PSCY Essay

Personality Disorders SSY 230: Lecture 13

The Nature of Personality Disorders

In this lecture, our focus shifts to the set of disorders that represent long-standing patterns of impairments in an individual’s self-understanding, ways of relating to others, and personality traits. A personality trait is an enduring pattern of perceiving, relating to, and thinking about the environment and others, a pattern that characterizes the majority of a person’s interactions and experiences. Most people are able to draw upon their personality traits in a flexible manner, adjusting their responses to the needs of the situation. When people become rigidly fixed on one particular trait or set of traits, however, they may place themselves at risk for developing a personality disorder.

When does a personality trait become a disorder? What may be a characteristic way of responding can develop into a fixed pattern that impairs a person’s ability to function satisfactorily. Perhaps you’re the type of person who likes to have your room look “just so.” If someone moves your books around or changes the arrangement of your clothes on the hanger, you may feel a little bothered. At what point does your unhappiness with a change in the order of your possessions become so problematic that you have crossed over from a being a little finicky to having a personality disorder characterized by extreme rigidity? Should this behavioral pattern place you in a diagnostic category with a distinct set of criteria that separates you from people with other personality traits and related behaviors? These are the questions raised in the diagnosis of the disorders you will learn about in this lecture.

Personality Disorders in the DSM-5

A personality disorder is an ingrained way of relating to other people, situations, and events, characterized by a rigid and maladaptive pattern of inner experience and behavior, dating back to adolescence or early adulthood. As conceptualized in the DSM-5, the personality disorders represent a collection of distinguishable sets of behavior falling into 10 distinct categories (plus one additional “not otherwise specified” diagnosis).

Fitting the general definition of a psychological disorder, a personality disorder deviates markedly from the individual’s culture and leads to distress or impairment. The types of behavior that personality disorders represent can be, for example, excessive dependency, overwhelming fear of intimacy, intense worry, exploitive behavior, or uncontrollable rage.

To fit the current diagnostic criteria, these behaviors must manifest themselves in at least two of four areas:

(1) cognition

(2) affectivity

(3) interpersonal functioning

(4) impulse control

As a result of these behaviors, the individual experiences distress or impairment.

Personality Disorders in the DSM-5

The DSM-5 groups the 10 diagnoses into three clusters based on the fundamental characteristics they share.

Cluster A includes paranoid, schizoid, and schizotypal personality disorders, all of which share features of odd and eccentric behavior. Cluster B includes antisocial, borderline, histrionic, and narcissistic personality disorders, marked by overdramatic, emotional, and erratic or unpredictable attitudes and behaviors. Cluster C includes avoidant, dependent, and obsessive-compulsive personality disorders, which have anxious and fearful behaviors in common. The 11th personality disorder is reserved for individuals who do not clearly meet one of the other 10 diagnostic criteria, which is why it receives the label “not otherwise specified.”

Because each personality disorder is defined as a distinct entity, clinicians evaluating individuals for a possible diagnosis must decide how many of the criteria a client meets within each category and assign a diagnosis on that basis. The clinician may start by trying to match the individual’s most prominent symptoms with the diagnostic criteria. If the client does not fit the criteria for that disorder, the clinician may either move to another disorder or decide that the client has a personality disorder “not otherwise specified” because it is not uniquely identifiable.

Currently, studies in both the United States and the United Kingdom yield an overall prevalence among nationally representative samples of 9 to 10 percent. Personality disorders are highly comorbid with drug dependence. For example, among people with antisocial personality disorder, the lifetime prevalence rate of alcohol dependence is 27 percent and 59 percent for nicotine dependence.

Alternative Personality Disorder Diagnostic System

As you can see, personality disorders represent distinct diagnostic entities. Whereas people can be high or low on a given personality trait, such as introversion or conscientiousness, they either have or do not have a given personality disorder.

Those who are critical of the DSM-5 maintain that the 10 diagnoses there require too many fine distinctions to be made about behaviors and qualities that, in reality, occur as a continuum. Indeed, because of the forced-choice categories the system requires, clinicians found that they were most often using the less-than-precise diagnosis of “personality disorder not otherwise specified”.

In response to these criticisms and questions, although they retained the categorical diagnostic system, the DSM-5 authors decided to include dimensional ratings of pathological personality traits on a trial basis. Clinicians can use these dimensional ratings of the six most readily differentiated personality disorders to evaluate the corresponding personality and interpersonal functioning of each. This dimensional system is shown in the following slide. It remains in Section 3 of DSM-5, allowing clinicians and researchers to test the new system and work to help decide whether it should replace the categorical diagnostic system.

Dimensional Ratings of DSM-5 Personality Disorders from Section 3 (Table 1)

To use the Section 3 dimensional ratings,

clinicians assign one of six personality

disorder diagnoses to their clients and

then evaluate them on the five

dimensions (divided into three groups).

The first group of dimensions reflects

“personality functioning,” defined as the

individual’s sense of identity and

self-direction.

The second group includes two ratings

of “interpersonal functioning” that tap

the client’s ability to understand other

people’s perspectives (empathy) and

form close relationships (intimacy).

Clinicians rate individuals from mild to

extreme in these domains.

The third group is actually a single rating

of the client on traits related to each of

the six personality disorders.

Alternative Personality Disorder Diagnostic System

Table 2 summarizes in brief how

personality disorders would be

diagnosed using the dimensional

criteria, and Table 3 defines each of the

personality traits listed in Table 1.

Keep in mind that this system is not yet

in place but is being actively

investigated as an alternative to the

categorization system in DSM-5

currently in use. To date, the evidence

generally supports the Section 3

dimensional rating system, but it also

suggests that further refinement is

needed before this system can replace

the categorical system entirely.

Cluster A Personality Disorders

Cluster A of the personality disorders in DSM-5 include those disorders characterized by odd and eccentric behavior.

People with these disorders have qualities suggesting they feel different, unlikable, and unable to fit into the social world of their friends, families, fellow students, and co-workers, leaving them with a preference for avoiding interpersonal relationships

Paranoid Personality Disorder

People with paranoid personality disorder are extremely suspicious of others and are always on guard against potential danger or harm. Their view of the world is narrowly focused, in that they seek to confirm their expectations that other people will take advantage of them, making it virtually impossible for them to trust even their friends and associates.

As an example, consider an individual with this disorder who believes a spouse or partner to be unfaithful, even if no substantiating evidence exists. Seeing an unexplained text on a partner’s phone, such an individual will regard this as proof that the partner is having an affair. Indeed, with their guarded behavior and suspiciousness, those with paranoid personality disorder are known to have difficulty establishing the type of interpersonal closeness that helps maintain the quality of a long-term intimate relationship.

Another manifestation of paranoid personality disorder is the inability to take blame for mistakes, seeing others as being at fault instead. The disorder also shows up as the perception that there is hidden meaning in innocent comments or glances. A real or imagined slight leads to years of resentment.

Paranoid Personality Disorder

On the positive side, individuals with this disorder may be relatively successful in certain kinds of jobs requiring that they be on the lookout for threats to themselves, co-workers, or the public. In dangerous political climates in which people must be on guard just to stay alive, these traits can be adaptive. However, in ordinary circumstances, individuals’ excessive

caution and high level of suspicion means they find it difficult to place trust in other people, even those who love and care about them.

Unfortunately, because people with paranoid personality disorder do not see themselves as the source of their problems, they refuse to seek professional help. In the unlikely event they do seek therapy, their rigidity and defensiveness make it difficult for the clinician to form the kind of working relationship needed to make progress and work toward any kind of lasting change.

Schizoid Personality Disorder

An indifference to social and sexual relationships characterizes schizoid personality disorder. With a limited range of emotional experience and expression, individuals with this disorder prefer to be by themselves rather than with others, and they appear to lack any desire for acceptance or love, even by their families. They are not even interested in becoming sexually involved with others. In turn, others perceive them as cold, reserved, withdrawn, and seclusive.

Throughout their lives, people with schizoid personality

disorder seek out situations that require only minimal

interaction with others. Those who are able to tolerate work

are drawn to jobs in which they spend all their work hours

alone. They choose to live alone, guarding their privacy and

avoiding any but the most superficial dealings with

neighbors.

Schizotypal Personality Disorder

Individuals with schizotypal personality disorder have odd if not eccentric beliefs, behavior, appearance, and interpersonal style. Unlike the term schizoid, the term schizotypal implies a connection with schizophrenia, and people who fit this diagnosis are vulnerable to developing a full-blown psychosis if exposed to difficult life circumstances that challenge their coping ability.

The pathological personality traits of people with schizotypal

personality disorder fall along the extremely maladaptive end of the

psychoticism dimension. Thus, individuals with this disorder may hold

eccentric ideas, have unusual beliefs and experiences, and have

difficulty forming accurate perceptions and cognitions about their

world, leading to more negative views about themselves than are

warranted by objective data. They also show a tendency to be high on

the personality trait of openness to experience, specifically, openness to

unusual ideas. As we show in Table 1, people with schizotypal

personality disorder also have restricted affect and withdrawal

tendencies, which reflect the pathological personality trait of

detachment.

Schizoid vs. Schizotypal

Cluster B Personality Disorders

People with Cluster B personality disorders behave in ways that are best described as dramatic, emotional, or erratic.

These individuals act impulsively, seem to have an inflated view of their own importance or self-esteem, and are high in the desire to seek stimulation.

Antisocial Personality Disorder

Synonymous in the past with “psychopath” or “sociopath,” the DSM-5 term antisocial personality disorder describes a personality disorder characterized by a lack of regard for society’s moral or legal standards and an impulsive and risky lifestyle.

People with this disorder are high in the quality of psychopathy and thus defined

as being able to exploit others, extremely egocentric and incapable of love,

unreliable and deceptive, charming but insincere, and unable to feel remorse. They

engage in impulsive and aggressive acts, take risks despite experiencing negative

consequences, and fail to conform to social or ethical norms. Their antisocial

lifestyle may also include a history of early behavioral problems or juvenile

delinquency.

People with antisocial personality disorder do not actually experience feelings of

remorse, but they may feign their regret for harming others in order to get

themselves out of a difficult situation when they get caught. These individuals also

try hard to present themselves in as favorable a light as possible. You might think

of them as the “smooth talkers” who can con anyone out of anything, such as asking

for money or favors they have no intention of repaying.

The Dark Triad

Personality researchers also believe that related to psychopathy is the trait of fearless dominance, a tendency toward boldness that includes a desire to dominate social situations, charm, willingness to take physical risks, and an immunity to feelings of anxiety.

Personality researchers coined the fitting term dark triad to reflect the makeup of individuals high in psychopathy who are also highly self-centered and regard other people as objects to be exploited.

Antisocial Personality Disorder

The accepted wisdom for many years in the field of abnormal psychology was that people with antisocial personality disorder are untreatable, and current therapy effectiveness studies unfortunately continue to support the difficulty of working with this population. Because they seem unable to experience empathy and do not learn from the negative consequences of their behaviors, they are resistant to approaches using either insight or behavioral interventions. Indeed, the problems of working with these individuals include the very characteristics of the disorder itself: a seeming lack of motivation to change, a tendency toward deception and manipulation, inability to see the world from the perspective of other people, and a lack of deep or lasting emotion.

What, then, are reasonable treatment goals? Should researchers measure the effectiveness of therapy in terms of rearrest or recividism (return of symptoms), or should they focus instead on changes in job performance, relationships with others, and engagement in noncriminal activities (such as sports or hobbies)?

Reflecting the many difficulties in both working with the population and defining reasonable goals of therapy, at present no one accepted method of treatment has been shown to be effective in reducing the core features of the disorder. Nevertheless, therapists can take a pragmatic approach to helping clients satisfy their needs through prosocial ways, such as cooperation rather than exploitation and manipulation. Motivational interviewing, focused on providing clients with opportunities to connect to core values and the need for fulfillment, can also be of value as a means to help these clients make better life decisions.

Borderline Personality Disorder

The central quality of instability of self and relationships forms the key diagnostic feature of borderline personality disorder (BPD). Diagnosis of BPD rests on the individual’s demonstration of at least five of nine possible behaviors:

● frantic efforts to avoid abandonment

● unstable and intense relationships

● identity disturbance

● impulsivity in areas such as sexuality, spending, or driving

● recurrent suicidal behavior

● unstable affect

● chronic feelings of emptiness

● difficulty controlling anger

● occasional feelings of paranoia or dissociative symptoms

Borderline Personality Disorder

The symptoms of BPD influence the lives of people with the disorder in a number of significant ways. Their insecurity reaches such an extreme that they rely on other people to help them feel “whole.” Even after they have passed through the customary time of identity questioning that most people experience in adolescence, these individuals remain unsure and conflicted about their life’s goals.

Their chronic feelings of emptiness also lead them to almost merge their identities into those of the people to whom they are close. Unfortunately for them, the more they seek the reassurance and closeness of others, the more they drive these people away. As a result, their disturbed feelings only become more intense, and they become more and more demanding, moody, and reckless. In this way, the symptoms of the disorder become cyclical and self-perpetuating, often escalating to the point at which the individual requires hospitalization.

A term that aptly describes the way that people with BPD often relate to others is splitting. This means their preoccupation with feelings of love for the object of their desire and attention can readily turn to extreme rage and hatred when that love object rejects them. They may apply this all-good versus all-bad dichotomy to other experiences and people as well.

The intense despair into which they can be thrust may also lead them to perform suicidal gestures, as a way to either gain attention or derive feelings of reality from the physical pain the action causes. These so-called parasuicides may lead to hospitalization, where clinicians detect that the act was, in fact, a gesture and not a true desire to end their lives.

Borderline Personality Disorder

At one time, researchers believed that women were more likely to have BPD than were men, but they now consider the prevalence equal between the genders. However, there are gender differences in specific symptoms and in other disorders that occur in conjunction with a diagnosis of BPD. Men with BPD are more likely to have substance use disorder and antisocial personality characteristics. Women have higher rates of mood and anxiety disorders, eating disorders, and post-traumatic stress disorder. These differences may account for the previous estimates of higher rates of the disorder in women, whom clinicians more likely encountered in mental health settings. In contrast, clinicians are more likely to see men in substance use disorder programs.

A diagnosis of BPD prior to the age of 19 may signify that the individual will face a difficult life ahead. In a review of 18 studies on long-term outcomes of BPD among children and adolescents, researchers found evidence that diagnosis prior to adulthood predicted significant social, educational, work, and financial impairment in the years to come.

Overall, however, there is a trend for individuals who have BPD to improve over the course of their lives in that their symptoms become less severe. Among a sample of 175 adults with BPD studied over the course of 10 years, 85 percent no longer had symptoms by the end of the period, although they improved at slower rates than did people with either major depressive disorder or other personality disorders. Furthermore, they remained less well adapted socially over time than did people with other personality disorders. Thus, although people with BPD may experience improved functioning in terms of their psychiatric disorder, they continue to face challenges in such areas as work and interpersonal relationships.

Borderline Personality Disorder

Disturbances in emotional functioning form an important component of the diagnosis of BPD, and researchers have thus focused their efforts on identifying the specific psychological processes that contribute to these disturbances. People with BPD seem to have an inability to regulate emotions, known as emotional dysregulation, limitations in the ability to withstand distress (distress tolerance), and avoidance of emotionally uncomfortable situations and feelings (experiential avoidance).

You might be able to imagine how these difficulties can translate into the symptoms of BPD in everyday life when individuals with BPD encounter stressful situations. More than other people, they dislike emotionally tense situations, feel uncomfortable when distressed, and have great difficulty handling their anger when something does go wrong.

Early childhood experiences play an important role in the development of BPD. These include childhood neglect, traumatic experiences, and marital or psychiatric difficulties in the home. Children who were insecurely attached are also more likely to develop into adults with BPD.

Treatment for Borderline Personality Disorder

The treatment with the greatest demonstrated effectiveness is dialectical

behavior therapy (DBT), a form of behavioral therapy. Psychologist Marsha

Linehan developed DBT specifically to treat individuals with BPD who might

otherwise not respond to conventional psychotherapy.

In DBT, the clinician integrates supportive and cognitive-behavioral

treatments with the goal of reducing the frequency of the client’s

self-destructive acts and increasing his or her ability to handle emotional

distress.

Using a process called core mindfulness, DBT clinicians teach their clients to

balance their emotions, reason, and intuition as they approach life’s

problems. Although important for any type of psychotherapy, the building of

the therapeutic alliance seems particularly crucial in DBT, and specifically in

reducing the likelihood of suicide attempts.

Treatment for Borderline Personality Disorder

Mentalization therapy, in which clients are helped to identify their feelings, can also assist these individuals in gaining control over their dysfunctional thoughts and corresponding emotions. In the early steps, the therapist provides support and empathy, an essential ingredient of much psychotherapy. Therapists then help clients clarify and elaborate on what they’re feeling by putting their feelings at the moment into words. Now they can start to identify their own feelings and where they originate. Finally, clients learn how to use what they gained in their relationships with people in their lives outside therapy.

Another evidence-based treatment for BPD, transference-focused psychotherapy, uses the client–clinician relationship as the framework for helping clients achieve greater understanding of their unconscious feelings and motives. Psychiatrically based management incorporates psychodynamic therapy as developed for BPD treatment, along with family interventions and pharmacologic treatment.

Basic Principles of Effective Treatment for Clients with BPD

Regardless of the specific treatment approach they use,

clinicians have the greatest success if they follow a set of basic

principles. These principles set the stage for the clinician to

help the client because they focus on providing key features

that can be therapeutic for people with this specific disorder.

Although many of these principles could generalize beyond

clients with BPD, the need to establish clear boundaries,

expectations, structure, and support are particularly important

for individuals with this diagnosis.

The last principle encourages clinicians to seek support

themselves when the client’s symptoms lead to difficulties

within therapy. For example, the symptom of splitting shown by

individuals with BPD may lead them alternatively to devalue

and idealize the clinician. In these cases, the clinician may

experience complicated reactions and may benefit from the

outside perspective of a supervisor or consultant.

Histrionic Personality Disorder

Clinicians diagnose histrionic personality disorder in people who show extreme pleasure at being the center of attention and who behave in whatever way necessary to ensure that this happens. The criteria for this disorder include excessive concern with physical appearance and constant and extreme efforts to draw attention to self.

Flirtatious and seductive, people with this disorder become furious if they don’t get the

attention they seek. They want immediate gratification of their wishes and overreact to

even minor provocations, usually in an exaggerated way such as by weeping or fainting.

Although their relationships are superficial, people with histrionic personality disorder

interpret them as being close and intimate. Even their casual acquaintances are “good

friends” in their eyes. Their cognitive style is vague and impressionistic, making them

easily influenced by others and unable to solve problems on their own. To some extent,

individuals with these traits may be successful because of their outward self-confidence

and attention-grabbing behavior, but in the long run their flightiness, tendency to flirt,

and shallowness lead to instability in close relationships, including higher divorce rates .

This disorder is rarely diagnosed and difficult to distinguish reliably from other

personality disorders.

Narcissistic Personality Disorder

People who meet the criteria for the diagnosis of narcissistic personality disorder (NPD) have as their core characteristic an extreme form of egocentrism in which they see themselves as the center of the universe. A term now in widespread popular use, “narcissism” refers to the excessive self-love and grandiosity believed to be a predominant feature of NPD.

Anyone in a relationship with a person truly having NPD (versus being highly narcissistic) knows how difficult such a person can be to tolerate. Entitled, haughty, and unable to see the world from anyone’s perspective but their own, people with NPD seem to show little regard for the people who care about them. Ironically, however, they are highly dependent on the way they believe others perceive them, and as a result they need constant flattery, attention, and reassurance.

The sense of entitlement is one of NPD’s most prominent symptoms, but it is a sword that can cut both ways. Because individuals with this disorder see themselves as exceptional, they may set their personal standards unrealistically high, being satisfied with nothing less than perfection. Conversely, they may regard themselves as deserving of whatever they want and therefore not push themselves as hard as they could, setting their personal standards far too low while believing they merit the best others can offer them.

Narcissistic Personality Disorder

The greatest paradox in NPD is the combination of grandiosity and vulnerability in the sense of self. Some individuals with NPD seem to think of themselves entirely in an inflated and self-aggrandizing way. These are the NPD individuals clinicians refer to as high in grandiose narcissism.

Those high in vulnerable narcissism, in contrast, have an internally weak sense of self and so become despondent when they feel someone important to them is humiliating or betraying them. The DSM-5 does not explicitly make this

distinction, but clinicians and researchers maintain that it is an important differentiation.

Narcissistic Personality Disorder: Psychodynamic Perspective

Some researchers believe the increasing presence of social media has in effect created a population of narcissists. Whatever position we may take in a debate about this (and it is a debatable point), a narcissist is not the same as a person with NPD. Further, there can be a healthy form of narcissism associated with having a positive sense of self-esteem.

The traditional Freudian psychoanalytic approach regards narcissism as the individual’s failure to progress beyond the early, highly self-focused stages of psychosexual development when we derive gratification solely from within ourselves. The disorder is no longer seen from this viewpoint. Theorists operating within the object relations approach regard the narcissistic individual as having failed to form a cohesive, integrated sense of self. The narcissistic individual expresses insecurity, paradoxically, in an inflated sense of self-importance as he or she tries to make up for early

parental support. Lacking the firm foundation of a healthy self, such a person develops a false self precariously based on grandiose and unrealistic notions about his or her competence and desirability.

The current psychodynamic perspective incorporates the object relations view in seeing narcissistic personality disorder as the adult’s expression of childhood insecurity and need for attention. Following this logic, clinicians attempt to provide a corrective developmental experience, using empathy to support the client’s search for recognition and admiration. At the same time, they attempt to guide the client toward a more realistic appreciation that no one is flawless. As clients feel their therapists increasingly support them, they become less grandiose and self-centered. Part of

this process may be a form of reparenting in which the therapist works with the client to foster early, unmet needs.

Narcissistic Personality Disorder: Cognitive-Behavioral Perspective

Cognitive-behavioral theorists focus on the maladaptive ideas their clients hold, particularly the view held by people with the grandiose variety of the disorder in which they regard themselves as exceptional people who deserve far better treatment than ordinary humans. These beliefs hamper their ability to perceive their experiences realistically, and as a result they encounter problems when their inflated ideas about themselves clash with their experiences of failure in the real world.

Rather than simply confronting them with their erroneous beliefs, clinicians working in the cognitive-behavioral perspective structure interventions that work with, rather than against, the client’s self-aggrandizing and egocentric tendencies. This allows the individual to accept the therapist’s help because the intervention seems less threatening. For example, rather than try to convince the client to act less selfishly, the therapist might try to show that there are better ways to reach important personal goals. At the same time, the therapist avoids capitulating to the client’s demands for special favors and attention. Interestingly, this approach is not all that different from the contemporary psychodynamic perspective, which supports the individual’s need to feel recognized and accepted while still helping him or her develop a more realistic sense of self.

Unfortunately, people with NPD are difficult to treat because they tend not to have insight into their disorder. Moreover, the therapists who treat them may experience strong negative reactions to them due to the very nature of their symptoms of grandiosity and entitlement, making them critical and demeaning of their therapists. Their extreme perfectionism can also obstruct treatment. Clients with NPD have filled their lives with success and accomplishments that preserve their self-esteem and ward off their insecurities. As a result, it is particularly difficult for them to confront their anxieties and insecurities.

Cluster C Personality Disorders

People within the Cluster C personality disorders tend to be extremely restrained and may draw little attention to

themselves, in contrast to those individuals with personality disorders in Cluster B.

Each disorder in Cluster C has its own unique qualities that distinguish it, but as a group they share this inner directedness.

Avoidant Personality Disorder

As the term implies, people with avoidant personality disorder stay away from others, believing they lack social skills and have no desirable qualities that would make others want to be with them. Their symptoms go beyond shyness to feelings of shame and inadequacy so strong that they prefer not to be around others. They stay away almost entirely from social encounters and are especially likely to avoid any situation that could embarrass them. They may set unrealistically high standards for themselves, which in turn lead them to avoid situations in which they feel doomed to fail. Intimate relationships present a severe threat to them because they fear shame or ridicule should they expose their flaws to a partner.

Researchers believe avoidant personality disorder exists along a continuum

extending from the normal personality trait of shyness to social anxiety disorder.

According to this view, avoidant personality disorder is a more severe form of social

anxiety disorder. Data from a longitudinal study of more than 34,000 adults found

people with avoidant personality disorder were more likely to continue to

experience symptoms of social anxiety disorder even after adjusting for a number

of demographic factors. It is possible that the link between social anxiety disorder

and avoidant personality disorder is that both are characterized by excessive

self-criticism, which in turn leads people with these disorders to expect the same

level of criticism from others.

Avoidant Personality Disorder: Theories and Treatment

The contemporary psychodynamic approach to this disorder regards it as the expression of fear of attachment in close relationships. People with this disorder avoid getting close to others because they fear being abandoned or neglected in the same way they were by their caregiver in early childhood.

From a cognitive-behavioral perspective, avoidant personality disorder may reflect the individuals’ hypersensitivity to shame. This hypersensitivity causes them to misinterpret seemingly neutral and even positive remarks. Hurt by perceived rejection, they retreat inward, placing further distance between themselves and others.

The main goal of therapists working in the cognitive-behavioral framework is to break the client’s negative cycle of avoidance. Clients learn to articulate the automatic thoughts and dysfunctional attitudes that interfere with their ability to establish relationships with others. Although clinicians point out the irrationality of these beliefs, they do so in a supportive atmosphere. In order for these interventions to be successful, however, clients must learn to trust the therapist rather than see him or her as yet another person who may ridicule or reject them.

Cognitive-behavioral therapists may also use graduated exposure to present the client with social situations that are increasingly more difficult to confront. They may train the client in specific skills intended to improve his or her intimate relationships. Consistent with the theory that dysfunctional cognitions are an important factor in this disorder, a pilot study of brief cognitive therapy showed that it produced improvements in negative affect and quality of life among individuals with avoidant personality disorder symptoms.

Dependent Personality Disorder

Individuals with dependent personality disorder are strongly drawn to others. However, they are so clinging and passive that they may achieve the opposite of their desires as others become impatient with their lack of autonomy. Convinced of their inadequacy, they cannot make even the most trivial decisions on their own.

Others may characterize individuals with dependent personality

disorder as “clingy,” and indeed, when alone these clients feel

despondent and abandoned. They are likely to throw themselves

wholeheartedly into relationships and are therefore devastated when

relationships end. Their extreme dependence causes them to urgently

seek another relationship to fill the void. Even when with others, they

become preoccupied with the fear of being left. They cannot

comfortably initiate new activities on their own because they are

hampered by worries that they will make mistakes unless others guide

their actions.

Dependent Personality Disorder: Theories and Treatment

As you might imagine, people with this disorder go to extremes to avoid having people dislike them—for example, by stating that they agree with others even when they do not. Such individuals may also seek approval by taking on responsibilities no one else wants, but if anyone criticizes them, they feel shattered.

Research on the personality traits of individuals with dependent personality disorder suggests that they have unusually high levels of agreeableness. Although we tend to think of agreeableness as an adaptive trait, at high levels it can become a tendency to be overly docile, self-sacrificing, and clinging. Anxiousness, submissiveness, and an insecure attachment style are the pathological traits associated with dependent personality disorder.

Cognitive-behavioral treatment for people with dependent personality disorder appears to be effective, particularly if the clinician alternates as needed between changing behaviors and challenging the client’s faulty beliefs. Mindfulness training can also be useful in helping individuals with this disorder identify and manage their interpersonal anxiety.

Obsessive Compulsive Personality Disorder

People with obsessive-compulsive personality disorder (OCPD) have a set of symptoms that revolve around defining their sense of self and self-worth in terms of their work productivity. Perfectionistic to a fault, people with OCPD find it difficult to complete a task because they can always see a flaw in what they have done. Their work products are never good enough to meet their unrealistic standards. They can also be overly moralistic because they stick to overly conscientious standards that almost anyone would find difficult to meet.

The interpersonal relationships of people with OCPD also suffer due to their difficulty

understanding how others feel, particularly when those feelings differ from their own.

Because they have such high standards for themselves, people with OCPD are critical of

other people who they see as not matching their own expectations. Others, in turn,

perceive those with OCPD as rigid and stubborn.

The words obsessive and compulsive as applied to the OCPD personality disorder have a

different meaning than in the context of obsessive compulsive disorder (OCD). Unlike

those with OCD, people with OCPD do not experience obsessions and compulsions but

instead are rigidly compulsive (such as being fixated on certain routines) and obsessed

with the need to be perfect.

Obsessive Compulsive Personality Disorder: Theories and Treatment

In exploring the causes of OCPD from a historical psychodynamic standpoint, Freud believed people with an obsessive-compulsive style have not progressed from, or are constantly returning to, the anal stage of psychosexual development. Contemporary psychodynamic theorists no longer focus entirely on psychosexual stages but instead give more attention to cognitive factors and prior learning experiences as central to the development of OCPD.

As a maladaptive personality disposition, OCPD can also be looked at from the perspective of trait theory. Rather than scoring high in overall conscientiousness, individuals with OCPD are particularly likely to be high in achievement striving and the need for order.

From the standpoint of cognitive-behavioral theory, people with this disorder have unrealistic expectations about being perfect and avoiding mistakes. Their feelings of self-worth depend on their behaving in ways that conform to an abstract ideal of perfectionism. If they fail to achieve that ideal (which, inevitably, they must), they regard themselves as worthless. In this framework, obsessive-compulsive personality disorder is based on a problematic way of viewing the self.

Clinicians using cognitive-behavioral treatment for clients with OCPD face challenges due to the characteristic features of this personality disorder. The person with OCPD tends to intellectualize, to ruminate over past actions, and to worry about making mistakes. Cognitive-behavioral therapy, with its focus on examining the client’s thought processes, may reinforce this ruminative tendency. Instead, metacognitive interpersonal therapy can help individuals with OCPD “think about their thinking.” In this procedure, clinicians help their clients take a step back and learn to identify their problematic ruminative thinking patterns in the context of building a supportive therapeutic alliance.

Activity prompt:

Select one personality disorder covered in this lecture, list some potential challenges you could anticipate in working with a client/patient with this disorder, and how you may go about treatment with these challenges in mind.

Personality

Disorders: The Biopsychosocial Perspective

The personality disorders represent a fascinating mix of long-standing personal dispositions and behavior patterns and disturbances in identity and interpersonal relationships.

Although we tend to focus on these disorders as they appear at one point in time, clearly they evolve over an individual’s life. The DSM authors will likely continue to refine and elaborate on their scientific base if not their

classification.

We may hope that mental health professionals will develop not only a better understanding of this form of disturbance but also, perhaps, a richer appreciation of the factors that contribute to normal personality growth and change through life.

Sources

Image 1: Text, page 354

Image 2: Text, page 355

Images 3-6, 8, and 11-15 : http://tabanacles.blogspot.com/2015/10/0008-personality-disorders-paranoid.html Image 7: https://theunityprocess.com/is-it-the-patriarchy-or-the-dark-triad-thats-exploiting-western-society/ Image 9: https://www.skylandtrail.org/4-differences-between-cbt-and-dbt-and-how-to-tell-which-is-right-for-you/ Image 10: Text, page 363

Video: https://www.youtube.com/watch?v=JmiARS9TIj8

Text: Whitbourne, Susan Krauss. Abnormal Psychology: Clinical Perspectives on Psychological Disorders. McGraw-Hill Higher Education.