMERT/AFP/Getty Images

Whereas men tend to engage in direct acting-out behaviors (e.g., physical aggression), women express themselves in an indirect or passive manner (e.g., spreading rumors or false gossip and rejecting others from their social group), behavior referred to as relational aggression (Millon et al., 2004). Other gender differences exist. Men are more likely to exhibit job problems, violence, and traffic offenses, whereas women are more likely to report relationship and occupational problems, engaging in forgery, and harassing or threatening others (Alegria et al., 2013). As gender roles continue to change, it is possible that antisocial tendencies will increase among females.

Cultural Values

To be born and raised in the United States is to be exposed to the standards, beliefs, and values of U.S. society. One dominant value is that of rugged individualism, which is composed of two assumptions: (a) individualism and independence are viewed as aspects of healthy functioning, and (b) people can and should master and control their own lives (Sue & Sue, 2016). Competition and the ability to effectively control the environment are considered pathways to success; achievement is measured by surpassing the attainment of others. In the extreme, this psychological orientation may fuel the manipulative and aggressive behaviors of people with APD.

Other societies, such as those in some Asian and Latin American countries, possess values and beliefs that are often at odds with individualistic values: Collectivism and interdependence are encouraged, development of the group is valued over the self, and harmony with the universe is preferred over mastery of it. Some have observed that antisocial behavior (e.g., crime and violence) is less likely to occur in Japan and China than in the United States because of these countries’ collectivistic orientation, in which harmony and relationships with others are emphasized (Ivey, D’Andrea, Ivey, & Simek-Morgan, 2007). Because traditional Asian values, for example, accentuate harmony, subtlety, and restraint of strong feelings, Asian American clients who seek therapy are less likely than their European American counterparts to engage in behaviors associated with APD such as physical aggression, verbal hostility, substance abuse, and criminal behavior (Sue & Sue, 2016). Thus, it is clear that sociocultural factors may exert a powerful influence on the etiology and manifestation of personality disorders.

14-3eTreatment of Antisocial Personality Disorder

APD is not an easy condition to treat. Because people with antisocial traits feel little anxiety, they have little motivation to change their behavior or seek treatment. They are unlikely to see their actions as problematic. If they do seek treatment, they may try to manipulate or con their therapists. Thus, traditional treatment approaches, which require the genuine cooperation of clients, are often ineffective for those with APD. Treatment is most likely to be successful in structured settings where behaviors can be observed and controlled; this provides more opportunities for individuals with APD to recognize the effect of their behaviors on others and to confront their inability to form close relationships. Such control is sometimes possible when individuals with APD are incarcerated or, for one reason or another, undergo psychiatric hospitalization.

Behavior modification programs are sometimes used for those at risk of developing APD, including juvenile offenders with antisocial traits. The most useful treatments focus on decreasing deviant activities, combined with opportunities to learn appropriate behaviors and social skills (Meloy, 2001). Historically, the use of material rewards has been fairly effective in changing antisocial behaviors under controlled conditions (Van Evra, 1983). For example, money or tokens that can be used to purchase items are earned if appropriate behaviors (e.g., punctuality, honesty, discussion of personal problems) are displayed. Once the young people leave the treatment programs, however, they are likely to revert to antisocial activities unless their families and peers help them maintain appropriate behaviors.

Cognitive approaches are also used in treatment. Because individuals with APD are often influenced by dysfunctional beliefs about themselves, the world, and the future, they may have difficulty objectively anticipating possible negative outcomes of their behaviors. Beck, Freeman, and their associates (1990) have advocated that therapists build rapport with clients with APD, attempting to guide clients away from thinking only in terms of self-interest and immediate gratification and toward higher levels of thinking. This might include, for example, recognizing the effects of one’s behaviors on others and developing a sense of responsibility. Because cognitive and behavioral approaches assume that antisocial behaviors are learned, treatment programs often target inappropriate behaviors by setting rules and enforcing consequences for rule violations; they teach participants to anticipate consequences of behaviors and practice new ways of interacting with others (Meloy, 2001).

Treating Antisocial Behaviors

Positive adult role models are critically important in the treatment of youth with antisocial personality characteristics and in maintaining progress made in treatment. Here, a counselor works with juvenile offenders who have been court-ordered to attend a treatment program in lieu of jail.

AP Images/Rich Pedroncelli

Since longitudinal studies show that the prevalence of APD diminishes with age as individuals become more aware of the social and interpersonal consequences of their behavior, emphasis is placed on intervention with antisocial youth (K. A. Phillips & Gunderson, 1999). Treatment programs often broaden the base of intervention to include not only young clients but also their families and peers. Because people with antisocial traits often seek thrills, they may respond to intervention programs that provide the physical and mental stimulation they need (Farley, 1986).

Critical Thinking

Sociocultural Considerations in the Assessment of Personality Disorders

In diagnosing a personality disorder, it is important to consider the individual’s cultural norms and expectations when considering whether personality traits are maladaptive (APA, 2013). Because culture shapes our habits, customs, values, and personality characteristics, expressions of personality in one culture often differ from those in another culture. Asians in Asia, for example, are more likely to exhibit social constraints and collectivism, whereas U.S. Americans are more likely to show assertiveness and individualism (Sue & Sue, 2016). Japanese people and individuals from India often display overtly dependent, submissive, and socially conforming behaviors, traits that have negative connotations in U.S. society. Does this mean that the people in Japan and India who conform to these norms have a personality disorder? The behaviors of dependence and submissiveness are influenced by cultural values and norms and, thus, would not reflect personality psychopathology. In fact, in these countries, these traits are considered desirable personality characteristics. As you can see, anyone making judgments about personality functioning and disturbance must consider the individual’s cultural, ethnic, and social background (APA, 2013).

Not surprisingly, there are differences in the prevalence and types of personality disorders between countries. For example, although obsessive-compulsive personality disorder is one of the most prevalent personality disorders in the United States and Australia, schizotypal personality disorder is the most common disorder in Iceland and avoidant personality disorder is most prevalent in Norway (Sansone & Sansone, 2011). Additionally, low rates of all personality disorders are found in Asian samples (Ryder, Sun, Dere, & Fung, 2014). What do you think might account for these differences?

Current treatment options for people with APD are only minimally effective. Although medication is usually used only when there are comorbid conditions such as depression or substance abuse, a recent study showed promising results with the use of clozapine (an atypical antipsychotic) to reduce impulsive and violent behaviors in a small sample of violent men with APD incarcerated in a high-security hospital setting (Brown et al., 2014).

Antisocial Personality Disorder: George

In this interview, George describes the symptoms of his antisocial personality disorder.

Volume 41%

 

Copyright © Cengage Learning.

Checkpoint Review

1. Describe how biological, psychological, social, and sociocultural factors contribute to the development of antisocial personality disorder.

2. Why is treating people with antisocial personality disorder so difficult? What interventions are most effectiv

14-4Issues with Diagnosing Personality Psychopathology

It has always been challenging to diagnose personality disorders using the current diagnostic system. Diagnosing specific forms of personality disorders has been problematic for several reasons. First, there is poor inter-rater reliability for the personality disorder categories (Pull, 2013). Although diagnosticians generally agree on whether a particular client has a personality disorder, the precise type of personality disorder is where there is less agreement (Reed, 2010). One of the reasons this occurs is because the different personality disorders have overlapping symptoms. A person who is diagnosed with paranoid personality disorder, for example, may also have symptoms of and can meet the diagnostic criteria for other personality disorders such as schizotypal, borderline, narcissistic, avoidant, and obsessive-compulsive personality disorders (Zimmerman, Rothschild, & Chelminski, 2005). Thus, for a specific client, one clinician might diagnose a paranoid personality disorder whereas another therapist might consider the same set of behaviors and diagnose a borderline personality. The individual might even receive both diagnoses. As you can see, the reliability of the personality disorder categories is a significant concern.

Critical Thinking

What Personality Traits Best Apply to This Man?

The following case study describes the behavior of a teenager, Roy W. He exhibits some very prominent, maladaptive personality traits. After reading the case, identify Roy’s most prominent personality characteristics.

What are Roy’s most prominent personality characteristics? If you were making a diagnosis, would a categorical or dimensional perspective be best in attempting to describe and diagnose Roy’s condition?

Case Study

Roy W. was an 18-year-old high school senior who was referred by the court for diagnosis and evaluation. He was arrested for stealing a car, something he had done on several other occasions. The court agreed with Roy’s mother that he needed evaluation and perhaps psychotherapy. During his interview with the psychologist, Roy was articulate, relaxed, and even witty. He said that stealing was wrong but that he never damaged any of the stolen cars. The last theft occurred because he needed transportation to a beer party (which was located only a mile from his home) and his leg was sore from playing basketball. When the psychologist asked Roy how he got along with young women, he grinned and explained that it is easy to “hustle” them. He then related the following incident:

“About three months ago, I was pulling out of the school parking lot real fast and accidentally sideswiped this other car. The girl who was driving it started to scream at me. God, there was only a small dent on her fender! Anyway, we exchanged names and addresses and I apologized for the accident. When I filled out the accident report later, I said that it was her car that pulled out and hit my car. When she heard about my claim that it was her fault, she had her old man call me. He said that his daughter had witnesses to the accident and that I could be arrested. Bull, he was just trying to bluff me. But I gave him a sob story—about how my parents were ready to get a divorce, how poor we were, and the trouble I would get into if they found out about the accident. I apologized for lying and told him I could fix the dent. Luckily, he never checked with my folks for the real story. Anyway, I went over to look at the girl’s car. I really didn’t have any idea of how to fix that old heap, so I said I had to wait a couple of weeks to get some tools for the repair job.

“Meanwhile, I started to talk to the girl. Gave her my sob story, told her how nice I thought her folks were. We started to date and I took her out three times. Then one night I laid her. The crummy thing was that she told her folks about it. Can you imagine that? Anyway, her old man called and told me never to get near his precious little thing again. At least I didn’t have to fix her old heap. I know I shouldn’t lie, but can you blame me? People make such a big thing out of nothing.”

Second, comorbidity (presence of other disorders) is high with personality disorders, which also reduces diagnostic accuracy. Up to 35 percent of those with PTSD, 47 percent with panic disorder with agoraphobia or generalized anxiety, 48 percent with social phobia, and 52 percent with obsessive-compulsive disorder also have a personality disorder (Latas & Milovanovic, 2014). Additionally, disorders such as depression, bipolar disorder, or substance-use disorders often accompany personality disorders (Lenzenweger, Lane, Loranger, & Kessler, 2007). When personality disorders are comorbid with other disorders, the other disorders are more likely to be diagnosed rather than the personality disorder (Westen et al., 2010).

Third, as we discussed in Chapter 3, an exclusive categorical approach has limitations because categorical diagnoses (1) are based on arbitrary diagnostic thresholds, (2) use an all-or-none method of classification (Reed, 2010), and (3) do not take into account the continuous nature of personality traits (Westen et al., 2010). In reality, people often have personality traits in varying degrees or at various times. Additionally, we all exhibit some of the traits that characterize personality disorders—for example, suspiciousness, dependency, sensitivity to rejection, or compulsiveness—but not to an extreme degree. Alternative methods of determining personality psychopathology have been proposed as a response to these diagnostic issues.

Because of concerns with categorical diagnosis and problems with the reliability and validity of some personality disorder diagnostic categories, members of the DSM-5 Work Group revising the diagnostic criteria for personality disorders proposed discarding the traditional categorical system with the 10 personality disorders we have reviewed in this chapter. They recommended substituting a dimensional model that would involve looking at personality traits on a continuum; a personality disorder diagnosis would occur if a person with maladaptive and pathological personality traits displayed a certain degree of impairment in personality functioning. In other words, the clinician would determine if the person had enough of certain traits to qualify as having a personality disorder. They cited experts in the field of personality who view personality disorders as the extremes of a continuum of normal personality traits (Skodol & Bender, 2009).

A dimensional approach such as this allows clinicians to consider the degree to which a client possesses specific traits rather than deciding whether or not the client meets the diagnostic criteria for a specific disorder in question (yes or no) as required in a categorical diagnosis (Millon et al., 2004). Using a dimensional approach, clinicians can assess clients on specific traits and then rate the extent to which they possess each trait. For example, rather than deciding if a client meets the diagnostic criteria for a schizoid personality disorder, the clinician could instead describe the client as possessing varying degrees of personality traits such as social withdrawal, social detachment, intimacy avoidance, and so forth.

Although the DSM-5 Personality Work Group favored replacing the categorical system with a dimensional, trait-based model, many clinicians expressed concerns about the complete removal of the traditional diagnostic categories for personality disorders. In particular, clinicians opposed the deletion of certain categories because of their high usage and clinical utility. In a highly unusual move, the APA Board of Trustees decided to retain the categorical framework of 10 personality disorders in the main text of the DSM-5 and to include an alternative model for personality disorder diagnosis in a separate section of the DSM-5 (see Figure 14.2). This alternative model retains some of the categorical diagnoses in a modified form (6 of the 10 traditional personality disorders were retained), but also includes a dimensional classification system based on personality traits. The rationale for including both the traditional and the alternative model of personality disorder diagnosis was to “preserve continuity with current clinical practice, while also introducing a new approach that aims to address numerous shortcomings of the current personality disorders” (APA, 2013, p. 761). The alternative model of personality disorders removed four of the more problematic personality disorders—paranoid, schizoid, histrionic, and dependent. Clinicians can choose to use the traditional categorical model or the alternative model when making a personality disorder diagnosis.

Figure 14.2Two Paths to Personality Disorder Diagnosis Using the DSM-5 Alternative Model

© Cengage Learning®