Biopsychosocial and Diagnosis

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Susan W. Gray

Psychopathology: A Competency-Based Assessment Model for Social Workers

Chapter 16 The Personality Disorders

A personality disorder is seen as a variant of character traits going far beyond the normative range found in most people characterized by:

An enduring pattern of inner experience and behavior that is stable and enduring beginning in at least adolescence (or early adulthood) causing significant functional impairment or subjective distress

Deviates from the expectations of one’s culture

Not attributed to effects of a substance or medical condition

Seen in 2 (or more areas) of:

Cognition

Affectivity

Interpersonal functioning

Impulse control

Grouping of the Personality Disorders

Cluster A: Odd and eccentric—Individuals who have paranoid, schizoid, and schizotypal personality disorders

Cluster B: Emotional, dramatic, or erratic—Individuals with antisocial, histrionic, borderline, and narcissistic personality disorders

Cluster C: Anxious, fearful—Individuals with avoidant, dependent, and obsessive-compulsive personality disorders

Paranoid Personality Disorder (Cluster A)

Central characteristics of paranoid personality include a pervasive pattern of distrust and suspicion seen by (4 or more) the following:

Suspicion

Unjustified doubts

Problems with intimacy

Perceptions of hidden meanings

Holding grudges

Paranoia

Recurrent suspicions

The case of Ben Rogers illustrates Paranoid Personality Disorder

Schizoid PersonalityDisorder (Cluster A)

The person shows a lifelong pattern of social withdrawal seen in at least 4 (or more) of the following symptoms:

No penchant for social relationships

Preference for solitary activities

Little or no sex drive

Takes pleasure in few, if any, activities

Lacks close friends other than first-degree relatives

Acts indifferent to praise (or criticism) of others

Limited range of emotions

The Case of Tyrone White Illustrates Schizoid Personality Disorder

Schizotypal Personality Disorder (Cluster A)

Individuals with schizotypal personality disorder exhibit strikingly odd or strange mannerisms in addition to having a very active fantasy life seen in 5 (or more) of the following symptoms:

Ideas of reference

Odd beliefs

Unusual perceptual experiences

Odd thinking or speech

Suspiciousness or paranoid ideation

Inappropriate or constricted affect

Behavior or appearance that is odd, eccentric, or peculiar

Lack of friends or close confidants other than relatives

Anxiety in social situations

The case of Juan Enrique Martinez Illustrates Schizotypal Personality Disorder

Antisocial Personality Disorder (Cluster B)

Characterized by continual asocial or criminal acts occurring since 15 years of age seen by 3 (or more) of the following:

Defiance of or failure to conform to social norms

Deceitful or the absence of consistent truthfulness

Impulsive

Irritable and aggressive

Reckless disregard for the safety of self or others

Irresponsible

Lack of remorse or empathy

The Case of Luke Rossey Illustrates Antisocial Personality Disorder

Borderline Personality Disorder (Cluster B)

Characterized by an unstable mood, extremely poor relationships with others, and low self-image alternating between extremes of idealization and devaluation seen in 5 (or more) of the following symptoms:

Frantic efforts to avoid abandonment

Poor interpersonal relationships

Identity disturbance or unstable self-image

Marked impulsivity

Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior

Affective instability

Chronic feelings of emptiness

Inappropriate, intense anger

Transient stress-related paranoid ideation or severe dissociative symptoms

The Case of Suzie Hutchfield Illustrates Borderline Personality Disorder

Histrionic Personality Disorder (Cluster B)

Individuals tend to have a long-standing pattern of excessive emotionality and attention seeking, which seeps into most areas of their lives and characterized by 5 (or more) of the following symptoms:

Grandiose sense of self-importance

Preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love

Show rapidly shifting and shallow expression of emotions

Concerns with “presentation” or physical appearance

Speech that is excessively impressionistic and lacks detail

Self-dramatization, theatric, and exaggerated expression of emotion

Easily influenced and susceptible

Considers relationships more intimate than they are

Tamika Brown’s Story Illustrates Histrionic Personality Disorder

Narcissistic Personality Disorder (Cluster B)

Characterized by a heightened sense of self-importance and unrealistic inflated self-worth, often disguising an underlying fragile sense of self seen in 5 (or more) symptoms of:

Grandiose sense of self-importance

Fantasies of unlimited success, power, brilliance, beauty, ideal love

Belief in being special and unique

Constant desire or need for admiration

Sense of entitlement

Interpersonally exploitative

Lacks empathy

Envious of others or believes that others are envious of them

Shows arrogant, haughty behaviors/attitudes

The Case of Lawrence Shull Illustrates Narcissistic Personality Disorder

Avoidant Personality Disorder (Cluster C)

Main characteristics are a pervasive pattern of social inhibition, constant feelings of inadequacy and ineptitude, especially in social situations, and hypersensitivity to negative evaluation beginning in early adulthood seen in 4 (or more) symptoms of:

Avoids occupational activities involving significant interpersonal contact

Unwilling to get involved with other unless they can be certain they will be liked

Shows restraint within intimate relationships

Preoccupied with being criticized or rejected

Inhibited in new interpersonal situations

Consider themselves as socially inept, personally unappealing or inferior to others

Reluctant to take personal risks or to engage in any new activities

The Case of Mabel Humphries Highlights Avoidant Personality Disorder

Dependent Personality Disorder (Cluster C)

Characterizes a pervasive pattern of extreme inability to act independently of others seen in 5 (or more) of the following symptoms:

Difficulty making everyday decisions

Need for others to assume responsibility for most major areas of his or her life

Difficulty expressing disagreement

Difficulty initiating projects or doing things independently

Goes to extreme lengths to obtain nurturance and support

Feels uncomfortable (or helpless) when alone

When a close relationship has ended, seeks another relationship for support

Preoccupied with fears of being left alone to care for him- or herself

Walter Pearson’s Story Illustrates Dependent Personality Disorder

Obsessive-compulsive Personality Disorder (Cluster C)

Individuals are characterized as rigid, orderly, inflexible, and emotionally constricted seen in 4 (or more) of the following symptoms:

Preoccupied with details, rules, lists, order, organization or schedules

Perfectionism

Excessively devoted to work and productivity

Over conscientious, scrupulous, and inflexible about matters of morality ethics, or values

Difficulty discarding worthless objects

Difficulty delegating tasks or to work with others

Miserly or stingy toward self and/or others

Shows rigidity or stubbornness

Geoffrey Hales Story Illustrates Obsessive-Compulsive Personality Disorder

Proposed DSM-5 Alternative Model

Included in Section III of the manual, “Emerging Measures and Models”

Describes a hybrid dimensional-categorical model

General diagnostic criteria requires:

An assessment of self and personality functioning (or how the individual typically experiences him- or herself as well as others) as well as interpersonal functioning

The presence of one or more pathological personality traits

These traits are consistent across social situations and stable over time

Comparing the DSM-IV-TR Multiaxial System and the DSM-5

Personality disorders were previously placed on Axis II in the DSM-IV, but in the DSM-5 this axis has been deleted and the personality disorders are situated on one axis with all other diagnoses

The 10 different types (and clusters) of personality disorders were retained

An alternative hybrid dimensional-categorical model for the personality disorders is included in Section III of the DSM-5, and this insertion is intended to encourage further research on this modified classification system