PD

1. Personality Disorders
Chapter 13

2. Personality
•What is personality?
•Personality is a unique and long-term pattern of inner
experience and outward behavior
•Tends to be consistent and is often described in terms of
“traits”
•Also flexible, allowing us to learn and adapt to new
environments
•For those with personality disorders, however, that
flexibility is usually missing
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3. Personality Disorders
• An enduring, rigid pattern of inner experience and outward
behavior that impairs sense of self, emotional experience,
goals, and capacity for empathy and/or intimacy
• The rigid traits of people with personality disorders often lead
to psychological pain for the individual or others
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4. Personality Disorders
•A personality disorder typically becomes recognizable in
adolescence or early adulthood and symptoms last for years
•Among the most difficult psychological disorders to treat
•Many sufferers are not even aware of their personality
disorder
•Estimated that 9% to 13% of all adults may have a personality
disorder
4

5. Personality Disorders
• High comorbidity
• complicates a person’s chances for a successful recovery from
other psychological problems
5

6. Classifying Personality Disorders
• The DSM-5 identifies ten personality disorders and separates these into
three groups or “clusters”:
• Odd or eccentric behavior
• Paranoid, schizoid, and schizotypal
• Dramatic, emotional, or erratic behavior
• Antisocial, borderline, histrionic, and narcissistic
• Anxious or fearful behavior
• Avoidant, dependent, and obsessive-compulsive
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7. Classifying Personality Disorders
•This DSM listing is called a categorical approach
•It assumes that:
•Problematic personality traits are either present or absent
•A personality disorder is either displayed or not
•A person who suffers from a personality disorder is not
markedly troubled by personality traits outside of that
disorder
•It turns out, however, that these assumptions are frequently
contradicted in clinical practice
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8. Classifying Personality Disorders
• In fact, the symptom of the personality disorders overlap each other so
much that it can be difficult to distinguish one from another
• In addition, diagnosticians sometimes determine that particular individuals have more
than one personality disorder
• This lack of agreement has raised concerns about the validity (accuracy) and
reliability (consistency) of these categories
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9. Classifying Personality Disorders
Odd or eccentric
Extreme suspiciousness,
social withdrawal, and
peculiar ways of thinking
and perceiving things

10. Paranoid Personality Disorder
• Includes four or more of the following:
• Suspiciousness of others
• Unjustified doubts about disloyalty
• Reluctance to confide in others
• Reading threatening meanings into benign events
• Persistent tendency to bear grudges
• Tendency to feel attacked and counterattack
• Unjustified suspiciousness about infidelity of partner

11. Diagnostic Criteria 301.0 (F60.0)
A. A pervasive distrust and suspiciousness of others such that their
motives are interpreted as malevolent, beginning by early adulthood and
present in a variety of contexts, as indicated by four (or more) of the
following:
1. Suspects, without sufficient basis, that others are exploiting,
harming, or deceiving him or her.
2. Is preoccupied with unjustified doubts about the loyalty or
trustworthiness of friends or associates.
3. Is reluctant to confide in others because of unwarranted fear
that the information will be used maliciously against him or her.
4. Reads hidden demeaning or threatening meanings into benign
remarks or events.

12. 5. Persistently bears grudges (i.e., is unforgiving of insults, injuries, or
slights).
6. Perceives attacks on his or her character or reputation that are
not apparent to others and is quick to react angrily or to counterattack.
7. Has recurrent suspicions, without justification, regarding fidelity of
spouse or sexual partner.
B. Does not occur exclusively during the course of schizophrenia, a bipolar
disorder or depressive disorder with psychotic features, or another psychotic
disorder and is not attributable to the physiological effects of another medical
condition.
Note: If criteria are met prior to the onset of schizophrenia, add “premorbid,”
i.e., “paranoid personality disorder (premorbid)*

13. Associated Features Supporting Diagnosis
• May experience very brief psychotic episodes (lasting minutes to hours).
• In some instances, paranoid personality disorder may appear as the
premorbid antecedent of delusional disorder or schizophrenia.
• Individuals with paranoid personality disorder may develop major
depressive disorder
• May be at increased risk for agoraphobia and obsessive-compulsive
disorder.
• Alcohol and other substance use disorders frequently occur

14. PREVALENCE
• A prevalence estimate for paranoid personality based on a probability
subsample from Part II of the National Comorbidity Survey Replication
suggests a prevalence of 2.3%, while the National Epidemiologic Survey on
Alcohol and Related Conditions data suggest a prevalence of paranoid
personality disorder of 4.4%.

15. RISK AND PROGNOSTIC FACTORS
• Genetic and physiological. There is some evidence for an increased
prevalence of paranoid personality disorder in relatives of probands with
schizophrenia and for a more specific familial relationship with delusional
disorder, persecutory type.

16. DIFFERENTIAL DIAGNOSIS
• Other mental disorders with psychotic symptoms. Paranoid personality
disorder can be distinguished from delusional disorder, persecutory type;
schizophrenia; and a bipolar or depressive disorder with psychotic features
because these disorders are all characterized by a period of persistent
psychotic symptoms (e.g., delusions and hallucinations).
• Personality change due to another medical condition.
• Substance use disorders.
• Other personality disorders and personality traits.

17. Treatments for
Paranoid Personality Disorder
•People with paranoid personality disorder do not typically see
themselves as needing help
• Few come to treatment willingly
• Those who are in treatment often distrust and rebel against their
therapists
•As a result, therapy for this disorder, as for most of the other
personality disorders, has limited effect and moves slowly
17

18. Schizoid Personality Disorder
•Include four or more of the following:
• Neither desires nor enjoys close relationships
• Almost always chooses solitude
• Little if any interest in sexual relationships
• Takes pleasure in few activities
• Lacks close friends
• Indifferent to praise or criticism
• Emotional coldness, detachment or flatness

19. Diagnostic Criteria 301.20 (F60.1)
A. A pervasive pattern of detachment from social relationships and a
restricted range of expression of emotions in interpersonal settings,
beginning by early adulthood and present in a variety of contexts, as
indicated by four (or more) of the following:
1. Neither desires nor enjoys close relationships, including being
part of a family.
2. Almost always chooses solitary activities.
3. Has little, if any, interest in having sexual experiences with another
person.
4.Takes pleasure in few, if any, activities.

20. 5. Lacks close friends or confidants other than first-degree relatives.
6. Appears indifferent to the praise or criticism of others.
7. Shows emotional coldness, detachment, or flattened affectivity.
B. Does not occur exclusively during the course of schizophrenia, a bipolar
disorder or depressive disorder with psychotic features, another psychotic
disorder, or autism spectrum disorder and is not attributable to the
physiological effects of another medical condition.
Note: If criteria are met prior to the onset of schizophrenia, add
“premorbid,” i.e., “schizoid personality disorder (premorbid).”

21. •Schizotypal Personality Disorder
Five or more of the following:
Ideas of reference
Odd beliefs or magical thinking
Unusual perceptual experiences
Odd thinking and speech
Suspiciousness or paranoid ideas
Inappropriate or constricted affect
Odd, eccentric or peculiar behavior or
appearance
Lack of close friends
Excessive social anxiety

22. How DoTheorists Explain
Schizotypal Personality Disorder?
• Because the symptoms of schizotypal personality disorder so often
resemble those of schizophrenia, researchers have hypothesized that
similar factors are at work in both disorders
• Schizotypal symptoms are often linked to family conflicts and to psychological
disorders in parents
• Researchers have also begun to link schizotypal personality disorder to some of the
same biological factors found in schizophrenia, such as high dopamine activity
• The disorder has also been linked to mood disorders, especially depression
22

23. Treatments for
Schizotypal Personality Disorder
• Therapy is as difficult in cases of schizotypal personality disorder, as in cases
of paranoid and schizoid personality disorders
• Most therapists agree on the need to help clients “reconnect” and recognize
the limits of their thinking and powers
• Cognitive-behavioral therapists further try to teach clients to objectively evaluate their
thoughts and perceptions and provide speech lessons and social skills training
• Antipsychotic drugs appear to be somewhat helpful in reducing certain
thought problems
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24. “Dramatic” Personality Disorders
• Behaviors so dramatic, emotional, or erratic that it is almost impossible for
them to have relationships that are truly giving and satisfying
• More commonly diagnosed than the others
• Only antisocial and borderline personality disorders have received much study
• Causes of the disorders not well understood
• Treatments range from ineffective to moderately effective
24

25. Antisocial Personality Disorder
Includes three or more of the following:
• Failure to conform to lawful behavior
• Deceitfulness
• Impulsivity
• Irritability or aggressiveness
• Reckless disregard for safety of self and
others
• Consistent irresponsibility
• Lack of remorse

26. Antisocial Personality Disorder
• Aside from substance use disorders, this is the disorder most linked to adult
criminal behavior
• The DSM-5 requires that a person be at least 18 years of age to receive this
diagnosis
• Most people with an antisocial personality disorder displayed some patterns of
misbehavior before they were 15 years old (conduct disorder).
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27. Antisocial Personality Disorder
•4 times more common in men than women
•Often arrested, therefore researchers frequently
look at prison populations
•Higher rates of alcoholism/substance use
disorders
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28. How DoTheorists Explain
Antisocial Personality Disorder?
• Psychodynamic theorists propose that this disorder begins with an absence
of parental love, leading to a lack of basic trust; Lack of superego
• Many behaviorists have suggested that antisocial symptoms may be learned
through modeling or unintentional reinforcement
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29. How DoTheorists Explain
Antisocial Personality Disorder?
• Cognitive view says that people with the disorder hold attitudes that
trivialize the importance of other people’s needs
• Biological factors may play a role:
• Lower levels of serotonin, impacting impulsivity and aggression
• Deficient functioning in the frontal lobes of the brain
• Lower levels of anxiety and arousal, leading them to be more likely than others to take
risks and seek thrills
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30. Treatments for
Antisocial Personality Disorder
• Treatments are typically ineffective
• A major obstacle is the individual’s lack of conscience or desire to change
• Most have been forced to come to treatment
• Some cognitive therapists try to guide clients to think about moral issues and the
needs of other people
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31. Borderline Personality Disorder
Five or more of the following:
Frantic efforts to avoid abandonment
Unstable and intense relationships
Unstable self image
Impulsivity (self destructive)
Suicidal behavior
Affective instability
Chronic feelings of emptiness
Inappropriate, intense anger

32. Borderline Personality Disorder
•Close to 75% of those diagnosed are women
•Highly comorbid
•The course of the disorder varies
•In the most common pattern, the instability and risk of suicide
reach a peak during young adulthood and then gradually
wane with advancing age
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33. How DoTheorists Explain Borderline
Personality Disorder?
•Because a fear of abandonment tortures so many people
with the disorder, psychodynamic theorists look to early
parental relationships to explain the disorder
•Lack of early acceptance or abuse/neglect by parents
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34. How DoTheorists Explain Borderline
Personality Disorder?
•Biological abnormalities: such as an overly reactive amygdala and
an underactive prefrontal cortex
•In addition, sufferers who are particularly impulsive
apparently have lower brain serotonin activity
•Close relatives of those with borderline personality disorder
are 5 times more likely than the general population to have
the disorder
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35. Treatments for
Borderline Personality Disorder
•It appears that psychotherapy can eventually lead to
some degree of improvement for people with this
disorder
•It is extraordinarily difficult, though, for a therapist to
strike a balance between empathizing with a patient’s
dependency and anger and challenging his or her way
of thinking 35

36. Treatments for
Borderline Personality Disorder
• “Dialectical behavior therapy”
•Largely from the cognitive-behavioral treatment model
and borrows heavily from zen buddism.
•DBT is often supplemented by the clients’
participation in social skill-building groups
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37. Treatments for
Borderline Personality Disorder
•Antidepressant, mood stabilizing, antianxiety, and
antipsychotic drugs have helped some individuals to
calm their emotional and aggressive storms
•Given the numerous suicide attempts by these
patients, their use of drugs on an outpatient basis is
controversial
•Most clients seem to benefit from a combination of drug
therapy and psychotherapy 37

38. Histrionic Personality Disorder
Five or more of the following:
Uncomfortable if not the center of attention
Inappropriately seductive or provocative
Rapidly shifting and shallow emotions
Use of appearance to draw attention
Speech is impressionistic and lacking in detail
Self-dramatization, theatricality
Suggestibility
Considers relationships more intimate than they
are

39. How DoTheorists Explain
Histrionic Personality Disorder?
•Most psychodynamic theorists believe that, as
children, people with this disorder experienced
unhealthy relationships in which cold parents left
them feeling unloved
•To defend against deep-seated fears of loss, the
individuals learned to behave dramatically, inventing
crises that would require people to act protectively39

40. Treatments for
Histrionic Personality Disorder
•Unlike people with most other personality disorders,
more likely to seek treatment on their own
•Working with them can be difficult because of their
demands, tantrums, seductiveness, and attempts to
please the therapist
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41. •Narcissistic Personality Disorder
• Five or more of the following:
• Grandiose sense of self-importance
• Preoccupied with fantasies of unlimited success,
power, brilliance, etc.
• Belief that he or she is “special”
• Requires excessive admiration
• Sense of entitlement
• Interpersonally exploitative
• Lacks empathy
• Often envious
• Arrogant or haughty

42. How DoTheorists Explain
Narcissistic Personality Disorder?
•Psychodynamic theorists more than others have theorized about
this disorder, focusing on cold, rejecting parents
•Interpret this grandiose self-presentation as a way for people
with this disorder to convince themselves that they are self-
sufficient and without need of warm relationships
•Research has found increased risk for developing the disorder
among abused children and those who lost parents through
adoption, divorce, or death 42

43. How DoTheorists Explain
Narcissistic Personality Disorder?
•Cognitive-behavioral theorists propose that narcissistic
personality disorder may develop when people are
treated too positively rather than too negatively in early
life
•Those with the disorder have been taught to
“overvalue their self-worth”
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44. “Anxious” Personality Disorders
•People with these disorders typically display anxious and fearful
behavior
•Although many of the symptoms are similar to those of anxiety
and depressive disorders, researchers have found no direct links
between this cluster and those diagnoses
•As with most of the personality disorders, research is very limited
•But treatments for this cluster appear to be modestly to
moderately helpful, considerably better than for other
personality disorders
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45. Avoidant Personality Disorder
Four or more of the following:
Avoids activities due to fear of criticism,
disapproval or rejection
Unwilling to get involved with people unless certain
of being liked
Restrained in relationships due to fear of being
shamed or ridiculed
Preoccupied with criticism or rejection in social
situations
Inhibited in new situations due to feelings of
inadequacy
Views self as inept, unappealing, inferior
Reluctant to take personal risks

46. How DoTheorists Explain
Avoidant Personality Disorder?
•Theorists often assume that avoidant personality disorder has
the same causes as anxiety disorders, including:
•Early trauma
•Conditioned fears
•Upsetting beliefs
•Biochemical abnormalities
•Research has not directly tied the personality disorder to the
anxiety disorders 46

47. How DoTheorists Explain
Avoidant Personality Disorder?
•Cognitive theorists believe that harsh criticism and
rejection in early childhood may lead people to
assume that their environment will always judge
them negatively
47

48. Dependent Personality Disorder
•People with dependent personality disorder have a
pervasive, excessive need to be taken care of
•As a result, they are clinging and obedient, fearing
separation from their loved ones
•They rely on others so much that they cannot make
the smallest decision for themselves
•The central feature of the disorder is a difficulty with
separation
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49. Dependent Personality Disorder
Five or more of the following:
Excessive need for advice and reassurance to make
decisions
Needs others to assume responsibility for most areas
of life
Difficulty expressing disagreement
Difficulty initiating or doing things on own
Goes to excessive lengths for nurturance or support
Feels helpless when alone, due to exaggerated fears
of being unable to care for self
Urgently seeks new relationship if close relationship
ends
Preoccupied with fears of being left to care for self

50. Obsessive-Compulsive Personality Disorder
Personality traits involving
preoccupation with
orderliness, perfectionism,
and control at the expense
of spontaneity, flexibility,
and enjoyment

51. Obsessive-Compulsive Personality Disorder
Four or more of the following:
Preoccupation with rules, lists, order, schedules, etc.
Perfectionism
Excessive devotion to work and productivity
Over-conscientious, scrupulous, inflexible about morality
Inability to discard worn-out or worthless objects
Reluctance to delegate tasks or work with
others unless they submit to exactly his or
her way of doing things
Miserly spending style
Rigidity and stubbornness