Personality disorders

Personality Disorders
Dan Andrei Elbambuena Navarro Navarette
Bagao, RPm

This chapter begins with a general definition of
personality disorder that applies to each of the
10 specific personality disorders. A personality
disorder is an enduring pattern of inner
experience and behavior that deviates markedly
from the expectations of the individual's
culture, is pervasive and inflexible, has an onset
in adolescence or early adulthood, is stable over
time, and leads to distress or impairment.

The following personality disorders are included in this
chapter.
• Paranoid personality disorder is a pattern of distrust and
suspiciousness such that others‘ motives are interpreted
as malevolent.
• Schizoid personality disorder is a pattern of detachment
from social relationships and a restricted range of
emotional expression.
• Schizotypal personality disorder is a pattern of acute
discomfort in close relationships, cognitive or perceptual
distortions, and eccentricities of behavior.
• Antisocial personality disorder is a pattern of disregard
for, and violation of, the rights of others.

• Borderline personality disorder is a pattern of
instability in interpersonal relationships, self-image, and
affects, and marked impulsivity.
• Histrionic personality disorder is a pattern of excessive
emotionality and attention seeking.
• Narcissistic personality disorder is a pattern of
grandiosity, need for admiration, and lack of empathy.
• Avoidant personality disorder is a pattern of social
inhibition, feelings of inadequacy, and hypersensitivity to
negative evaluation.
• Dependent personality disorder is a pattern of
submissive and clinging behavior related to an excessive
need to be taken care of.

• Obsessive-compulsive personality disorder is a pattern of
preoccupation with orderliness, perfectionism, and control.
• Personality change due to another medical condition is a
persistent personality disturbance that is judged to be due to
the direct physiological effects of a medical condition (e.g.,
frontal lobe lesion).
• Other specified personality disorder and unspecified
personality disorder is a category provided for two
situations: 1) the individual's personality pattern meets the
general criteria for a personality disorder, and traits of several
different personality disorders are present, but the criteria for
any specific personality disorder are not met; or 2) the
individual's personality pattern meets the general criteria for a
personality disorder, but the individual is considered to have a
personality disorder that is not included in the DSM-5
classification (e.g., passive-aggressive personality disorder).

General Personal ity Disorder
Criteria
A. A n enduring pattern o f inner experience and
behavior that deviates markedly from the expectations
of the individual's culture. This pattern is manifested
in two (or more) of the following areas:
1 . Cognition ( i . e . , ways of perceiving and
interpreting self, other people, and events).
2 . Affectivity (i.e., the range, intensity, lability, and
appropriateness of emotional response).
3. Interpersonal functioning.
4. Impulse control.

B. The enduring pattern is inflexible and pervasive across a
broad range of personal and social situations.
C. The enduring pattern leads to clinically significant
distress or impairment in social, occupational, or other
important areas of functioning.
D. The pattern is stable and of long duration, and its onset
can be traced back at least to
adolescence ,or early adulthood.
E. The enduring pattern is not better explained as a
manifestation or consequence of another
mental disorder.
F. The enduring pattern is not attributable to the
physiological effects of a substance (e. g . ,
a drug o f abuse, a medication) or another medical condition
(e. g . , head trauma) .

Introduction
Each of us has a personality—a set of uniquely
expressed characteristics that influence our behaviors,
emotions, thoughts, and interactions. Our particular
characteristics, often called personality traits, lead
us to react in fairly predictable ways as we move
through life. Yet our personalities are also flexible.
We learn from experience. As we interact with our
surroundings, we try out various responses to see
which feel better and which are more effective. This is
a flexibility that people who suffer from a personality
disorder usually do not have.

Introduction
People with a personality disorder display an
enduring, rigid pattern of inner experience and
outward behavior that impairs their sense of
self, emotional experiences, goals, capacity for
empathy, and/or capacity for intimacy. Put
another way, they have personality traits that are
much more extreme and dysfunctional than those
of most other people in their culture, leading to
significant problems and psychological pain for
themselves or others.

Introduction
The symptoms of personality disorders last for years
and typically become recognizable in adolescence or
early adulthood, although some start during childhood
(APA, 2013; Westen et al., 2011). These disorders are
among the most difficult psychological disorders to
treat. Many people with the disorders are not even
aware of their personality problems and fail to trace
their difficulties to their maladaptive style of thinking
and behaving. Surveys indicate that between 10 and
15 percent all adults in the United States have a
personality disorder (APA,
2013; Sansone & Sansone, 2011).

Introduction
It is common for a person with a personality
disorder to also suffer from another disorder, a
relationship called comorbidity. For example,
many people with avoidant personality disorder,
who fearfully shy away from all relationships, also
display social anxiety disorder. Perhaps avoidant
personality disorder predisposes people to develop
social anxiety disorder. Or perhaps social anxiety
disorder sets the stage for the personality disorder.

Introduction
Then again, some biological factor may create a
predisposition to both the personality disorder and
the anxiety disorder. Whatever the reason for the
relationship, research indicates that the presence of
a personality disorder complicates a person’s
chances for a successful recovery from other
psychological problems (Fok et al., 2014; Abbass
et al., 2011).

Introduction
DSM-5, like its predecessor, DSM-IV-TR, identifies
10 personality disorders (APA, 2013). Often these
disorders are separated into three groups, or clusters.
One cluster, marked by odd or eccentric behavior,
consists of the paranoid, schizoid, and schizotypal
personality disorders. A second cluster features
dramatic behavior and consists of the antisocial,
borderline, histrionic, and narcissistic personality
disorders. The final cluster features a high degree of
anxiety and includes the avoidant, dependent, and
obsessive-compulsive personality disorders.

Introduction
The DSM’s listing of 10 distinct personality
disorders is called a categorical approach. Like a
light switch that is either on or off, this kind of
approach assumes that
(1)problematic personality traits are either present
or absent in people
(2) a personality disorder is either displayed or not
displayed by a person, and (3) a person who
suffers from a personality disorder is not markedly
troubled by personality traits outside of that
disorder.

“Odd” Personality Disorders
The cluster of “odd” personality disorders consists of
the paranoid, schizoid, and schizotypal personality
disorders. People with these disorders typically have
odd or eccentric behaviors that are similar to but not
as extensive as those seen in schizophrenia, including
extreme suspiciousness, social withdrawal, and
peculiar ways of thinking and perceiving things. Such
behaviors often leave the person isolated. Some
clinicians believe that these personality disorders are
related to schizophrenia.

In fact, schizotypal personality disorder is listed
twice in DSM-5—as one of the schizophrenia
spectrum disorders and as one of the personality
disorders (Rosell et al., 2014; APA, 2013).
Directly related or not, people with an odd cluster
personality disorder often qualify for an additional
diagnosis of schizophrenia or have close relatives
with schizophrenia (Chemerinski & Siever, 2011).

Clinicians have learned much about the
symptoms of the odd cluster personality
disorders but have not been so successful in
determining their causes or how to treat
them. In fact, as you’ll soon see, people with
these disorders rarely seek treatment.

Paranoid Personality Disorder
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.

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)."

People with paranoid personality disorder deeply
distrust other people and are suspicious of their
motives (APA, 2013). Because they believe that
everyone intends them harm, they shun close
relationships. They find “hidden” meanings, which
are usually belittling or threatening, in everything.
In a study that required people to role-play,
participants with paranoia were more likely than
control participants to read hostile intentions into
the actions of others (Turkat et al., 1990). In
addition, they more often chose anger as the
appropriate role-play response.

Quick to challenge the loyalty or trustworthiness
of acquaintances, people with paranoid
personality disorder remain cold and distant. A
woman might avoid confiding in anyone, for
example, for fear of being hurt; or a husband
might, without any justification, persist in
questioning his wife’s faithfulness. Although
inaccurate and inappropriate, their suspicions are
not usually delusional; the ideas are not so
bizarre or so firmly held as to clearly remove the
individuals from reality (Millon, 2011).

People with this disorder are critical of weakness
and fault in others, particularly at work (McGurk et
al., 2013). They are unable to recognize their own
mistakes, though, and are extremely sensitive to
criticism. They often blame others for the things that
go wrong
in their lives, and they repeatedly bear grudges
(Rotter, 2011). As many as 4.4 percent of adults in
the United States experience this disorder, which is
apparently more common in men than in women
(APA, 2013; Sansone & Sansone, 2011).

How Do Theorists Explain Paranoid
Personality Disorder?
Psychodynamic theories, the oldest of these
explanations, trace the pattern to early interactions
with demanding parents, particularly distant, rigid
fathers and overcontrolling, rejecting mothers
(Caligor & Clarkin, 2010; Williams, 2010). (You
will see that psychodynamic explanations for almost
all the personality disorders begin the same way—
with repeated mistreatment during childhood and
lack of love.) According to one psychodynamic
view, some people come to view their environment
as hostile as a result of their parents’ persistently
unreasonable demands.

They must always be on the alert because they
cannot trust others, and they are likely to develop
feelings of extreme anger. They also project
these feelings onto others and, as a result, feel
increasingly persecuted (Koenigsberg et al.,
2001). Similarly, some cognitive theorists
suggest that people with paranoid personality
disorder generally hold broad maladaptive
assumptions, such as “People are evil” and
“People will attack you if given the chance”
(Beck & Weishaar, 2014; Weishaar & Beck,
2006; Beck et al., 2004).

Biological theorists propose that paranoid
personality disorder has genetic causes (APA,
2013; Bernstein & Useda, 2007). An early study
that looked at self-reports of suspiciousness in
3,810 Australian twin pairs found that if one twin
was excessively suspicious, the other had an
increased likelihood of also being suspicious
(Kendler et al., 1987). Once again, however, it is
important to note that such similarities
between twins might also be the result of
common environmental experiences.

Treatments for Paranoid Personality
Disorder People
People with paranoid personality disorder do not
typically see themselves as needing help, and
few come to treatment willingly (Millon, 2011).
Furthermore, many who are in treatment view
the role of patient as inferior and distrust and
rebel against their therapists (Kellett & Hardy,
2013; Bender, 2005). Thus it is not surprising
that therapy for this disorder, as for most other
personality disorders, has limited effect and
moves very slowly (Piper & Joyce, 2001).

Disorder People
Object relations therapists—the psychodynamic therapists
who give center stage to relationships—try to see past the
patient’s anger and work on what they view as his or her
deep wish for a satisfying relationship (Caligor & Clarkin,
2010; Salvatore et al., 2005). Self-therapists the
psychodynamic clinicians who focus on the need for a
healthy and unified self—try to help clients reestablish
self- cohesion (a unified personality), which they believe
has been lost in the person’s continuing negative focus on
others (Vermote et al., 2010; Silverstein, 2007).

Disorder People
Cognitive and behavioral techniques have also been used
to treat people with paranoid personality disorder, and are
often combined into an integrated cognitive-behavioral
approach. On the behavioral side, therapists help clients to
master anxiety-reduction techniques and to improve their
skills at solving interpersonal problems. On the cognitive
side, therapists guide the clients to develop more realistic
interpretations of other people’s words and actions and to
become more aware of other people’s points of view
(Kellett & Hardy, 2013; Leahy, Beck, & Beck, 2005).
Antipsychotic drug therapy seems to be of limited help
(Birkeland, 2013; Silk & Jibson, 2010).

Schizoid Personality Disorder
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.
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) ."

People with schizoid personality disorder
persistently avoid and are removed from social
relationships and demonstrate little in the way of
emotion (APA, 2013). Like people with paranoid
personality disorder, they do not have close ties
with other people. The reason they avoid social
contact, however, has nothing to do with
paranoid feelings of distrust or suspicion; it is
because they genuinely prefer to be alone.

People with this personality disorder often described
as “loners,” make no effort to start or keep
friendships, take little interest in having sexual
relationships, and even seem indifferent to their
families. They seek out jobs that require little or no
contact with others. When necessary, they can form
work relations to a degree, but they prefer to keep to
themselves. Many live by themselves as well. Not
surprisingly, their social skills tend to be weak. If
they marry, their lack of interest in intimacy may
create marital or family problems.

People with schizoid personality disorder focus
mainly on themselves and are generally unaffected
by praise or criticism. They rarely show any
feelings, expressing neither joy nor anger. They
seem to have no need for attention or acceptance;
are typically viewed as cold, humorless, or dull; and
generally succeed in being ignored. This disorder is
present in 3.1 percent of the adult population (APA,
2013; Sansone & Sansone, 2011). Men are slightly
more likely to experience it than are women, and
men may also be more impaired by it.

How Do Theorists Explain Schizoid
Many psychodynamic theorists, particularly object relations
theorists, propose that schizoid personality disorder has its
roots in an unsatisfied need for human contact (Caligor &
Clarkin, 2010; Kernberg & Caligor, 2005). The parents of
people with this disorder, like those of people with paranoid
personality disorder, are believed to have been unaccepting
or even abusive of their children. Whereas people with
paranoid symptoms react to such parenting chiefly with
distrust, those with schizoid personality disorder are left
unable to give or receive love. They cope by avoiding all
relationships.

How Do Theorists Explain Schizoid
Cognitive theorists propose, not surprisingly, that
people with schizoid personality disorder suffer
from deficiencies in their thinking. Their thoughts
tend to be vague, empty, and without much
meaning, and they have trouble scanning the
environment to arrive at accurate perceptions
(Kramer & Meystre, 2010). Unable to pick up
emotional cues from others, they simply cannot
respond to emotions. As this theory might predict,
children with schizoid personality disorder develop
language and motor skills very slowly, whatever
their level of intelligence (APA, 2013; Wolff, 2000,
1991).

Treatments for Schizoid Personality
Disorder
Their social withdrawal prevents most people
with schizoid personality disorder from entering
therapy unless some other disorder, such as
alcoholism, makes treatment necessary (Mittal et
al., 2007). These clients are likely to remain
emotionally distant from the therapist, seem not
to care about their treatment, and make limited
progress at best (Colli et al., 2014; Millon, 2011).

Disorder
Cognitive-behavioral therapists have sometimes
been able to help people with this disorder
experience more positive emotions and more
satisfying social interactions (Beck & Weishaar,
2011; Weishaar & Beck, 2006; Beck et al.,
2004). On the cognitive end, their techniques
include presenting clients with lists of emotions
to think about or having them write down and
remember pleasurable experiences.

Disorder
On the behavioral end, therapists have sometimes
had success teaching social skills to such clients,
using role-playing, exposure techniques, and
homework assignments as tools. Group therapy
is apparently useful when it offers a safe setting
for social contact, although people with schizoid
personality disorder may resist pressure to take
part (Piper & Joyce, 2001). As with paranoid
personality disorder, drug therapy seems to offer
limited help (Silk & Jibson, 2010; Koenigsberg
et al., 2002).

Schizotypal Personality Disorder
A. A pervasive pattern of social and interpersonal deficits marked by
acute discomfort with, and reduced capacity for, close relationships as
well as by cognitive or perceptual distortions and eccentricities of
behavior, beginning by early adulthood and present in a variety of
contexts, as indicated by five (or more) of the following:
1 . Ideas of reference (excluding delusions of reference) .
2. Odd beliefs or magical thinking that influences behavior and is
inconsistent with subcultural norms (e.g. , superstitiousness, belief in
clairvoyance, telepathy, or "sixth sense"; in children and adolescents,
bizarre fantasies or preoccupations) .
3. Unusual perceptual experiences, including bodily illusions.

4. Odd thinking and speech (e. g . , vague, circumstantial,
metaphorical , overelaborate , or stereotyped ) .
5. Suspiciousness or paranoid ideation .
6. Inappropriate or constricted affect.
7. Behavior or appearance that is odd , eccentric, or peculiar.
8. Lack of close friends or confidants other than first-degree relatives.
9. Excessive social anxiety that does not diminish with familiarity and
tends to be associated with paranoid fears rather than negative
judgments about self.
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.
Note: If criteria are met prior to the onset of schizophrenia, add
"premorbid," e . g . , "schizotypal personality disorder (premorbid)."

People with schizotypal personality disorder
display a range of interpersonal problems
marked by extreme discomfort in close
relationships, very odd patterns of thinking
and perceiving, and behavioral eccentricities
(APA, 2013). Anxious around others, they
seek isolation and have few close friends.
Some feel intensely lonely.

People with schizotypal personality disorder can be
noticeably disturbed. These symptoms may include ideas
of reference— beliefs that unrelated events pertain to
them in some important way— and bodily illusions, such
as sensing an external “force” or presence. A number of
people with this disorder see themselves as having special
extrasensory abilities, and some believe that they have
magical control over others. Examples of schizotypal
eccentricities include repeatedly arranging cans to align
their labels, organizing closets extensively, or wearing an
odd assortment of clothing. The emotions of these
individuals may be inappropriate, flat, or humorless.

People with schizotypal personality disorder often have
great difficulty keeping their attention focused.
Correspondingly, their conversation is typically digressive
and vague, even sprinkled with loose associations (Millon,
2011). They tend to drift aimlessly and lead an idle,
unproductive life (Hengartner et al., 2014). They are likely
to choose undemanding jobs in which they can work below
their capacity and are not required to interact with other
people. Surveys suggest that 3.9 percent of adults—slightly
more males than females—display schizotypal personality
disorder (Rosell et al., 2014; Sansone & Sansone, 2011).

How Do Theorists Explain Schizotypal
Because the symptoms of schizotypal personality disorder
so often resemble those of schizophrenia, researchers have
hypothesized that similar factors may be at work in both
disorders. A wide range of studies have supported such
expectations (Hazlett et al., 2014; Rosell et al., 2014;
Thompson et al., 2014). Investigators have found that
schizotypal symptoms, like schizophrenic patterns, are often
linked to family conflicts and to psychological disorders in
parents. They have also learned that defects in attention and
short-term memory may contribute to schizotypal
personality disorder, just as they apparently do to
schizophrenia.

For example, research participants with either disorder
perform poorly on backward masking, a laboratory test of
attention that requires a person to identify a visual
stimulus immediately after a previous stimulus has
flashed on and off the screen. People with these disorders
have a hard time shutting out the first stimulus in order to
focus on the second. Finally, researchers have linked
schizotypal personality disorder to some of the same
biological factors found in schizophrenia, such as high
activity of the neurotransmitter dopamine, enlarged brain
ventricles, smaller temporal lobes, and loss of gray matter
(Ettinger et al., 2014).

Although these findings do suggest a close relationship
between schizotypal personality disorder and
schizophrenia, the personality disorder also has been
linked to disorders of mood (Lentz, Robinson, & Bolton,
2010). More than half of people with schizotypal
personality disorder also suffer from major depressive
disorder at some point in their lives (APA, 2013).
Moreover, relatives of people with depression have a
higher than usual rate of schizotypal personality disorder,
and vice versa. Thus, at the very least, this personality
disorder is not tied exclusively to schizophrenia.

Treatments for Schizotypal Personality
Disorder
Therapy is as difficult in cases of schizotypal personality
disorder as it is in cases of paranoid and schizoid
personality disorders. Most therapists agree on the need to
help these clients “reconnect” with the world and
recognize the limits of their thinking and their powers.
The therapists may thus try to set clear limits—for
example, by requiring punctuality—and work on helping
the clients recognize where their views end and those of
the therapist begin. Other therapy goals are to increase
positive social contacts, ease loneliness, reduce
overstimulation, and help the individuals become more
aware of their personal feelings (Colli et al., 2014; Sperry,
2003; Piper & Joyce, 2001).

Disorder
Cognitive-behavioral therapists further combine cognitive
and behavioral techniques to help people with schizotypal
personality disorder function more effectively. Using
cognitive interventions, they try to teach clients to evaluate
their unusual thoughts or perceptions objectively and to
ignore the inappropriate ones (Beck & Weishaar, 2011;
Weishaar & Beck, 2006; Beck et al., 2004). Therapists may
keep track of clients’ odd or magical predictions, for
example, and later point out their inaccuracy. When clients
are speaking and begin to digress, the therapists might ask
them to sum up what they are trying to say.

Disorder
In addition, specific behavioral methods,
such as speech lessons, social skills training,
and tips on appropriate dress and manners,
have sometimes helped clients learn to blend
in better with and be more comfortable
around others (Farmer & Nelson-Gray,
2005).

Disorder
Antipsychotic drugs have been given to
people with schizotypal personality disorder,
again because of the disorder’s similarity to
schizophrenia. In low doses the drugs appear
to have helped some people, usually by
reducing certain of their thought problems
(Rosenbluth & Sinyor, 2012; Silk & Jibson,
2010).

“Dramatic” Personality Disorders
The cluster of “dramatic” personality
disorders includes the antisocial, borderline,
histrionic, and narcissistic personality
disorders. The behaviors of people with these
problems are so dramatic, emotional, or
erratic that it is almost impossible for them
to have relationships that are truly giving and
satisfying.

“Dramatic” Personality Disorders
These personality disorders are more commonly
diagnosed than the others. However, only the
antisocial and borderline personality disorders
have received much study, partly because they
create so many problems for other people. The
causes of the disorders, like those of the odd
personality disorders, are not well understood.
Treatments range from ineffective to moderately
effective.

Antisocial Personality Disorder
A. A pervasive pattern of disregard for and violation of
the rights of others, occurring since age 1 5 years, as
indicated by three (or more) of the following:
1 . Failure to conform to social norms with respect to
lawful behaviors, as indicated by repeatedly performing
acts that are grounds for arrest.
2. Deceitfulness, as indicated by repeated lying, use of
aliases, or conning others for
personal profit or pleasure.
3. Impulsivity or failure to plan ahead .
4. Irritability and aggressiveness, as indicated by repeated
physical fights or assaults.

5. Reckless disregard for safety of self or others.
6. Consistent irresponsibility, as indicated by repeated
failure to sustain consistent
work behavior or honor financial obligations.
7. Lack of remorse, as indicated by being indifferent to or
rationalizing having hurt,
mistreated, or stolen from another.
B. The individual is at least age 1 8 years.
C. There is evidence of conduct disorder with onset
before age 1 5 years.
D . The occurrence of antisocial behavior is not
exclusively during the course of schizophrenia or bipolar
disorder.

Sometimes described as “psychopaths” or
“sociopaths,” people with antisocial personality
disorder persistently disregard and violate others’
rights (APA, 2013). Aside from substance use
disorders, this is the disorder most closely linked to
adult criminal behavior. DSM-5 stipulates that a
person must be at least 18 years of age to receive
this diagnosis; however, most people with antisocial
personality disorder displayed some patterns of
misbehavior before they were 15, including truancy,
running away, cruelty to animals or people, and
destroying property.

People with antisocial personality disorder lie
repeatedly (APA, 2013). Many cannot work
consistently at a job; they are absent frequently
and are likely to quit their jobs altogether
(Hengartner et al., 2014). Usually they are also
careless with money and frequently fail to pay
their debts. They are often impulsive, taking
action without thinking of the consequences
(Millon, 2011). Correspondingly, they may be
irritable, aggressive, and quick to start fights.
Many travel from place to place.

Recklessness is another common trait: people with
antisocial personality disorder have little regard for their
own safety or for that of others, even their children. They
are self-centered as well, and are likely to have trouble
maintaining close relationships. Usually they develop a
knack for gaining personal profit at the expense of other
people. Because the pain or damage they cause seldom
concerns them, clinicians commonly say that they lack a
moral conscience. They think of their victims as weak and
deserving of being conned, robbed, or even physically
harmed (see PsychWatch on page 534).

Surveys indicate that 3.6 percent of adults in
the United States meet the criteria for
antisocial personality disorder (Sansone &
Sansone, 2011). The disorder is as much as
four times more common among men than
women.

Because people with this disorder are often arrested,
researchers frequently look for people with antisocial
patterns in prison populations (Pondé et al., 2014; Black
et al., 2010). It is estimated that at least 40 percent of
people in prison meet the diagnostic criteria for this
disorder (Naidoo & Mkize, 2012). Among men in urban
jails, the antisocial personality pattern has been linked
strongly to past arrests for crimes of violence (De Matteo
et al., 2005). The criminal behavior of many people with
this disorder declines after the age of 40; some, however,
continue their criminal activities throughout their lives
(APA, 2013).

Studies and clinical observations also indicate
that people with antisocial personality disorder
have higher rates of alcoholism and other
substance use disorders than do the rest of the
population (Brook et al., 2014; Reese et al.,
2010). Perhaps intoxication and substance
misuse help trigger the development of antisocial
personality disorder by loosening a person’s
inhibitions.

Perhaps this personality disorder somehow
makes a person more prone to abuse substances.
Or perhaps antisocial personality disorder and
substance use disorders both have the same
cause, such as a deep-seated need to take risks.
Interestingly, drug users with the personality
disorder often cite the recreational aspects of
drug use as their reason for starting and
continuing it.

It appears that children with conduct disorder and an
accompanying attentiondeficit/ hyperactivity disorder
have a heightened risk of developing antisocial
personality disorder (APA, 2013; Black et al., 2010). Like
adults with antisocial personality disorder, children with a
conduct disorder persistently lie and violate rules and
other people’s rights, and children with attention-
deficit/hyperactivity disorder lack foresight and judgment
and fail to learn from experience. Intriguing as these
observations may be, however, the precise connection
between the childhood disorders and antisocial
personality disorder has been difficult to pinpoint.

How Do Theorists Explain Antisocial
Explanations of antisocial personality
disorder come from the psychodynamic,
behavioral, cognitive, and biological models.
As with many other personality disorders,
psychodynamic theorists propose that this
one begins with an absence of parental love
during infancy, leading to a lack of basic
trust (Meloy & Yakeley, 2010; Sperry, 2003).

In this view, some children—the ones who develop
antisocial personality disorder—respond to the early
inadequacies by becoming emotionally distant, and
they bond with others through the use of power and
destructiveness. In support of the psychodynamic
explanation, researchers have found that people with
this disorder are more likely than others to have had
significant stress in their childhoods, particularly in
such forms as family poverty, family violence, child
abuse, and parental conflict or divorce (Kumari et
al., 2014; Martens, 2005).

Many behavioral theorists have suggested that antisocial
symptoms may be learned through modeling, or imitation
(Gaynor & Baird, 2007). As evidence, they point to the
higher rate of antisocial personality disorder found among
the parents of people with this disorder (APA, 2013; Paris,
2001). Other behaviorists have suggested that some
parents unintentionally teach antisocial behavior by
regularly rewarding a child’s aggressive behavior
(Kazdin, 2005). When the child misbehaves or becomes
violent in reaction to the parents’ requests or orders, for
example, the parents may give in to restore peace.
Without meaning to, they may be teaching the child to be
stubborn and perhaps even violent.

The cognitive view says that people with
antisocial personality disorder hold attitudes that
trivialize the importance of other people’s needs
(Elwood et al., 2004). Such a philosophy of life,
some theorists suggest, may be far more common
in our society than people recognize. Cognitive
theorists further propose that people with this
disorder have genuine difficulty recognizing
points of view or feelings other than their own (
Herpertz & Bertsch, 2014).

Finally, studies suggest that biological factors may
play an important role in antisocial personality
disorder. Researchers have found that antisocial
people, particularly those who are highly impulsive
and aggressive, have lower serotonin activity than
other people (Thompson, Ramos, & Willett, 2014;
Patrick, 2007). As you’ll recall (see page 300), both
impulsivity and aggression also have been linked to
low serotonin activity in other kinds of studies, so
the presence of this biological factor in people with
antisocial personality disorder is not surprising.

Other studies indicate that individuals with this
disorder display deficient functioning in their
frontal lobes, particularly in the prefrontal cortex
(Liu et al., 2014; Thompson et al., 2014). Among
other duties, this brain region helps people to
plan and execute realistic strategies and to have
personal characteristics such as sympathy,
judgment, and empathy. These are, of course, all
qualities found wanting in people with antisocial
personality
disorder.

In yet another line of research, investigators
have found that people with antisocial
personality disorder often feel less anxiety
than other people, and so lack a key
ingredient for learning (Blair et al., 2005).
This would help explain why they have so
much trouble learning from negative life
experiences or tuning in to the emotional
cues of others.

Why should people with antisocial personality
disorder experience less anxiety than other
people? The answer may lie once again in the
biological realm. Research participants with the
disorder often respond to warnings or
expectations of stress with low brain and bodily
arousal, such as slow autonomic arousal and
slow EEG waves (Thompson et al., 2014;
Perdeci et al., 2010). Perhaps because of the low
arousal, they easily tune out threatening or
emotional situations, and so are unaffected by
them.

It could also be argued that because of their
physical underarousal, people with antisocial
personality disorder would be more likely than
other people to take risks and seek thrills. That is,
they may be drawn to antisocial activity precisely
because it meets an underlying biological need
for more excitement and arousal. In support of
this idea, as you read earlier, antisocial
personality disorder often goes hand in hand with
sensation-seeking behavior.

Treatments for Antisocial Personality
Disorder
Treatments for people with antisocial personality
disorder are typically ineffective (Millon, 2011;
Meloy & Yakeley, 2010). Major obstacles to
treatment include the individuals’ lack of
conscience, desire to change, or respect for
therapy (Colli et al., 2014; Kantor, 2006). Most
of those in therapy have been forced to
participate by an employer, their school, or the
law, or they come to the attention of therapists
when they also develop another psychological
disorder (Agronin, 2006).

Disorder
Some cognitive therapists try to guide clients
with antisocial personality disorder to think
about moral issues and about the needs of other
people (Beck & Weishaar, 2011; Weishaar &
Beck, 2006; Beck et al., 2004). In a similar vein,
a number of hospitals and prisons have tried to
create a therapeutic community for people with
this disorder, a structured environment that
teaches responsibility toward others (Harris &
Rice, 2006).

Disorder
Some patients seem to profit from such
approaches, but it appears that most do not. In
recent years, clinicians have also used
psychotropic medications, particularly atypical
antipsychotic drugs, to treat people with
antisocial personality disorder. Some report that
these drugs help reduce certain features of the
disorder, but systematic studies of this claim are
still needed (Brown et al., 2014; Thompson et al.,
2014; Silk & Jibson, 2010).

Borderline Personality Disorder
A pervasive pattern of instability of interpersonal
relationships, self-image, and affects, and marked
impulsivity, beginning by early adulthood and present in a
variety of contexts, as indicated by five (or more) of the
following:
1 . Frantic efforts to avoid real or imagined abandonment.
(Note: Do not include suicidal or self-mutilating behavior
covered in Criterion 5 . )
2 . A pattern o f unstable a n d intense interpersonal
relationships characterized b y alternating between
extremes of idealization and devaluation .
3 . Identity disturbance: markedly and persistently
unstable self-image or sense of self.

4. Impulsivity in at least two areas that are potentially self-damaging
(e. g . , spending, sex, substance abuse , reckless driving , binge
eating) . (Note: Do not include suicidal or self-mutilating behavior
covered in Criterion 5.)
5. Recurrent suicidal behavior, gestures, or threats, or self-mutilating
behavior.
6. Affective instability due to a marked reactivity of mood (e.g.,
intense episodic dysphoria, irritability, or anxiety usually lasting a few
hours and only rarely more than a few days).
7. Chronic feelings of emptiness.
8. Inappropriate, intense anger or difficulty controlling anger (e.g . ,
frequent displays of temper, constant anger, recurrent physical fights).
9 . Transient, stress-related paranoid ideation or severe dissociative
symptoms.

People with borderline personality disorder
display great instability, including major
shifts in mood, an unstable self-image, and
impulsivity (APA, 2013). These
characteristics combine to make their
relationships very unstable as well (Paris,
2010, 2005).

swing in and out of very depressive, anxious, and
irritable states that last anywhere from a few
hours to a few days or more. Their emotions
seem to be always in conflict with the world
around them. They are prone to bouts of anger,
which sometimes result in physical aggression
and violence (Scott et al., 2014). Just as often,
however, they direct their impulsive anger
inward and inflict bodily harm on themselves.
Many seem troubled by deep feelings of
emptiness.

Borderline personality disorder is a complex
disorder, and it is fast becoming one of the more
common conditions seen in clinical practice.
Many of the patients who come to mental health
emergency rooms are people with this disorder
who have intentionally hurt themselves. Their
impulsive, self-destructive activities may range
from alcohol and substance abuse to delinquency,
unsafe sex, and reckless driving (Kienast et al.,
2014; Coffey et al., 2011).

Many engage in self-injurious or self-mutilation
behaviors, such as cutting or burning themselves or
banging their heads (Bracken-Minor & McDevitt-
Murphy, 2014; Chiesa, Sharp, & Fonagy, 2011). As you
saw in Chapter 9, such behaviors typically cause immense
physical suffering, but those with borderline personality
disorder often feel as if the physical discomfort offers
relief from their emotional suffering. It may serve as a
distraction from their emotional or interpersonal upsets,
“snapping” them out of an “emotional overload” (Sadeh
et al., 2014; Stanley & Brodsky, 2005).

Many try to hurt themselves as a way of
dealing with their chronic feelings of
emptiness, boredom, and identity confusion.
Scars and bruises also may provide them
with a kind of concrete evidence of their
emotional distress (Paris, 2010, 2005). Many
theorists believe that borderline patterns are
more severe among people who injure
themselves (Whipple & Fowler, 2011).

Suicidal threats and actions are also common
(Amore et al., 2014; Zimmerman et al., 2014;
Leichsenring et al., 2011). Studies suggest that
around 75 percent of people with borderline
personality disorder attempt suicide at least once
in their lives; as many as 10 percent actually
commit suicide. It is common for people with
this disorder to enter clinical treatment by way of
the emergency room after a suicide attempt.

frequently form intense, conflict ridden
relationships in which their feelings are not
necessarily shared by the other person. They may
come to idealize another person’s qualities and
abilities after just a brief first encounter. They
also may violate the boundaries of relationships (
Lazarus
et al., 2014; Skodol et al., 2002).

Thinking in dichotomous (black-and-white) terms,
they quickly feel rejected and become furious when
their expectations are not met; yet they remain very
attached to the relationships (Berenson et al., 2011).
In fact, they have recurrent fears of impending
abandonment and frequently engage in frantic
efforts to avoid real or imagined separations from
important people in their lives (Gunderson, 2011;
Sherry & Whilde, 2008). Sometimes they cut
themselves or carry out other self-destructive acts to
prevent partners from leaving.

typically have dramatic identity shifts. Because
of this unstable sense of self, their goals,
aspirations, friends, and even sexual orientation
may shift rapidly (Westen et al., 2011; Skodol,
2005).They may also occasionally have a sense
of dissociation, or detachment, from their own
thoughts or bodies (Zanarini et al., 2014). Indeed,
at times they may have no sense of themselves at
all, leading to the feelings of emptiness described
earlier.

According to surveys, 5.9 percent of the
adult population display borderline
personality disorder (Zanarini et al., 2014;
Sansone & Sansone, 2011). Close to 75
percent of the patients who receive the
diagnosis are women (Gunderson, 2011).
The course of the disorder varies from
person to person.

In the most common pattern, the person’s
instability and risk of suicide peak during young
adulthood and then gradually wane with
advancing age (APA, 2013; Hurt & Oltmanns,
2002). Given the chaotic and unstable
relationships characteristic of borderline
personality disorder, it is not surprising that the
disorder tends to interfere with job performance
even more than most other personality disorders
do (Hengartner et al., 2014).

How Do Theorists Explain Borderline
Because a fear of abandonment tortures so many
people with borderline personality disorder,
psychodynamic theorists have looked once again
to early parental relationships to explain the
disorder (Gabbard, 2010). Object relations
theorists, for example, propose that an early lack
of acceptance by parents may lead to a loss of
self-esteem, increased dependence, and an
inability to cope with separation (Caligor &
Clarkin, 2010; Sherry & Whilde, 2008).

Research has found that this is consistent with
the early childhoods of people with borderline
personality disorder. In many cases, when they
were children, their parents neglected or rejected
them, verbally abused them, or otherwise
behaved inappropriately (Martín-Blanco et al.,
2014). Their childhoods were often marked by
multiple parent substitutes, divorce, death, or
traumas such as physical or sexual abuse.

Indeed, research suggests that early sexual abuse is
a common contributor to the development of
borderline personality disorder (Newnham & Janca,
2014; Huang, Yang, & Wu, 2010). Indeed, children
who experience such abuse are four times more
likely to develop the disorder than those who do not
(Zelkowitz et al., 2001). At the same time, it is
important to recognize that the vast majority of
people with histories of physical, sexual, or
psychological abuse do not go on to develop
borderline personality disorder (Skodol, 2005).

Borderline personality disorder also has been
linked to certain biological abnormalities,
such as an overly reactive amygdala, the
brain structure that is closely tied to fear and
other negative emotions, and an underactive
prefrontal cortex, the brain region linked to
planning, self-control, and decision making
(Mitchell et al., 2014;
Richter et al., 2014; Stone, 2014).

Moreover, people with borderline personality
disorder who are particularly impulsive—those
who attempt suicide or are very aggressive
toward others—apparently have lower brain
serotonin activity (Soloff et al., 2014; Herpertz,
2011). Some, although not all, studies have tied
this lower activity to an abnormality of the 5-
HTT gene (the serotonin transporter gene)
(Amad et al., 2014; Ni et al., 2006).

As you may recall, this gene also has been linked
to major depressive disorder, suicide, aggression,
and impulsivity (see page 223). In accord with
these various biological findings, close relatives
of those with borderline personality disorder are
five times more likely than the general
population to have the same personality disorder
(Amad et al., 2014; Torgersen, 2000, 1984;
Kendler et al., 1991).

A number of theorists currently use a biosocial theory to
explain borderline personality disorder (Neacsiu &
Linehan, 2014; Rizvi et al., 2011). According to this view,
the disorder results from a combination of internal forces
(for example, difficulty identifying and controlling one’s
emotions, social skill deficits, abnormal neurotransmitter
reactions) and external forces (for example, an
environment in which a child’s emotions are punished,
ignored, trivialized, or disregarded). Parents may, for
instance, misinterpret their child’s intense emotions as
exaggerations or attempts at manipulation rather than as
serious expressions of unsettled internal states.

According to the biosocial theory, if children have
intrinsic difficulty identifying and controlling their
emotions and if their parents teach them to ignore their
intense feelings, they may never learn how properly to
recognize and control their emotional arousal, how to
tolerate emotional distress, or when to trust their
emotional responses (Herpertz & Bertsch, 2014; Lazarus
et al., 2014; Gratz & Tull, 2011). Such children will be at
risk for the development of borderline personality
disorder. This theory has received some, but not
consistent, research support (Gill & Warburton, 2014).

Note that the biosocial theory is similar to one of the
leading explanations for eating disorders. As you saw in
Chapter 11, theorist Hilde Bruch proposed that children
whose parents do not respond accurately to the children’s
internal cues may never learn to identify cues of hunger,
thus increasing their risk of developing an eating disorder
(see pages 359–360). Small wonder that a large number of
people with borderline personality disorder also have an
eating disorder (Gabriel & Waller, 2014; Rowe et al.,
2010).

Finally, some sociocultural theorists suggest that
cases of borderline personality disorder are
particularly likely to emerge in cultures that change
rapidly. As a culture loses its stability, they argue, it
inevitably leaves many of its members with
problems of identity, a sense of emptiness, high
anxiety, and fears of abandonment. Family units
may come apart, leaving people with little sense of
belonging.
Changes of this kind in society today may explain
growing reports of the disorder
(Millon, 2011; Paris, 2010, 1991).

Treatments for Borderline Personality
Disorder
It appears that psychotherapy can eventually lead to
some degree of improvement for people with
borderline personality disorder (Omar et al., 2014;
Neville, 2014). It is, however, extraordinarily
difficult for a therapist to strike a balance between
empathizing with the borderline client’s dependency
and anger and challenging his or her way of
thinking (Goodman, Edwards, & Chung, 2014;
Gabbard, 2010). Given the emotionally draining
demands of clients with borderline personality
disorder, some therapists refuse to treat such people.

Disorder
The wildly fluctuating interpersonal attitudes of
clients with the disorder can also make it difficult
for therapists to establish collaborative working
relationships with them (Colli et al., 2014;
Goodman et al., 2014). Moreover, clients with
borderline personality disorder may violate the
boundaries of the client–therapist relationship
(for example, calling the therapist’s emergency
contact number to discuss matters of a less
urgent nature) (Colli et al., 2014; Gutheil, 2005).

Disorder
Traditional psychoanalysis has not been effective
with people with borderline personality disorder
(Doering et al., 2010). The clients often
experience the psychoanalytic therapist’s
reserved style and encouragement of free
association as suggesting disinterest and
abandonment. The clients may also have
difficulty tolerating interpretations made by
psychoanalytic therapists and see them as
attacks.

Disorder
Contemporary psychodynamic approaches, such as relational
psychoanalytic therapy, in which therapists take a more
supportive and egalitarian posture, have been more effective than
traditional psychoanalytic approaches. In approaches of this
kind, therapists work to provide an empathic setting within
which borderline clients can explore their unconscious conflicts
and pay particular attention to their central relationship
disturbance, poor sense of self, and pervasive loneliness and
emptiness (Goodman et al., 2014; Gabbard, 2010, 2001; Muran
et al., 2010). Research has found that contemporary
psychodynamic treatments sometimes help reduce suicide
attempts, self-harm behaviors, and the number of
hospitalizations and bring at least some improvement to those
with the disorder (Neville, 2014; Clarkin et al., 2010, 2001).

Disorder
Over the past two decades, an integrative
treatment for borderline personality disorder,
called dialectical behavior therapy (DBT), has
been receiving considerable research support and
is now considered the treatment of choice in
many clinical circles (Neacsiu & Linehan, 2014;
Linehan et al., 2006, 2002, 2001). DBT,
developed by psychologist Marsha Linehan,
grows largely from the cognitive-behavioral
treatment model.

Disorder
It includes a number of the same cognitive and,
at the same time, behavioral techniques that are
applied to other disorders: homework
assignments, psycho-education, the teaching of
social and other skills, modeling by the therapist,
clear goal setting, reinforcements for appropriate
behaviors, ongoing assessment of the client’s
behaviors and treatment progress, and
collaborative examinations by the client and
therapist of the client’s ways of thinking
(Neacsiu & Linehan, 2014; Rizvi et al., 2011).

Disorder
DBT also borrows heavily from the humanistic and
contemporary psychodynamic approaches, placing the
client–therapist relationship itself at the center of
treatment interactions, making sure that appropriate
treatment boundaries are adhered to and providing an
environment of acceptance and validation of the client.
Indeed, DBT therapists regularly empathize with their
borderline clients and with the emotional turmoil they are
experiencing; locate kernels of truth in the clients’
complaints or demands; and examine alternative ways for
them to address valid needs.

Disorder
DBT is often supplemented by the clients’
participation in social skill-building groups
(Roney & Cannon, 2014). In these groups,
clients practice new ways of relating to other
people in a safe environment and receive
validation and support from other group
members.

Disorder
DBT has received more research support than any other
treatment for borderline personality disorder (Neacsiu &
Linehan, 2014; Roepke et al., 2011). Many clients who
receive DBT become more able to tolerate stress; develop
new, more appropriate, social skills; respond more
effectively to life situations; and develop a more stable
identity. They also have significantly fewer suicidal
behaviors and require fewer hospitalizations than those
who receive other forms of treatment (Klein & Miller,
2011). In addition, they are more likely to remain in
treatment and to report less anger, more social
gratification, improved work performance, and reductions
in substance abuse (Rizvi et al., 2011).

Disorder
Antidepressant, antibipolar, antianxiety, and antipsychotic drugs
have helped calm the emotional and aggressive storms of some
people with borderline personality disorder (Black et al., 2014;
Knappich et al., 2014; Martinho et al., 2014). However, given
the numerous suicide attempts by people with this disorder, the
use of drugs on an outpatient basis is controversial (Gunderson,
2011). Additionally, clients with the disorder have been known to
adjust or discontinue their medication dosages without
consulting their clinicians. Many professionals believe that
psychotropic drug treatment for borderline personality disorder
should be used largely as an adjunct to psychotherapy
approaches, and indeed many clients seem to benefit from a
combination of psychotherapy and drug therapy (Omar et al.,
2014; Soloff, 2005).

Histrionic Personality Disorder
A pervasive pattern of excessive emotionality and
attention seeking, beginning by early adulthood and
present in a variety of contexts, as indicated by five
(or more) of the following:
1 . Is uncomfortable in situations in which he or she
is not the center of attention.
2. Interaction with others is often characterized by
inappropriate sexually seductive or provocative
behavior.
3. Displays rapidly shifting and shallow expression
of emotions.

4. Consistently uses physical appearance to draw
attention to self.
5. Has a style of speech that is excessively
impressionistic and lacking in detail.
6. Shows self-dramatization , theatricality, and
exaggerated expression of emotion.
7. Is suggestible ( i . e . , easily influenced by
others or circumstances) .
8. Considers relationships to be more intimate
than they actually are.

People with histrionic personality disorder,
once called hysterical personality disorder,
are extremely emotional—they are typically
described as “emotionally charged”—and
continually seek to be the center of attention
(APA, 2013). Their exaggerated moods and
neediness can complicate life considerably.

People with histrionic personality disorder are
always “on stage,” using theatrical gestures and
mannerisms and grandiose language to describe
ordinary everyday events. Like chameleons, they
keep changing themselves to attract and impress
an audience, and in their pursuit they change not
only their surface characteristics— according to
the latest fads—but also their opinions and
beliefs. In fact, their speech is actually scanty in
detail and substance, and they seem to lack a
sense of who they really are.

Approval and praise are their lifeblood; they
must have others present to witness their
exaggerated emotional states. Vain, self-
centered, demanding, and unable to delay
gratification for long, they overreact to any
minor event that gets in the way of their
quest for attention. Some make suicide
attempts, often to manipulate others (APA,
2013; Lambert, 2003).

People with histrionic personality disorder
may draw attention to themselves by
exaggerating their physical illnesses or
fatigues. They may also behave very
provocatively and try to achieve their goals
through sexual seduction. Most obsess over
how they look and how others will perceive
them, often wearing bright, eye-catching
clothes.

They exaggerate the depth of their
relationships, considering themselves to be
the intimate friends of people who see them
as no more than casual acquaintances. Often
they become involved with romantic partners
who may be exciting but who do not treat
them well.

This disorder was once believed to be more
common in women than in men, and
clinicians long described the “hysterical
wife” (Anderson et al., 2001). Research,
however, has revealed gender bias in past
diagnoses (APA, 2013; Fowler et al., 2007;
Ford & Widiger, 1989).

When evaluating case studies of people with
a mixture of histrionic and antisocial traits,
clinicians in several studies gave a diagnosis
of histrionic personality disorder to women
more than men. Surveys suggest that 1.8
percent of adults have this personality
disorder, with males and females equally
affected (APA, 2013; Sansone & Sansone,
2011).

How Do Theorists Explain Histrionic
The psychodynamic perspective was originally developed
to help explain cases of hysteria, so it is no surprise that
psychodynamic theorists continue to have a strong interest
in histrionic personality disorder. Most psychodynamic
theorists believe that as children, people with this disorder
had cold and controlling parents who left them feeling
unloved and afraid of abandonment (Horowitz & Lerner,
2010; Bender et al., 2001). To defend against deep-seated
fears of loss, the children learned to behave dramatically,
inventing crises that would require other people to act
protectively.

Cognitive explanations look instead at the lack of
substance and extreme suggestibility that people with
histrionic personality disorder have. Cognitive theorists
see these people as becoming less and less interested in
knowing about the world at large because they are so self-
focused and emotional. With no detailed memories of
what they never learned, they must rely on hunches or on
other people to provide them with direction in life
(Blagov et al., 2007). Some cognitive theorists also
believe that people with this disorder hold a general
assumption that they are helpless to care for themselves,
and so they constantly seek out others who will meet their
needs (Weishaar & Beck, 2006; Beck et al., 2004).

Sociocultural, particularly multicultural, theorists
believe that histrionic personality disorder is
produced in part by cultural norms and
expectations. Until recently, our society
encouraged girls to hold on to childhood and
dependency as they grew up. The vain, dramatic,
and selfish behavior of the histrionic personality
may actually be an exaggeration of femininity as
our culture once defined it (Fowler et al., 2007).

Similarly, some clinical observers claim that
histrionic personality disorder is diagnosed less
often in Asian and other cultures that discourage
overt sexualization and more often in Hispanic
American and Latin American cultures that are
more tolerant of overt sexualization (Patrick,
2007; Trull & Widiger, 2003). Researchers have
not, however, investigated this claim
systematically.

Treatments for Histrionic Personality
Disorder
People with histrionic personality disorder are more likely
than those with most other personality disorders to seek
out treatment on their own (Tyrer et al., 2003). Working
with them can be very difficult, however, because of the
demands, tantrums, and seductiveness they are likely to
deploy. Another problem is that these clients may pretend
to have important insights or to change during treatment
merely to please the therapist. To head off such problems,
therapists must remain objective and maintain strict
professional boundaries (Colli et al., 2014; Blagov et al.,
2007).

Disorder
Cognitive therapists have tried to help people with
this disorder to change their belief that they are
helpless and also to develop better, more
deliberate ways of thinking and solving problems
(Beck & Weishaar, 2014; Weishaar & Beck, 2006;
Beck et al., 2004). Psychodynamic therapy and
various group therapy formats have also been used
(Horowitz & Lerner, 2010).

Disorder
In all these approaches, therapists ultimately aim
to help the clients recognize their excessive
dependency, find inner satisfaction, and become
more self-reliant. Clinical case reports suggest
that each of the approaches can be useful. Drug
therapy appears less successful except as a means
of relieving the depressive symptoms that some
patients have (Bock et al., 2010; Grossman,
2004; Koenigsberg et al., 2002).

Narcissistic Personality Disorder
A pervasive pattern of grandiosity (in fantasy or behavior) , need
for admiration, and lack of empathy, beginning by early
adulthood and present in a variety of contexts, as indicated by
five (or more) of the following:
1 . Has a grandiose sense of self-importance (e. g . , exaggerates
achievements and talents, expects to be recognized as superior
without commensurate achievements).
2. Is preoccupied with fantasies of unlimited success, power,
brilliance, beauty, or ideal love.
3. Believes that he or she is "special" and unique and can only be
understood by, or
should associate with, other special or high-status people (or
institutions) .

4. Requires excessive admiration .
5. Has a sense of entitlement (i.e., unreasonable
expectations of especially favorable treatment or
automatic compliance with his or her expectations).
6. Is interpersonally exploitative ( i . e . , takes advantage
of others to achieve his or her own ends).
7. Lacks empathy: is unwilling to recognize or identify
with the feelings and needs of others.
8. Is often envious of others or believes that others are
envious of him or her.
9. Shows arrogant, haughty behaviors or attitudes.

People with narcissistic personality disorder
are generally grandiose, need much
admiration, and feel no empathy with others
(APA, 2013). Convinced of their own great
success, power, or beauty, they expect
constant attention and admiration from those
around them.

In the Greek myth, Narcissus died
enraptured by the beauty of his own
reflection in a pool, pining away with
longing to possess his own image. His name
has come to be synonymous with extreme
self-involvement, and indeed people with
narcissistic personality disorder have a
grandiose sense of self-importance.

They exaggerate their achievements and talents,
expecting others to recognize them as superior,
and often appear arrogant. They are very choosy
about their friends and associates, believing that
their problems are unique and can be appreciated
only by other “special,” high-status people.
Because of their charm, they often make
favorable first impressions, yet they can rarely
maintain long-term relationships ( Campbell &
Miller, 2011).

People with narcissistic personality disorder
are seldom interested in the feelings of
others. They may not even be able to
empathize with such feelings (Baskin-
Sommers et al., 2014; Roepke & Vater, 2014;
Ritter et al., 2011). Many take advantage of
other people to achieve their own ends,
perhaps partly out of envy; at the same time
they believe others envy them.

Though grandiose, some react to criticism or
frustration with bouts of rage, humiliation, or
embitterment (APA, 2013; Campbell & Miller,
2011; Rotter, 2011). Others may react with cold
indifference. And still others become extremely
pessimistic and filled with depression. They may
have periods of zest that alternate with periods of
disappointment (Ronningstam, 2011).

As many as 6.2 percent of adults display
narcissistic personality disorder, up to 75
percent of them men (APA, 2013; Sansone &
Sansone, 2011). Narcissistic-type behaviors
and thoughts are common and normal among
teenagers and do not usually lead to adult
narcissism (APA, 2013).

How Do Theorists Explain Narcissistic
Psychodynamic theorists more than others have
theorized about narcissistic personality disorder,
and they again propose that the problem begins
with cold, rejecting parents. They argue that
some people with this background spend their
lives defending against feeling unsatisfied,
rejected, unworthy, ashamed, and wary of the
world ( Roepke & Vater, 2014; Ronningstam,
2011; Bornstein, 2005).

They do so by repeatedly telling themselves that
they are actually perfect and desirable, and also
by seeking admiration from others. Object
relations theorists— the psychodynamic theorists
who emphasize relationships— interpret the
grandiose self-image as a way for these people to
convince themselves that they are totally self-
sufficient and without need of warm
relationships with their parents or anyone else
(Celani, 2014; Diamond & Meehan, 2013).

In support of the psychodynamic theories, research
has found that children who are abused or who lose
parents through adoption, divorce, or death are at
particular risk for the later development of
narcissistic personality
disorder (Kernberg, 2010, 1992, 1989). Studies also
show that people with this disorder do indeed earn
relatively high shame and rejection scores on
various scales and believe that other people are
basically unavailable to them (Ritter et al., 2014;
Bender et al., 2001).

A number of cognitive-behavioral theorists
propose that narcissistic personality disorder may
develop when people are treated too positively
rather than too negatively in early life. They hold
that certain children acquire a superior and
grandiose attitude when their “admiring or doting
parents” teach them to “overvalue their self
worth,” repeatedly rewarding them for minor
accomplishments or for no accomplishment at all
(Millon, 2011; Sperry, 2003).

Many sociocultural theorists see a link
between narcissistic personality disorder and
“eras of narcissism” in society (Paris, 2014;
Campbell & Miller, 2011). They suggest that
family values and social ideals in certain
societies periodically break down, producing
generations of young people who are self-
centered and materialistic and have short
attention spans.

Western cultures in particular, which encourage
self-expression, individualism, and
competitiveness, are considered likely to produce
such generations of narcissism. In fact, one
worldwide study conducted on the Internet found
that respondents from the United States had the
highest narcissism scores, followed, in
descending order, by those from Europe, Canada,
Asia, and the Middle East (Foster, Campbell, &
Twenge, 2003).

Treatments for Narcissistic Personality
Disorder
Narcissistic personality disorder is one of the
most difficult personality patterns to treat
because the clients are unable to
acknowledge weaknesses, to appreciate the
effect of their behavior on others, or to
incorporate feedback from others (Campbell
& Miller, 2011).

Disorder
The clients who consult therapists usually do so
because of a related disorder such as depression
(APA, 2013; Piper & Joyce, 2001). Once in
treatment, the clients may try to manipulate the
therapist into supporting their sense of
superiority. Some also seem to project their
grandiose attitudes onto their therapists and
develop a love-hate stance toward them (Colli et
al., 2014; Shapiro, 2004).

Disorder
Psychodynamic therapists seek to help people with this
disorder recognize and work through their basic insecurities
and defenses (Diamond & Meehan, 2013; Messer & Abbass,
2010). Cognitive therapists, focusing on the self-centered
thinking of such individuals, try to redirect the clients’ focus
onto the opinions of others, teach them to interpret criticism
more rationally, increase their ability to empathize, and
change their all-or-nothing notions (Beck & Weishaar, 2014;
Weishaar & Beck, 2006; Beck et al., 2004). None of the
approaches have had clear success, however (Paris, 2014;
Dhawan et al., 2010).

“Anxious” Personality Disorders
The cluster of “anxious” personality disorders
includes the avoidant, dependent, and obsessive-
compulsive personality disorders. People with
these patterns typically display anxious and
fearful behavior. Although many of the
symptoms of these personality disorders are
similar to those of the anxiety and depressive
disorders, researchers have not found direct links
between this cluster and those disorders
(O’Donohue et al., 2007).

As with most of the other personality
disorders, research support for the various
explanations is very limited. At the same
time, treatments for these disorders appear to
be modestly to moderately helpful—
considerably better than for other personality
disorders.

A pervasive pattern of social inhibition, feelings of
inadequacy, and hypersensitivity to negative
evaluation, beginning by early adulthood and
present in a variety of contexts, as indicated by
four (or more) of the following:
1 . Avoids occupational activities that involve
significant interpersonal contact because of fears
of criticism , disapproval, or rejection .
2. Is unwilling to get involved with people unless
certain of being liked .

3. Shows restraint within intimate relationships
because of the fear of being shamed or
ridiculed .
4. Is preoccupied with being criticized or rejected in
social situations.
5. Is inhibited in new interpersonal situations
because of feelings of inadequacy.
6. Views self as socially inept, personally
unappealing, or inferior to others.
7. Is unusually reluctant to take personal risks or to
engage in any new activities because
they may prove embarrassing.

People with avoidant personality disorder are
very uncomfortable and inhibited in social
situations, overwhelmed by feelings of
inadequacy, and extremely sensitive to
negative evaluation (APA, 2013). They are
so fearful of being rejected that they give no
one an opportunity to reject them—or to
accept them either:

People with this disorder actively avoid
occasions for social contact. At the center of this
withdrawal lies not so much poor social skills as
a dread of criticism, disapproval, or rejection.
They are timid and hesitant in social situations,
afraid of saying something foolish or of
embarrassing themselves by blushing or acting
nervous. Even in intimate relationships they
express themselves very carefully, afraid of being
shamed or ridiculed.

People with this disorder believe themselves to be
unappealing or inferior to
others. They exaggerate the potential difficulties of
new situations, so they seldom
take risks or try out new activities. They usually
have few or no close friends,
though they actually yearn for intimate
relationships, and frequently feel depressed
and lonely. As a substitute, some develop an inner
world of fantasy and imagination
(Millon, 2011).

Avoidant personality disorder is similar to social anxiety
disorder, and many people with one of these disorders
also experience the other (Eikenaes et al., 2013). The
similarities include a fear of humiliation and low
confidence. Some theorists believe that there is a key
difference between the two disorders—namely, that
people with social anxiety disorder primarily fear social
circumstances, while people with the personality disorder
tend to fear close social relationships (Lampe &
Sunderland, 2013; Kantor, 2010). Other theorists,
however, believe that the two disorders reflect the same
core of psychopathology and should be combined
(Eikenaes et al., 2013; Herbert, 2007).

Around 2.4 percent of adults have avoidant
personality disorder, men as frequently as
women (APA, 2013;
Sansone & Sansone, 2011). Many children
and teenagers are also painfully shy and
avoid other people, but this is usually just a
normal part of their development.

How Do Theorists Explain Avoidant
Theorists often assume that avoidant personality
disorder has the same causes as anxiety
disorders—such as early traumas, conditioned
fears, upsetting beliefs, or biochemical
abnormalities. However, with the exception of
social anxiety disorder, research has not yet tied
the personality disorder directly to the anxiety
disorders (Herbert, 2007). Psychodynamic,
cognitive, and behavioral explanations of
avoidant personality disorder are the most
popular among clinicians.

Psychodynamic theorists focus mainly on the
general sense of shame that people with avoidant
personality disorder feel (Svartberg &
McCullough, 2010). Some trace the shame to
childhood experiences such as early bowel and
bladder accidents. If parents repeatedly punish or
ridicule a child for having such accidents, the
child may develop a negative self-image. This
may lead to the child’s feeling unlovable
throughout life and distrusting the love of others.

Similarly, cognitive theorists believe that harsh
criticism and rejection in early childhood may
lead certain people to assume that others in their
environment will always judge them negatively.
These people come to expect rejection,
misinterpret the reactions of others to fit that
expectation, discount positive feedback, and
generally fear social involvements—setting the
stage for avoidant personality disorder (Rees &
Pritchard, 2013; Weishaar & Beck, 2006; Beck et
al., 2004).

In several studies, participants with this disorder
were asked to recall their childhood, and their
descriptions supported both the psychodynamic
and the cognitive theories (Carr & Francis, 2010;
Herbert, 2007). They remembered, for example,
feeling criticized, rejected, and isolated;
receiving little encouragement from their parents;
and experiencing few displays of parental love or
pride.

Behavioral theorists suggest that people with
avoidant personality disorder typically fail to
develop normal social skills, a failure that helps
maintain the disorder. In support of this position,
several studies have found social skills deficits
among people with avoidant personality disorder
(Kantor, 2010; Herbert, 2007). Most behaviorists
agree, however, that these deficits first develop
as a result of the individuals avoiding so many
social situations.

Treatments for Avoidant Personality
Disorder
People with avoidant personality disorder come
to therapy in the hope of finding acceptance and
affection. Keeping them in treatment can be a
challenge, however, for many of them soon begin
to avoid the sessions. Often they distrust the
therapist’s sincerity and start to fear his or her
rejection. Thus, as with several of the other
personality disorders, a key task of the therapist
is to gain the person’s trust (Colli et al., 2014;
Leichsenring & Salzer, 2014).

Disorder
Beyond building trust, therapists tend to treat
people with avoidant personality disorder much
as they treat people with social anxiety disorder
and other anxiety disorders (Svartberg, Stiles, &
Seltzer, 2004; Markovitz, 2001). Such
approaches have had at least modest success
(Kantor, 2010; Porcerelli et al., 2007).
Psychodynamic therapists try to help clients
recognize and resolve the unconscious conflicts
that may be operating (Leichsenring & Salzer,
2014; Messer & Abbass, 2010).

Disorder
Cognitive therapists help them change their
distressing beliefs and thoughts, carry on in the
face of painful emotions, and improve their self-
image (Rees & Pritchard, 2013; Weishaar &
Beck, 2006; Beck et al., 2004). Behavioral
therapists provide social skills training as well as
exposure treatments that require people to
gradually increase their social contacts (Herbert,
2007; Farmer & Nelson-Gray, 2005).

Disorder
Group therapy formats, especially groups that
follow cognitive and behavioral principles, have
the added advantage of providing clients with
practice in social interactions (Herbert et al.,
2005). Anti -anxiety and antidepressant drugs are
sometimes useful in reducing the social anxiety
of people with the disorder, although the
symptoms may return when medication is
stopped (Ripoll et al., 2011; Fava et al., 2002).

Dependent Personality Disorder
A pervasive and excessive need to be taken care of that
leads to submissive and clinging behavior and fears of
separation , beginning by early adulthood and present in a
variety of contexts, as indicated by five (or more) of the
following:
1 . Has difficulty making everyday decisions without an
excessive amount of advice and reassurance from others.
2 . Needs others to assume responsibility for most major
areas of his or her life.
3. Has difficulty expressing disagreement with others
because of fear of loss of support or approval. (Note: Do
not include realistic fears of retribution . )

4. Has difficulty initiating projects or doing things o n h i s or h e
r own (because o f a lack of self-confidence in judgment or
abilities rather than a lack of motivation or energy) .
5. Goes to excessive lengths to obtain nurturance and support
from others, to the point of volunteering to do things that are
unpleasant.
6. Feels uncomfortable or helpless when alone because of
exaggerated fears of being unable to care for himself or herself.
7 . Urgently seeks another relationship as a source of care and
support when a close relationship ends.
8. Is unrealistically preoccupied with fears of being left to take
care of himself or herself.

People with dependent personality disorder
have a pervasive, excessive need to be taken
care of (APA, 2013). As a result, they are
clinging and obedient, fearing separation
from their parent, spouse, or other person
with whom they are in a close relationship.
They rely on others so much that they cannot
make the smallest decision for themselves.

It is normal and healthy to depend on others,
but those with dependent personality
disorder constantly need assistance with
even the simplest matters and have extreme
feelings of inadequacy and helplessness.
Afraid that they cannot care for themselves,
they cling desperately to friends or relatives.

As you just observed, people with avoidant
personality disorder have difficulty initiating
relationships. In contrast, people with dependent
personality disorder have difficulty with
separation. They feel completely helpless and
devastated when a close relationship ends, and
they quickly seek out another relationship to fill
the void. Many cling persistently to relationships
with partners who physically or psychologically
abuse them (Loas et al., 2011).

Lacking confidence in their own ability and
judgment, people with this disorder seldom disagree
with others and allow even important decisions to be
made for them (Bornstein, 2012, 2007; Millon,
2011). They may depend on a parent or spouse to
decide where to live, what job to have, and which
neighbors to befriend. Because they so fear
rejection, they are overly sensitive to disapproval
and keep trying to meet other people’s wishes and
expectations, even if it means volunteering for
unpleasant or demeaning tasks.

Many people with dependent personality disorder
feel distressed, lonely, and sad; often they dislike
themselves. Thus they are at risk for depressive,
anxiety, and eating disorders (Bornstein, 2012,
2007). Their fear of separation and their feelings
of helplessness may leave them particularly
prone to suicidal thoughts, especially when they
believe that a relationship is about to end
(Bornstein, 2012; Kiev, 1989).

Surveys suggest that fewer than 1 percent of
the population experience dependent
personality disorder (APA, 2013; Sansone &
Sansone, 2011). For years, clinicians have
believed that more women than men display
this pattern, but some research suggests that
the disorder is just as common in men (APA,
2013).

How Do Theorists Explain Dependent
Psychodynamic explanations for dependeng
personality disorder are very similar to those for
depression ( Svartberg & McCullough, 2010).
Freudian theorists argue, for example, that
unresolved conflicts during the oral stage of
development can give rise to a lifelong need for
nurturance, thus heightening the likelihood of a
dependent personality disorder (Bornstein, 2012,
2007, 2005).

Similarly, object relations theorists say that
early parental loss or rejection may prevent
normal experiences of attachment and
separation, leaving some children with fears
of abandonment that persist throughout their
lives (Caligor & Clarkin, 2010).

Still other psychodynamic theorists suggest
that, to the contrary, many parents of people
with this disorder were overinvolved and
overprotective, thus increasing their
children’s dependency, insecurity, and
separation anxiety (Sperry, 2003).

Behaviorists propose that parents of people with
dependent personality disorder unintentionally
rewarded their children’s clinging and “loyal”
behavior, while at the same time punishing acts
of independence, perhaps through the withdrawal
of love. Alternatively, some parents’ own
dependent behaviors may have served as models
for their children (Bornstein, 2012, 2007).

Cognitive theorists identify two maladaptive attitudes as
helping to produce and maintain this disorder:
(1) “I am inadequate and helpless to deal with the
world,”
(2) “I must find a person to provide protection so I can
cope.”
Dichotomous (black-and-white) thinking may also play a
key role: “If I am to be dependent, I must be completely
helpless,” or “If I am to be independent, I must be alone.”
Such thinking prevents sufferers from making efforts to
be autonomous (Borge et al., 2010; Weishaar & Beck,
2006; Beck et al., 2004).

Treatments for Dependent Personality
Disorder
In therapy, people with dependent personality
disorder usually place all responsibility for their
treatment and well-being on the clinician. Thus a
key task of therapy is to help patients accept
responsibility for themselves (Colli et al., 2014;
Gutheil, 2005). Because the domineering behaviors
of a spouse or parent may help foster a patient’s
symptoms, some clinicians suggest couple or family
therapy as well, or even separate therapy for the
partner or parent (Lebow & Uliaszek, 2010;
Nichols, 2004).

Disorder
Treatment for dependent personality disorder
can be at least modestly helpful.
Psychodynamic therapy for this pattern
focuses on many of the same issues as
therapy for depressed people, including the
transference of dependency needs onto the
therapist (Svartberg & McCullough, 2010).

Disorder
Cognitive-behavioral therapists combine
behavioral and cognitive interventions to help the
clients take control of their lives. On the
behavioral end, the therapists often provide
assertiveness training to help the individuals
better express their own wishes in relationships
(Farmer & Nelson-Gray, 2005). On the cognitive
end, the therapists also try to help the clients
challenge and change their assumptions of
incompetence and helplessness (Borge et al.,
2010; Weishaar & Beck, 2006; Beck et al.,
2004).

Disorder
Antidepressant drug therapy has been helpful for
people whose personality disorder is
accompanied by depression (Fava et al., 2002).
As with avoidant personality disorder, a group
therapy format can be helpful because it provides
opportunities for the client to receive support
from a number of peers rather than from a single
dominant person (Perry, 2005; Sperry, 2003). In
addition, group members may serve as models
for one another as they practice better ways to
express feelings and solve problems.

Obsessive-Compulsive Personality
Disorder
A pervasive pattern of preoccupation with orderliness,
perfectionism , and mental and interpersonal control, at the
expense of flexibility, openness, and efficiency, beginning by
early adulthood and present in a variety of contexts, as indicated
by four (or more) of the following:
1 . Is preoccupied with details, rules, lists, order, organization, or
schedules to the extent that the major point of the activity is lost.
2. Shows perfectionism that interferes with task completion (e.g .
, is unable to complete a project because his or her own overly
strict standards are not met) .
3. Is excessively devoted to work and productivity to the
exclusion of leisure activities and friendships (not accounted for
by obvious economic necessity) .

Disorder
4. Is over-conscientious, scrupulous, and inflexible about
matters of morality, ethics, or values (not accounted for by
cultural or religious identification).
5. Is unable to discard worn-out or worthless objects even
when they have no sentimental value.
6. Is reluctant to delegate tasks or to work with others
unless they submit to exactly his or her way of doing
things.
7. Adopts a miserly spending style toward both self and
others; money is viewed as something to be hoarded for
future catastrophes.
8. Shows rigidity and stubbornness.

Disorder
People with obsessive-compulsive
personality disorder are so preoccupied with
order, perfection, and control that they lose
all flexibility, openness, and efficiency
(APA, 2013). Their concern for doing
everything “right” impairs their productivity.

Disorder
People with this personality disorder set
unreasonably high standards for themselves and
others. Their behaviors extend well beyond the
realm of conscientiousness. They can never be
satisfied with their performance, but they
typically refuse to seek help or to work with a
team, convinced that others are too careless or
incompetent to do the job right. Because they are
so afraid of making mistakes, they may be
reluctant to make decisions.

Disorder
They also tend to be rigid and stubborn,
particularly in their morals, ethics, and values.
They live by a strict personal code and use it as a
yardstick for measuring others. They may have
trouble expressing much affection, and their
relationships are sometimes stiff and superficial.
In addition, they are often stingy with their time
or money. Some cannot even throw away objects
that are worn out or useless (APA, 2013).

Disorder
According to surveys, as many as 7.9 percent
of the adult population display obsessive-
compulsive personality disorder, with white,
educated, married, and employed people
receiving the diagnosis most often (APA,
2013; Sansone & Sansone, 2011). Men are
twice as likely as women to display the
disorder.

Disorder
Many clinicians believe that obsessive
compulsive personality disorder and
obsessive-compulsive disorder are closely
related. Certainly, the two disorders share a
number of features, and many people who
suffer from one of the disorders meet the
diagnostic criteria for the other disorder
(Pinto et al., 2014; Gordon et al., 2013).

Disorder
However, it is worth noting that people with the
personality disorder are more likely to suffer
from either major depressive disorder,
generalized disorder, or a substance use disorder
than from obsessive-compulsive disorder (APA,
2013; Pena-Garijo et al., 2013; Pinto et al.,
2008). In fact, researchers have not consistently
found a specific link between obsessive
compulsive personality disorder and obsessive-
compulsive disorder (Starcevic & Brakoulias,
2014; Gordon et al., 2013).

How Do Theorists Explain Obsessive-
Compulsive Personality Disorder?
Most explanations of obsessive-compulsive
personality disorder borrow heavily from
those of obsessive-compulsive disorder,
despite the doubts concerning a link between
the two disorders. As with so many of
the personality disorders, psychodynamic
explanations dominate and research evidence
is limited.

How Do Theorists Explain Obsessive-
Compulsive Personality Disorder?
Freudian theorists suggest that people with
obsessive-compulsive personality disorder
are anal retentive. That is, because of overly
harsh toilet training during the anal stage,
they become filled with anger, and they
remain fixated at this stage. To keep their
anger under control, they persistently resist
both their anger and their instincts to have
bowel movements.

Personality disorders

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