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Learning Objectives
After reading this chapter, you should be
able to:
• Name and briefly describe the criteria used to
differentiate normal from abnormal manifes-
tations of behavior, thought, and affect.
• Identify the most common diagnostic system
used in the United States and some of the
prevalence rates for personality disorders.
• Name and define the DSM-5 personality dis-
orders found in clusters A, B, and C.
• Discuss the different prevalence rates for the
personality disorders, especially with respect
to sex differences.
• Identify some of the alternative models for
categorizing personality disorders, such as
those proposed by the International Classifi-
cation of Diseases, Millon, and the Five Factor
Model.
• Name and briefly describe some measures
of personality commonly used in clinical set-
tings, particularly the MMPI--2.

Personality and Psychopathology 10
Chapter Outline
Introduction
10.1 Defining Personality Disorders
• Criteria to Define Abnormal Functioning
• Criteria for Defining Problematic Functioning
in Terms of Personality
• Conceptualizing Personality Disorders
10.2 Types of Personality Disorders
• Cluster A Personality Disorders
• Cluster B Personality Disorders
• Cluster C Personality Disorders
• Other Specified Personality Disorder
• The Prevalence of Personality Disorders
• Alternative Organizational Models for the
Personality Disorders
• Questioning the Legitimacy of Mental Illness
• Explain why we need measures of response tendencies when
assessing personality in clinical settings.
• Name some common validity scales used to assess over- and
under-reporting tendencies.
• Read a case study and interpret some basic personality data in
order to diagnose the patient, and provide a theo-
retical account of their etiology based on one or more of the
theories presented in this text.
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CHAPTER 10
Introduction
Try to recall the last time you took an exam. How many pencils
did you bring with
you? If you didn’t bring any, you might be considered
unprepared. If you brought
one, you might still be considered to be acting carelessly, given
that the point
might break. Perhaps you brought one extra, just in case. But
what if you brought
three, four, or five backup pencils? Would this suggest that you
were acting in
an obsessive manner, possibly demonstrating symptoms of
obsessive-compulsive
personality disorder? These are subtle distinctions, and it’s hard
to decide at what
point behavior—even a simple, mundane behavior, such as
bringing pencils to a
test—goes from normal to abnormal, or nonpathological to
problematic.
This example illustrates the complexity of differentiating subtle
variations of
behavior, ranging from “normal” personality functioning to
personality disorders.
Three extra pencils (or any particular number of pencils)
doesn’t necessarily mean
anything diagnostically, but it might, especially if you spent too
much of your
exam preparation time collecting and sharpening pencils or if
you spent much
of the time taking the exam worrying about the durability of
your pencils and

whether you brought enough.
So far we’ve explored how personality functions. In this
chapter, we turn our
attention to the symptoms and development of personality
dysfunction. The his-
tory of personality psychology developed hand in hand with
clinical psychology.
Therefore, it is somewhat artificial to consider these two areas
as distinct. Indeed,
throughout this text, there have been both implicit and explicit
references to psy-
chopathology (e.g., depression, anxiety, personality disorders,
etc.). In this chap-
ter, we will more directly deal with personality disorders, the
criteria by which they
are defined and diagnosed, and assessment tools commonly used
to assess per-
sonality disorders. We will conclude the chapter with two case
studies that bring
these issues together with the explanatory accounts forwarded
in earlier chapters.
As we explore the current thinking regarding personality
disorders, it behooves us
to remember our discussion about defining “normal” from
Chapter One. Much of
this chapter deals with abnormal personality as it is defined by
the Diagnostic and
Statistical Manual of Mental Disorders (DSM) published by the
American Psychi-
atric Association (APA), and while many of the behaviors
discussed in this chapter
are clearly problematic, it is important to remember that
“normal” is a relative,
culturally defined construct. And when it comes to defining

what is normal or
abnormal in personality, our culture has collectively decided to
let the American
Psychiatric Association decide.
10.3 Assessing Personality Disorders
• The Minnesota Multiphasic Personality
Inventory (MMPI--2)
• Personality Assessment Inventory
(PAI-)
• The Millon Clinical Multiaxial Inven-
tory-III (MCMI-III/)
• Common Features of Each Assessment
10.4 Case Illustrations
• Case 1: Bob G.
• Case 2: Samantha K.
Summary
Introduction
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CHAPTER 10
Personality disorders share many of the same defining features
with the concept of personal-ity; both, for example, have a

stable pattern of behavior, affect, and cognition that charac-
terize the individual. But to be considered a personality disorder
there must also be a clear
indication that a person’s behavior, affect, or cognition is
problematic in some way—maladaptive
or rigid, for example—and compromises the individual’s level
of functioning. Personality disorders
can be differentiated from clinical disorders that do not involve
personality (e.g., alcohol depen-
dence, schizophrenia, depression, anxiety, etc.), in that the
former are typically more longstanding
and pervasive, and they typically manifest in more subtle ways.
One of the biggest challenges to identifying and diagnosing any
disorder is establishing a set of
criteria that can help differentiate normal manifestations of
behavior, affect, and cognition from
what might be labeled as abnormal or even pathological
manifestations. Over the years, a number
of criteria have emerged by consensus, and some of those are
briefly discussed in this section.
Note that these criteria are broadly applied to abnormal
behavior, and there are separate factors
that will make them applicable to personality.
Criteria to Define Abnormal Functioning
Four basic criteria are considered relevant to differentiating
abnormal from normal functioning:
1. statistical deviance,
2. dysfunction in daily living,
3. the experience of distress, and
4. danger to self or others.
Each criterion is important in defining
abnormal functioning, but none are nec-

essary or sufficient to determine that a
disorder is present. As an example, it is
true that behavior that is markedly differ-
ent (statistically deviant) from what most
people do is more likely to be defined as
abnormal, but some rare behaviors are
not disorders, and in fact can be quite
adaptive. For example, consider the life
and behavior of Mother Teresa, which
could be an extreme case of altruism,
or that of Bill Gates, which could be an
extreme case of financial and technologi-
cal success. Neither of these would be
considered maladaptive, but they are cer-
tainly deviant from a statistical standpoint.
It is also the case that, despite these criteria, debate has
continued with respect to what specifically
should or should not be considered a disorder. Consider
homosexuality, which prior to 1980 was
considered a psychiatric disorder by the World Health
Organization (WHO) and was also included
in the Diagnostic and Statistical Manual of Mental Disorders,
2nd Edition (DSM-II; APA, 1968), but
since that time has not been considered a disorder. A wide range
of factors influence what we
consider disordered, and the criteria—and interpretations of the
criteria—will change over time.
Trevor Smith/iStockphoto/Thinkstock
What do we consider disordered behavior? When is
abnormal behavior pathological?

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CHAPTER 10 10.1 Defining Personality Disorders
Statistical Deviance
Statistical deviance refers to the infrequency of a behavior or
trait in the general population, with
the assumption that a lower frequency is typically associated
with abnormal behavior. Statistical
deviance is determined by the context, including the temporal
context and the social/cultural
context. Thus, what is considered typical today may have been
labeled atypical in the past, and
vice versa.
Consider for example, the incidence of women engaging in roles
traditionally considered mascu-
line, such as playing competitive sports, which was very rare a
century ago, but today is not only
common, but is also considered healthy. Likewise, behavioral
standards and normative experi-
ences vary tremendously around the world. For example,
Windigo psychosis refers to a condition
sometimes observed in Native American (especially Algonquin)
Indians where the afflicted indi-
vidual believes that he has been possessed by a spirit that
results in a desire to consume human
flesh (cannibalism). This disorder is rarely observed in other
cultures. Or consider a disorder like
anorexia nervosa and its incidence in Western civilization, with
rates of occurrence of approxi-
mately 0.5% overall, but with higher rates among high school
and college-aged females at almost

6% (Makino, Tsuboi, & Dennerstein, 2004). This disorder,
however, is virtually non-existent in non-
Western cultures, with rates of approximately 0.0063%, even in
females (Kuboki, Nomura, Ide,
Suematsu, & Araki, 1996). Of course, there is no specific value
that defines statistical deviance,
and therefore this criterion is considered on a continuum.
Dysfunction in Daily Living
Simply being statistically unusual is not enough to consider a
behavior disordered because rare
behaviors and traits can be adaptive—and common behaviors
and traits, such as heavy alcohol
consumption among college students, are not necessarily
adaptive. Thus, an important addi-
tional feature is the extent to which the behavior or trait leads
to problematic functioning, or
dysfunction, in areas such as work, school, and relationships.
For example, if someone is very
task-driven and highly competitive, and this results in their
attaining considerable professional
success, establishing friendships, and attracting intimate
partners who like that trait, then it would
be considered adaptive. However, if that same level of
competitive drive results in the alienation
of intimate others, the inability to cooperate with colleagues,
and, therefore, less career success,
then the behavior would be more likely labeled as abnormal and
problematic.
The Experience of Distress
Behaviors and traits can also result in the individual or those
around them reacting with distress,
and this criterion can help define abnormality. In fact, the

individual’s own experience of distress
has been a major predictor (e.g., Cepeda-Benito & Short, 1998;
Kimerling & Calhoun, 1994; Mond
et al., 2009; see also Vogel & Wei, 2005) of help-seeking
behavior across a wide range of condi-
tions. From a practical standpoint, psychological distress
increases the likelihood that a contact/
interaction will occur with a mental health professional and that
a diagnosis will be made.
In addition to the individual’s own experience of it, distress can
affect others, and this will simi-
larly increase the potential for the individual being encouraged
(or even coerced) into treatment.
In this way, this criterion addresses the circumstance of people
who behave abnormally but have
very little self-awareness. In this instance, the psychological
distress is likely to be experienced by
those who interact with the individual. This criterion also
interacts closely with the criterion of
dysfunction, as the experience of distress leads to dysfunction.
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Danger to Self or Others
Some instances of behaviors and traits are a danger—risky or
harmful—either to the individual
or to others. Consider suicidal behavior, which can be
conceptualized as either an active (e.g.,
trying to take one’s own life) or passive (e.g., failure to engage
in safer actions or avoid high-risk

circumstances) threat to the self. Self-injurious behavior, which
is distinct from a suicide attempt,
would also be captured by this category of self-harm.
Regardless of the specific example, this cri-
terion emphasizes what might be considered the ultimate
dysfunction, as it threatens existence.
Moreover, such threats are also likely to involve distress by the
individual and others. Thus, even
though the criteria can be theoretically distinguished, from a
practical standpoint, they are highly
interrelated.
Criteria for Defining Problematic Functioning in Terms of
Personality
In addition to defining a behavior or trait along a continuum
from normal to abnormal, it is also
important to highlight the factors that help categorize it as a
problem specific to the domain of
personality. Disorders of personality are somewhat unique in
that they involve behaviors or traits
that are pervasive and longstanding. By pervasive we mean that
the problematic behavior or trait
emerges in virtually all aspects of the individual’s life (this
would be similar to Allport’s term, car-
dinal traits, as described in Chapter 8). By longstanding, we
mean that the problematic behavior
or trait has been present for a significant portion of the
individual’s life. As we shall see when
presenting the diagnostic criteria, personality disorders must be
present since at least late ado-
lescence or early adulthood, and therefore personality disorders
should generally not be assigned
until adulthood.
Despite the requirement that there be some durability to the
personality disorder over the life-

time, some research suggests that personality disorders may not
be stable in their presentation,
especially when there are overlying mood disorders, such as
anxiety and depression (e.g., Ottos-
son, Grann, & Kullgren, 2000). Studies have also found
somewhat modest temporal stability for
several measures of personality disorders (as indicated by the
test-retest reliability coefficients;
e.g., Trull, 1993), and it is unclear if this means that it is the
measures that are unstable or the
personality disorders themselves. Indeed, longitudinal studies
have generally questioned whether
personality disorders are, in fact, stable over time (Cohen,
Crawford, Johnson, & Kasen, 2005;
Skodol et al., 2005; Zanarini, Frankenburg, Hennen, Reich, &
Silk, 2005), and this may have some
important consequences for the construct itself (i.e., how we
define personality disorders).
Although this chapter will focus on the disorders of personality,
it is important to acknowledge that
personality functioning is a critical aspect of understanding how
other psychiatric disorders mani-
fest in the individual and how they can best be treated. For
example, a diagnosis of post-traumatic
stress disorder (PTSD) may present very differently for a highly
extraverted, conscientious, and
neurotic individual relative to one scoring low on these traits
(factors); both intervention strate-
gies and treatment outcomes may likewise be affected by these
traits (e.g., Bock, Bukh, Vinberg,
Gether, & Kessing, 2010; Canuto et al., 2009; Ogrodniczuk,
Piper, Joyce, McCallum, & Rosie, 2003).
Conceptualizing Personality Disorders
Beginning with the diagnostic system published in 1980 (DSM-

III; APA), there has been an interest
in considering personality disorders as extreme versions of
normal traits. In this approach, the dif-
ference between clinical and nonclinical manifestations of
personality would be quantitative, not
Lec81110_10_c10_283-312.indd 287 5/21/15 12:40 PM
qualitative. That is, personality disorders and normal
personality functioning would be defined
along the same continuum. In contrast, the more prevailing
historical trend was to consider clini-
cal (disordered) presentations of personality and nonclinical
(normal) presentations of personality
as qualitatively distinct, with medical terms used to define the
former and traits to describe the
latter. Using this approach, the two manifestations of
personality are considered categorically dis-
tinct. This highlights the division between at least two camps:
those that believe that personality
disorders are quantitatively different from normal personality
functioning (i.e., they are simply
extreme examples of the same traits) and those who believe that
there are important qualitative
distinctions that require the use of different constructs in
clinical and nonclinical settings (see
Clark, 2007; Strack & Lorr, 1994; Widiger & Samuel, 2005).
The categorical model that emphasizes
the qualitative distinctions continues to be a central feature of
the newest incarnation of the Diag-
nostic and Statistical Manual (DSM-5; APA, 2013).

A third, hybrid approach assumes that the quantitative
differences, when combined in certain
ways, can result in qualitative differences as well. There is
some support for the latter position,
as researchers have found that the traits that co-occur in
nonclinical populations differ from the
most common co-occurring traits in clinical settings (Livesley
& Jang, 2005).
Yet another way to address this conceptual issue is to consider
the distinction between abnormal
personality and disordered personality. Most researchers would
agree that abnormal personality
is simply a variant of normal personality (i.e., a statistical
oddity) that can be defined as an extreme
score (too little or too much) on the basic personality traits (see
also Eysenck, 1987; Wiggins &
Pincus, 1989). In contrast, a personality disorder implies
deficits in functioning and maladaptive
behavior (or in the very least, the absence of adaptive
behavior). Thus, in referring to the criteria
noted earlier in this chapter, statistical deviance allows for a
designation of abnormal, while some
of the remaining criteria, most notably the presence of
dysfunction, results in a qualitatively dif-
ferent label (a disorder). Indeed, statistical deviance by itself is
neither necessary nor sufficient to
meet criteria for a disorder.
Although the qualitative versus quantitative distinction may
seem like nothing more than a the-
oretical debate, there are in fact some important implications.
For example, if one adopts the
qualitative model, then it would be necessary to develop
separate measures for use in clinical and
nonclinical settings (this is in fact the most common practice

today). In contrast, the quantitative
model would not require separate measures to be developed,
only separate norms (i.e., to quan-
tify the typical scores in clinical settings).
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CHAPTER 10 10.2 Types of Personality Disorders
10.2 Types of Personality Disorders
In 2013, the Diagnostic and Statistical Manual of Mental
Disorders, Fifth Edition (DSM-5) was published by the
American Psychiatric Association (2013). Previous versions of
the DSM adopted a multi-axial system to categorize disorders.
Axis I identified the clinical disorders and conditions
that might be the focus of clinical attention. Axis II included
the personality disorders, learning dis-
orders, and mental retardation. Axes III through V covered
medical disorders, psychosocial prob-
lems (e.g., homelessness, job loss, etc.), and a global (overall)
rating of individuals’ functioning,
respectively. Traditionally, there has been considerable
diagnostic overlap and interdependence
between the five axes, and in particular Axes I and II.
The DSM-5 adopts a very different approach by completely
dropping the multi-axial system, and
combining what was formerly categorized as Axes I, II, and III
into a single diagnostic system, owing
largely to the considerable overlap among the axes and the
artificial nature of separating these dis-
orders. This now aligns the DSM more closely with the most
widely used diagnostic system around

the world: the World Health Organization’s (WHO)
International Classification of Diseases (ICD).
The disorders of the DSM-5 are now organized based on their
relatedness to each other, focusing
on such factors as symptom overlap and similar underlying
vulnerabilities. The DSM-5’s documen-
tation of diagnoses does retain separate notations for
psychosocial and contextual factors, as well
as disability (formerly Axes IV and V, respectively), and none
of the 10 personality disorders defined
in the previous DSM-IV have changed with respect to their
specific criteria in DSM-5.
According to the DSM-5 (APA, 2013), personality disorders
must also present in at least two of the
following four areas:
1. cognition (i.e., thinking; referring specifically to perceptions
of the self, others, and
events)
2. affect (i.e., emotional experiences, referring specifically to
impact on affective range,
lability, intensity, and appropriateness)
3. interpersonal functioning (i.e., relationships)
4. impulse control (i.e., the ability to, essentially, delay
gratifying one’s needs and wants)
By requiring that at least two of the above-mentioned areas be
affected, this assures that person-
ality disorders will be pervasive in their impact on the
individual’s life, and this is in keeping with
the definition of personality.
Up to this point in the chapter, the more general requirements of

personality disorders have been
reviewed. Now we turn our attention to the specific diagnostic
criteria for each disorder. Each of
the personality disorders and their diagnostic criteria will be
presented here, as forwarded in the
DSM-5. Importantly, the presence of the previously noted
features (e.g., distress, dysfunction,
pervasiveness, etc.) is necessary for the diagnosis of a
personality disorder in general, whereas the
following criteria are necessary for the diagnosis of a specific
disorder.
The personality disorder criteria are presented in three
groupings, referred to as clusters. There is
more symptom overlap within clusters rather than between the
clusters.
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Cluster A Personality Disorders
The cluster A personality disorders all involve odd or eccentric
behavior, resulting in decreased
socialization experiences and often increased isolation. Such
behavior will most closely match the
presentation seen with other clinical disorders with psychotic
symptoms, such as schizophrenia or
mood disorders with psychotic features. To qualify for the
diagnosis of a personality disorder, the
symptoms cannot be better explained by one of the clinical
disorders.
Paranoid Personality Disorder

The primary presenting features of paranoid personality
disorder is a persistent and universal
distrust and suspiciousness of others. These individuals
interpret the intentions of others as hos-
tile and demeaning in nature, and as a result they often take
umbrage to these perceived slights
and respond with anger and provocation. Importantly, the
suspiciousness is without justification
and may be very subtle (if present at all), even though the
general themes may be common (e.g.,
fidelity of an intimate partner, loyalties of others, persecution
from a government agency, etc.).
Thus, the symptomatic nature of the paranoid presentation is
made most obvious by its recurrent
nature.
Because of these beliefs, close relationships will be difficult to
maintain, both because of the per-
ception of attack and threat from others and because of the
counterattacks that invariably occur.
As a result, they often engage in social isolation and self-
sufficiency, they may present as emo-
tionally volatile, and they typically blame others for their
shortcomings. According to the DSM-5,
stress may exacerbate paranoia, and this personality disorder
may be a precursor to a more severe
psychotic presentation (i.e., schizophrenia). Prevalence rates
have ranged from 2.3% to 4.3%, with
the disorder being more commonly diagnosed in males (DSM-5;
APA, 2013).
Schizoid Personality Disorder
The primary presenting feature for schizoid personality disorder
is flat affect and disengagement

from social interactions. Due at least in part to their lack of
emotional experience, these individu-
als have few interests and goals in life, and they do not desire
or derive pleasure from close rela-
tionships. As a result, these individuals present as indifferent
and detached; they tend to choose
to engage in isolated activities. They are unlikely to have
friendships or close connections (e.g.,
they rarely date or marry), and aside from first-degree relatives,
they may have no one in whom
they might confide.
As was the case for paranoid personality disorder, the schizoid
individual may experience height-
ened symptoms during times of stress, and this disorder may be
a precursor to a delusional disor-
der or schizophrenia. Prevalence rates range from 3.1% to 4.9%,
and this disorder is slightly more
common in males (DSM-5; APA, 2013).
Schizotypal Personality Disorder
The diagnostic category for schizotypal personality disorder
includes a wide range of symptoms
that parallel what is often seen with schizophrenia, though
symptoms tend to be less acute but
more pervasive. Symptoms include referential thinking (i.e.,
mistakenly believing that the actions
of others or events have special meaning or significance for the
individual); magical thinking, which
includes superstitious beliefs as well as belief in telepathy or
clairvoyance; odd or unusual percep-
tions; and unusual thinking or speech. Individuals with this
diagnosis also have either restricted or
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inappropriate affective responses, and their behavior can be
characterized as peculiar. Schizotypal
personality disorder also tends to result in social isolation, with
few if any close relationships, and
the presence of social anxiety that is unaffected by the
familiarity of those with whom they inter-
act. Paranoia may be present, but it is not the primary or
dominant symptom, as with paranoid
personality disorder. Likewise, restricted affect and social
withdrawal are also present but are less
prominent relative to schizoid personality disorder.
As with the other cluster A personality disorders, schizophrenia
and other psychotic disorders may
manifest later in life, though this occurs in a relatively small
percentage of those affected. Between
30% and 50% of those with schizotypal personality disorder
have a co-occurring major depressive
disorder. The prevalence rates for the cluster A personality
disorders range from 3.9% to 4.6% in
the United States, but the rates are much lower in other parts of
the world (e.g., less than 1% in
Norway). This disorder also appears to be slightly more
common in males, and this is considered
one of the more stable personality disorders, in that symptoms
tend to present in a consistent
manner throughout one’s life (APA, 2013).
Differentiating schizophrenia from the personality disorders of
schizotypal, schizoid, and paranoid
is complex, and misdiagnoses can occur. Research suggests that

one of the more effective ways
of differentiating schizophrenia from the personality disorders
is that the former tends to have
more of what are referred to as the positive symptoms (e.g.,
active hallucinations and delusions),
whereas such symptoms are more subtle or even absent with the
cluster A personality disorders.
Instead, it appears to be symptoms such as social and physical
anhedonia that characterize the
personality disorders (e.g., Clementz, Grove, Katsanis, &
lacono, 1991; Kendler, Thacker, & Walsh,
1996).
Cluster B Personality Disorders
The cluster B personality disorders
involve dramatic or emotional behavior,
and although relationships will be pres-
ent, there will be conflict, instability,
and exploitation. Moreover, unlike the
cluster A personality disorders, those in
this cluster typically present with con-
siderable affect and affective dysregula-
tion. This cluster most closely resembles
the mood disorders, although a cluster
B personality disorder diagnosis should
not be applied if the behavior is better
accounted for by a mood disorder.
Antisocial Personality Disorder
This diagnosis is explicitly not permit-
ted until the individual is aged 18 or
older, and a conduct disorder diagno-
sis is common prior to the age of 15.
Antisocial personality disorder also differs from other
personality disorders in that it tends to

remit, or at least become less prominent, on its own, thereby
suggesting that this is part of its
normal course (i.e., with more pronounced presentation earlier
in life).
Click Images/iStock/Thinkstock
Antisocial personality disorder is much more common
in this context, with rates as high as 70 percent of
incarcerated men.
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The most prominent feature of this disorder is the universal and
longstanding practice of complete
disregard for social norms, with the individual typically
engaging in a long history of illegal behav-
ior. In fact, these individuals often come to clinical attention by
way of the police (i.e., they rarely
present for voluntary assessment or treatment of antisocial
traits). These individuals routinely vio-
late the rights of others, with little regard, remorse, concern, or
empathy. They are callous, cynical,
aggressive (e.g., fights, assaults, etc.), irritable, impulsive,
reckless, and irresponsible. They pres-
ent as opinionated and even arrogant, with a superficial charm
and glib demeanor.
Because deceitfulness (lying) is a common feature of this
personality disorder, there is often a
history of taking advantage of others for personal (typically
material) gain. The prominence of

deceitfulness can be problematic from a diagnostic standpoint,
as the clinician often relies on the
individual’s self-report to arrive at a diagnosis. Thus, it is often
necessary to rely more on objective
information, such as arrest records and legal history, to arrive at
an accurate diagnosis.
Antisocial personality disorder may be comorbid (co-occur)
with mood disorders, substance abuse
disorders, and impulse control disorders. According to the
DSM-5 (APA, 2013), prevalence rates
range from 0.2% to 3.3%, though rates can exceed 70% among
males in legal and forensic set-
tings and substance abuse clinics. The disorder is significantly
more common in males relative to
females (approximately three times greater in males; Eaton et
al., 2012), though there are some
concerns that this difference is due to an overemphasis on the
symptoms of aggression. Spe-
cifically, a recent study suggests rates of 1.9% for females and
5.5% in males (Eaton et al., 2012).
Socioeconomic status also appears to be a risk factor, with
higher rates among those who are
economically depressed.
Borderline Personality Disorder
The trajectory for borderline personality disorder appears to
result in decreasing symptoms as the
individual ages, with greater stability beginning during the
individual’s third and fourth decades
of life. The most noteworthy symptoms include instability of
affect and relationships, with the
individual making dramatic attempts to avoid perceived
abandonment by others. Those with bor-
derline personality disorder often vacillate between the

idealization of others and the complete
devaluing of others, thereby leading to unstable relationships.
Feelings of emptiness, anger, and
problems with intense anger control are common, along with
instability of the individual’s self-
image. Impulsive and self-damaging behavior is common,
sometimes marked by suicidal behavior
or threats. The suicidal behavior may be best described as
suicidal gestures, as they can often be
described as high-visibility acts (i.e., making them known to
others) with low lethality, thereby
suggesting that the primary purpose of such behavior is to
manipulate others and avoid abandon-
ment. These individuals also have a pattern of disengaging from
goal-directed behavior shortly
before accomplishing a goal, and, as a result, they tend to be
underachievers.
At times of stress, psychotic symptoms can occur, and mood
disorders are also comorbid with
borderline personality disorder. Histories of physical and sexual
abuse, along with neglect, are
commonly observed in the families of origin. Prevalence rates
range from 1.6% to 5.9%, with
the higher end of that range seen in primary care settings.
Upwards of 10% prevalence rates are
observed in outpatient mental health settings and up to 20% of
those in inpatient psychiatric
facilities. This disorder is largely diagnosed in females
(approximately 75% of cases are female)
(DSM-5; APA, 2013).
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Histrionic Personality Disorder
Prominent features of histrionic personality disorder include a
dramatic and exaggerated emo-
tional presentation that is almost theatrical in nature. These
individuals often inappropriately
sexualize situations, presenting as seductive and provocative,
even when such behavior is clearly
inappropriate (i.e., either the situation is inappropriate or the
target is inappropriate). These indi-
viduals strive to be the center of attention and often use their
physical appearance to draw atten-
tion to themselves. Depression or intense emotional reactions
can occur when they are not the
center of attention. Histrionic personality disorder involves
rapidly shifting and shallow emotions
(e.g., uncontrollable sobbing and temper tantrums), and speech
is often shallow and impression-
istic. They may depict themselves as victims in relationships
with others.
Histrionic personality disorder is comorbid with somatization
and mood disorders. Prevalence
rates are estimated to be approximately 1.8% in the general
population, and females appear to be
more commonly diagnosed than males (DSM-5; APA, 2013).
Narcissistic Personality Disorder
The most prominent feature for narcissistic personality disorder
is a grandiose self-presentation,
with an attendant need to be admired. These individuals will
often exaggerate their achievements
(which are often quite ordinary) and thus expect to be

recognized as superior to others. Narcis-
sistic personality disorder involves excessive self-absorption,
with fantasies of power and success
and even intellectual prowess and beauty. They present as
entitled, expecting favorable treatment
from others. This also leads to interpersonal exploitation and a
lack of empathy (i.e., unwilling or
unable to recognize the viewpoint of others). Interestingly,
despite presenting as superior, their
self-esteem tends to be very fragile (hence the need for
excessive admiration), and they can react
quite strongly to perceived criticism.
This disorder co-occurs with mood disorders, anorexia nervosa,
and substance abuse disorders
(especially cocaine). Depending on the stringency of the criteria
use, prevalence rates for narcis-
sistic personality disorder can range from 0% to 62% in the
general community, and males com-
prise 50–75% of the diagnosed cases. This indicates that this
disorder has one of the largest ranges
in prevalence (DSM-5; APA, 2013).
Cluster C Personality Disorders
Cluster C personality disorders are marked by fear and anxiety.
Interpersonal relationships occur,
but may be limited. Each of these disorders has a parallel
clinical disorder that shares similar fea-
tures but is nevertheless distinct.
Avoidant Personality Disorder
Individuals with avoidant personality disorder are socially
inhibited and are fearful of, and hyper-
sensitive to, negative evaluations from others. For these
reasons, these individuals avoid interper-

sonal interactions, fearing that they will be criticized and
rejected. Thus, they may only interact
with others if they are assured or certain of being liked and
accepted (i.e., they require consider-
able nurturance and support). Those with avoidant personality
disorder consider themselves as
inept, unappealing, inadequate, and inferior. They often
exaggerate the potential for and conse-
quences of interpersonal failure, choosing instead to remain
isolated and safe.
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This personality disorder has considerable overlap with social
phobia, agoraphobia, and other
mood and anxiety disorders. This diagnosis can also co-occur
with dependent personality disor-
der, because they identify a small number of close trusted
friends to help them navigate daily life.
Prevalence rates are approximately 2.4% in the general
population (DSM-5; APA, 2013).
Dependent Personality Disorder
Individuals with dependent personality disorder exhibit a
pervasive need to be cared for by oth-
ers. They are overly reliant on close friends or family and
constantly fear losing that support net-
work. They are extremely reluctant to make decisions for
themselves, even minor decisions (e.g.,
what clothing to wear, what movie to see, what restaurant to
select, etc.), and are reluctant to take

any personal responsibility for their actions. They constantly
seek the advice and guidance of oth-
ers, and they require considerable reassurance. Because of their
dependence on others, they are
reluctant to express any disagreement; they fear losing the
support of others. Even acts that may
lead to greater independence are met with fears of losing social
support, thereby undermining
the desire to be more independent. These individuals are also
willing to engage in self-sacrifice to
maintain a relationship and may be willing to endure demeaning
and humiliating circumstances.
This sometimes results in their tolerating emotional, verbal,
physical, or sexual abuse at the hands
of those upon whom they depend.
This diagnosis is generally not recommended for use in children
or adolescents. Mood disorders
most often co-occur with dependent personality disorder, and
typically there is a higher rate of
occurrence in females. Prevalence rates are approximately 0.5%
in the population (DSM-5; APA,
2013).
Obsessive-Compulsive Personality Disorder
Individuals with obsessive-compulsive personality disorder are
overly preoccupied with details
and trivial rules; they are stubborn; and they follow rigid moral
standards, often forcing others to
do so as well. Although they consider themselves to be
perfectionists, their perceived perfection-
ism actually interferes with the completion of tasks and the
accomplishment of goals (or, in the
very least, the missing of deadlines) because of their meticulous
preoccupation with details and

standards. They will refuse help even when they are behind
schedule and are unwilling to delegate
responsibilities to others because of concerns that others will
not complete the task in a manner
consistent with their own standards. If they do allow others to
help, they will provide detailed
instructions and are unwilling to compromise on how things
should be done (i.e., there is only one
way to accomplish any given task). Relationships are often
compromised because they cannot see
the perspective of others, and they lack awareness of the
frustration they cause in others with
their overly meticulous and rigid manner.
They are very poor allocators of time, sometimes spending more
time planning an activity than
actually executing it. For example, a student with obsessive-
compulsive personality disorder might
spend more time developing a study schedule and plan than
actually studying for the test; he or
she might not even get to the point of studying.
These individuals often adopt extreme cautiousness in spending
both for themselves and others,
and they may find it difficult to discard even worthless objects.
Those with obsessive-compulsive
personality disorder often feel they are too busy to take any
time off or engage in any pleasurable
activities like vacations. Excessive time is often spent on
household chores, such as cleaning.
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Anxiety disorders often co-occur with obsessive-compulsive
personality disorder, including
obsessive-compulsive disorder (the latter involves repeatedly
having an obsessive thought and
then repeatedly engaging in ritualistic behavior to decrease the
anxiety associated with that
thought). Obsessive-compulsive personality disorder tends to
show little variability over one’s
lifetime. Prevalence rates in the general population range from
2.1 to 7.9%, and the disorder is
diagnosed in males about twice as often as females (DSM-5;
APA, 2013).
Other Specified Personality Disorder
When individuals do not fit into any of the aforementioned
categories, but they still have person-
ality patterns that result in deviance, dysfunction, distress,
and/or danger, then they may qualify
for other specified personality disorder. In such instances, it is
also possible to list the associated
features, some of which could correspond to the other
diagnostic categories (e.g., antisocial fea-
tures) while others might not (e.g., passive-aggressive features).
This diagnosis is also given when
mixed personality features are present.
The Prevalence of Personality Disorders
Personality disorders do not reflect acute problems or changes
in functioning because, much like
personality itself, they are stable and almost lifelong in their
presentation. Thus, researchers esti-
mate that those with personality disorders may be under-
represented in clinical settings; thereby
leading to an underestimation of their occurrence in the general
population.

One of the largest (N = 5,692) and most recent attempts at
determining the prevalence of person-
ality disorders in the United States was published in 2007 and
used DSM-IV criteria. The data are
still relevant because there have been few functional changes in
the criteria for the personality
disorders between the DSM-5 and the previous version.
Researchers concluded that the incidence
of personality disorders in the general population was
approximately 1 in 11 (9.1%). Research also
finds that obsessive-compulsive personality disorder is one of
the most common, with narcissistic
and borderline personality disorders being the next most
common (Lenzenweger, Lane, Loranger,
& Kessler, 2007).
Relative to other countries, the United States appears to have a
consistent and stable pattern of occur-
rence, whereas greater variability is seen elsewhere.
Specifically, outside the United States, published
rates range from approximately 6% to 13%, but the average of
these figures is commensurate with
U.S. rates (Sansone & Sansone, 2011). It also appears to be the
case that personality disorders are at
least as common among those who identify as ethnic minorities
(e.g., Blacks and Latinos) as among
those who identify as White in America (e.g., Crawford,
Rushwaya, Bajaj, Tyrer, & Yang, 2012).
Not surprisingly, researchers examining psychiatric samples
have found high rates of occurrence and
comorbidity (co-occurrence of different disorders). For
example, in one such study, 23% of admitted
psychiatric patients were found to have a personality disorder
(Mors & Sørensen, 1994). Moreover,

the researchers found that of those diagnosed with
schizophrenia, 44% also had a personality disor-
der (PD), while 20% of those with mood disorders also had a
PD (Mors & Sørensen, 1994). In general,
it appears that meeting criteria for one personality disorder
makes it more likely that the individual
will meet criteria for a second personality disorder, and those
with a personality disorder are more
likely to also have a diagnosed clinical (formerly Axis I)
disorder.
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There are several possible explanations
for the high comorbidity with personal-
ity disorders, including the fact that the
diagnostic criteria overlap to a certain
degree, that having one diagnosis simply
increases the possibility that one will be
diagnosed for any other disorder, and
that problems of one kind increase the
probability that one will manifest other
types of problems. The issue of comor-
bidity is especially important when con-
sidering where the data are collected.
That is, when studying clinical samples
(those seeking treatment) it is reason-
able to assume that comorbidity will be
higher because multiple problems are
precisely why these individuals are seek-
ing treatment.

Personality Disorders as Primarily Adult Disorders
Although one might be tempted to assign a personality disorder
(e.g., narcissistic personality
disorder) to an adolescent girl who appears egocentric in her
thinking, or antisocial personality
disorder to a young, undisciplined boy, it is important to note
that personality disorders are sup-
posed to have a history of at least one year and have begun to
manifest since late adolescence
or early adulthood. In fact, the DSM-5 explicitly states that
some PDs, like antisocial personality
disorder, should not be diagnosed prior to the age of 18.
Instead, other diagnoses would be more
appropriate. As an example, a conduct disorder would be a more
appropriate diagnosis for a per-
sistently disobedient child, whereas similar behavior as an adult
would be more appropriately
labeled antisocial in nature. Similarly, an identity disorder
might be a more appropriate diagnosis
for a teenager, whereas the same behaviors (identity
disturbance) would be better characterized
as borderline personality disorder as an adult. Finally, it is
noted that behaviors that manifest in
childhood and even adolescence may not continue to manifest
into adulthood, even those that
are thought to reflect highly stable characteristics. Consider the
research showing that a signifi-
cant portion of adolescents who are diagnosed with antisocial
traits (e.g., psychopaths), do not
exhibit this behavior when they are later assessed as adults
(e.g., Lynam, Caspi, Moffitt, Loeber, &
Stouthamer-Loeber, 2007; Salekin, Rosenbaum, Lee, & Lester,
2009).
Alternative Organizational Models for the Personality Disorders

The DSM nosological (referring to the science of diagnostic
classification) structure is the domi-
nant model used in the United States to organize psychiatric
disorders, including the personality
disorders (as noted in the previous section). Other
organizational systems exist; some of the alter-
native models are here briefly reviewed.
Creatas/Thinkstock
Although a child may exhibit disobedient behavior, a
conduct disorder diagnosis is more appropriate than an
antisocial personality disorder diagnosis.
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The International Classification of Diseases, 11th Revision
(ICD-11)
The World Health Organization (WHO) publishes the ICD and
reports that the final version of the
International Classification of Diseases, 11th Revision (ICD-11)
will be officially endorsed in 2015,
though a draft of the proposal was made available in 2012. The
current version, the ICD-10, was
published in 1992 by WHO. Regardless of the specific version,
this health classification system is
used around the world to facilitate diagnoses.
The ICD system assesses the severity of personality disorders
using the following five levels:

1. normal personality
2. personality dysfunction
3. personality disorder
4. complex personality disorder
5. severe personality disorder
There are five personality disorder dimensions of the ICD
system: asocial/schizoid, dissocial,
obsessional/anankastic, anxious-dependency, and emotionally
unstable. According to the ICD-11
draft, the last dimension will be incorporated into the anxious-
dependency dimensions, such that
anxious-dependency can be either anxious-dependency or
emotional instability. Another signifi-
cant change proposed for the ICD-11 is that the clinician will
determine whether the disorder is
present, rather than determining severity.
This system is quite different from the DSM-5, in that the ICD’s
five categories are considerably
fewer than the DSM-5’s ten categories, and the ICD rates the
severity of the disorder, whereas the
DSM only allows one to indicate whether it is present.
Millon’s Model for Classifying Personality Disorders
Millon devised a model to define both normal and clinical
manifestations of different personality
traits (i.e., a continuum approach), he tied his diagnoses to a
theoretical (evolutionary) model (the
DSM is atheoretical; that is, the categories are not based on any
underlying theory), and he tied
the diagnostic categories to a specific measure (the DSM is not
tied to any assessment tool). Mil-
lon’s model, which can be derived from the Millon Clinical
Multiaxial Inventory-III (MCMI-III/; see

the next section of this chapter which examines the MCMI-III/
along with other assessments of
personality disorders), includes a total of 15 traits. Those
defined under the clinical heading essen-
tially parallel the DSM-5 disorders; the first 10 match the DSM,
whereas the last 5 are additional
categories (see Table 10.1).
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Table 10.1: Millon’s personality disorder classifications and
corresponding
normal traits
Normal Clinical
Retiring Schizoid
Eccentric Schizotypal
Suspicious Paranoid
Sociable Histrionic
Confident Narcissistic
Nonconforming Antisocial
Capricious Borderline
Conscientious Compulsive

Shy Avoidant
Cooperative Dependent
Exuberant Hypomanic*
Skeptical Negativistic*
Aggrieved Masochistic*
Pessimistic Melancholic*
Assertive Sadistic*
*Additional category that does not match the DSM
Source: Adapted from Millon, T. (2011). The disorders of
personality: Introducing a DSM/ICD spectrum from normal to
abnormal (3rd
ed.). Hoboken, NJ.: John Wiley & Sons Inc.
Millon believed that most individuals would not present with a
“pure” personality prototype,
but would instead present with a mixed picture of several of the
personality variants. For exam-
ple, Millon suggested that the schizoid personality had four
subtypes: (1) remote (i.e., avoidant,
schizotypal features), (2) languid (i.e., melancholic features),
(3) affectless (i.e., compulsive fea-
tures), and (4) depersonalized (i.e., schizotypal features) (see
Millon & Davis, 1996b).
The Five Factor Model for Classifying Personality Disorders
Researchers have also suggested that the Five Factor Model
(FFM; introduced in Chapter 8) can
also serve to organize personality disorders. The advantage of

using this model is that it allows
for continuity between clinical and nonclinical manifestations
of personality disorders, and it is
based on a more empirically sound and tested model for
organizing traits (Widiger, 2005). This is
in sharp contrast to the DSM structure, which has always
struggled to establish construct validity
(e.g., Livesley, 2001).
In two independent reviews of the literature (Saulsman & Page,
2004; Widiger & Costa, 2002),
researchers have found that the disorders of personality fit very
well into the Five Factor Model
of personality. Moreover, even lexical studies of the descriptive
terms used for the personality
disorders (e.g., Coker, Samuel, & Widiger, 2002) suggest
considerable overlap between the DSM
nomenclature and the Five Factor Model (see also Widiger,
2005; Widiger, Trull, Clarkin, Sander-
son, & Costa, 2002).
As an example, schizotypal PD is defined by high neuroticism,
low extraversion, and high openness
to new experience (see Widiger et al., 2002, Table 6.1). The
same researchers found that histrionic
PD is defined by high scores on neuroticism, extraversion,
agreeableness, and openness to new
Lec81110_10_c10_283-312.indd 298 5/21/15 12:40 PM
experience. Obsessive-compulsive PD is defined by high scores
on extraversion and conscientious-

ness, and low scores on agreeableness and openness to new
experience.
Summary
Obviously, the models defining personality disorders that have
been put forth vary considerably
in their structure and basic assumptions. Moreover, research
comparing several of the models
defining personality disorders reviewed here suggests that
Millon’s configuration tends to have
the least support, followed by the DSM which has moderate
support. The strongest support has
emerged for the Five Factor Model, or similar, empirically
derived variants (O’Connor & Dyce,
1998). Of course, the Five Factor Model has yet to be employed
in clinical practice. Therefore,
although it is strong with respect to its basic scientific roots,
research is needed to see how effec-
tively it can translate to applied clinical settings.
Questioning the Legitimacy of Mental Illness
The basic thesis of this chapter is that psychiatric illnesses such
as personality disorders are legit-
imate—that they can be defined and organized into a coherent
structure, assessed, and even
treated. However, there have been some theorists who have
taken a very different position on the
matter. Although we have just presented the various criteria for
the DSM personality disorders, we
will now consider an anti-establishment perspective.
Thomas Szasz was a psychiatrist who was one of the most vocal
anti-psychiatry voices in the field.
Szasz argued that psychiatric illnesses (which would include
personality disorders) are essentially

fabricated (e.g., Szasz, 1960, 2011a). Specifically, Szasz
contrasted mental illness with medical con-
ditions like cancer and argued that the medical model should
not be applied equally to mental
illness. Szasz argued that, unlike physical illnesses, there is no
way to definitively determine if
mental illness is present in any given individual, as there is no
test or objective method that allows
one to find a disease from the DSM or any other classification.
Instead, Szasz argues that mental ill-
ness defines unusual behavior but that
what we define as a mental illness is a
social construct, reflecting the prevail-
ing views of the professionals governing
the field. Szasz argues that the decision
about what to include in the DSM is
arbitrary; one version has homosexual-
ity as a disorder, while the next version
removes homosexuality but adds pre-
menstrual syndrome. Szasz argues that
true diseases do not move in and out of
favor; they should be more objectively
observable.
Szasz was also a strong proponent of giv-
ing people control over their lives rather
than imposing a diagnosis and, worst
of all, an involuntary treatment. Thus,
Szasz wouldn’t argue with someone who
.Getty Images/Dynamic Graphics/Creatas/Thinkstock
Previous versions of the DSM considered homosexuality
to be a disorder. Szasz argues that this and all other DSM
“disorders” simply reflect social and cultural standards,

not diseases.
Lec81110_10_c10_283-312.indd 299 5/21/15 12:40 PM
CHAPTER 10 10.3 Assessing Personality Disorders
wanted to change for self-improvement. His concern was with
the imposition of treatment (i.e.,
involuntary commitments), especially given the arbitrary nature
of mental illness.
In his 1988 book, Cruel Compassion, Szasz argued that we
justify our attempts to control and
change others by considering the behavior as compassion, when
in reality it is cruelty to impose
unwanted treatment on others. In fact, he argued, we are being
selfish, because the true justi-
fication for our behavior is to either (1) change those who
remain in society (i.e., those we have
to interact with) with medications, surgeries (e.g., lobotomies),
or therapy, or (2) relegate those
who do not change to psychiatric hospitals so we do not have to
interact with them. Because the
field of psychiatry essentially substituted the term disease
(mental illness) for bad or undesirable
behavior, this now legitimizes treatment (Szasz, 1988; see also
Szasz, 2011b).
Szasz was not alone in his criticism of the DSM. For example,
despite the American Psychiatric
Association’s endorsement of the DSM-5, the current director of
the National Institute of Mental
Health (NIMH), Dr. Thomas Insel, has expressed concerns over
the lack of validity of the DSM-5

and its overreliance on symptoms to diagnose disorders.
Of course, Szasz’s perspective does not reflect the majority
view, but there are some important
arguments that should be considered, including the fact that the
determination of what consti-
tutes a disorder is essentially a process of consensus and is
subject to change. Thus, we should be
cautious of attributing too much importance to any specific
diagnostic criteria such as the DSM.
Moreover, if we accept that diagnostic categories are less than
definitive, then we must be espe-
cially cautious about imposing treatments on the individual, as
those treatments are based on the
assumption that the underlying problem to be changed is real.
Szasz’s critics countered that he
was an extremist in his position,
and like the very field he was
critiquing, he overstated reality.
For example, even though label-
ing behavior as a “mental illness”
may overstate reality, so too does
a complete denial that there is
any problem (see Phillips et al.,
2012, for a complete discussion
of these issues, especially as they
apply to the DSM-5).
10.3 Assessing Personality Disorders
Several measures have been developed and validated to broadly
assess psychiatric disorders, including personality disorders.
We will here review three of the more commonly studied,
modern-day measures.
The Minnesota Multiphasic Personality Inventory (MMPI®-2)

As noted in Chapter 1, this instrument is often considered the
gold standard in the assessment of
psychopathology because it is one of the most frequently used
instruments, and it is arguably the
most widely researched measure (Graham, 2006).
Beyond the Text: Classic Writings
In this 2001 paper, Thomas Szasz attempts to discredit the
legitimization of psychiatric disorders. Read it at http://
www.independent.org/pdf/tir/tir_05_4_szasz.pdf.
Reference: Szasz, T. (2001). The therapeutic state: The
tyranny of pharmacracy. The Independent Review, V(4),
485–521.
Lec81110_10_c10_283-312.indd 300 5/21/15 12:40 PM
http://www.independent.org/pdf/tir/tir_05_4_szasz.pdf
http://www.independent.org/pdf/tir/tir_05_4_szasz.pdf
The instrument was developed by comparing samples of those
who had a particular psychiatric
diagnosis to control groups with no psychiatric diagnosis (the
Minnesota normals) with respect to
their responses on a large number of items. The items that were
consistently answered in a dif-
ferent way by the criterion group (those diagnosed) and the
control groups formed the basis of
the initial scales. These scales were then cross-validated
(replicated in other criterion and control
groups) and the items that survived comprised the original
MMPI-. It was revised in 1989, result-

ing in a 567-item true/false inventory (the MMPI--2; Butcher,
Dahlstrom, Graham, Tellegen, &
Kaemmer, 1989).
The MMPI--2 has validity measures to assess the respondent’s
test-taking approach (i.e., under-
or over-reporting), basic scales to assess several clinical
syndromes, and supplemental scales
that assess such areas as general adjustment, ego strength, how
one handles the expression of
anger and hostility, and substance abuse measures, to name a
few. The 10 basic scales from the
MMPI--2 are summarized in Table 10.2.
Table 10.2: Ten basic scales and descriptors from the MMPI--2
Scale Abbreviation—Name Description
1 Hs – Hypochondriasis somatic complaints, constricted by
symptoms
2 D – Depression dysphoria, shy, irritable, guilt ridden
3 Hy – Hysteria sudden anxiety, naïve, self-centered, infantile
4 Pd – Psychopathic deviate poor judgment, antisocial,
irresponsible, hostile
5 Mf – Masculinity–Femininity *traditional masculine or
feminine traits
6 Pa – Paranoia ideas of reference, angry, resentful, suspicious
7 Pt – Psychasthenia ruminating, anxiety, fearful, apprehensive
8 Sc – Schizophrenia disordered thinking, delusional, bizarre,

alienated
9 Ma – Hypomania expansive, grandiose, euphoric, overly
extended
0 Si – Social Introversion withdrawn, aloof, insecure, low self-
confidence
* This scale is scored separately by gender. High scores for
each gender denote a gender stereotype
consistent presentation.
Source: Adapted from Butcher, J. N., Dahlstrom, W. G.,
Graham, J. R., Tellegen, A., & Kaemmer, B. (1989). Minnesota
Multiphasic
Personality Inventory-2 (MMPI-2): Manual for administration
and scoring. Minneapolis: University of Minnesota Press.
One of the unique features of the MMPI--2 is that it is not
closely aligned with any theoretical
perspective, given that the selection of items was based almost
exclusively on the statistical dif-
ferentiation of groups. In fact, this technique for scale
development was sometimes referred to as
a “black box” or empirical approach to item selection because
of the lack of clear theory-driven
decisions.
Three more recent updates to the MMPI--2 are noteworthy. The
first was a significant psycho-
metric revision that resulted in the addition of the Restructured
Clinical (RC) Scales (Tellegen et al.,
2003). These scales were designed to be more psychometrically
sound than the original MMPI--2
clinical scales and they attempt to control for a response
tendency (demoralization) that results in
considerable overlap among the scales.

The second change occurred in 2008 with the publication of the
MMPI--2-RF (Restructure Form;
Ben-Porath & Tellegen, 2008), which was based on the RC scale
revision. This new measure, which
provided further psychometric improvements over the MMPI--2,
is briefer than the previous
Lec81110_10_c10_283-312.indd 301 5/21/15 12:40 PM
versions (338 true/false items), thereby simplifying the
resources needed to administer and inter-
pret the measure.
Finally, it should be noted that new MMPI--2 scales, the
Personality Psychopathology
Five (PSY-5)—Aggressiveness (AGGR), Psychoticism (PSYC),
Disconstraint (DISC), Negative
Emotionality/Neuroticism (NEGE), and Introversion/ Low
Positive Emotionality (INTR)—were
also introduced to parallel the dominant theoretical framework
in personality psychology, the
Five Factor Model (discussed at length in Chapter 8). However,
these new PSY-5 scales were
thought to have relevance in both clinical and nonclinical
settings and are not intended as a
substitute or proxy for the big five (Harkness, McNulty, Ben-
Porath, & Graham, 2002). The PSY-5
scales differ from the five factors identified in nonclinical
populations, in that the former were
meant to determine the extent to which personality disorders
might manifest and be recogniz-

able in clinical populations (see Harkness et al., 2002). They
also differ from the other MMPI--2
scales by adding significantly to the prediction of personality
disorders (Wygant, Sellbom,
Graham, & Schenk, 2006).
Personality Assessment Inventory (PAI®)
The PAI- is a 344-item measure that assesses 22 non-
overlapping scales that were intended to
broadly assess psychiatric disorders, and like the MMPI- scales,
it also includes validity indexes
(Morey, 2007). Its 11 clinical scales are grouped within the
neurotic and psychotic spectrum,
and a third grouping is referred to as behavioral disorders or
problems of impulse control. Other
scales assess such constructs as complications and motivation
for treatment, harm potential, and
interpersonal relations, to name a few. Two specific clusters of
personality disorder traits are also
assessed: borderline and antisocial.
The PAI- has normative data from patients, students, and the
population at large, and reliability
and validity figures are adequate for both clinical and
nonclinical settings.
Recent research also suggests that the PAI- is correlated with
several life-event variables in mean-
ingful ways, providing further validation for this relatively new
measure (Slavin-Mulford et al.,
2012). Moreover, recent studies have attempted to validate the
PAI- for use in various settings,
including forensic populations (e.g., Newberry & Shuker, 2012)
and neuropsychological settings
(Aikman & Souheaver, 2008).

The Millon Clinical Multiaxial Inventory-III (MCMI-III™)
The MCMI-III/ provides a standardized assessment of
psychopathology matched to the Axis I
and II disorders of the DSM-IV. The current 175-item version
was published in 1994 and was most
recently updated in 2009 (Millon, Millon, Davis, & Grossman).
Although explicitly intended for use
in clinical populations, this measure has also been used in
nonclinical settings to predict clinical
outcomes. The measure has validity indicators and 10 measures
of clinical syndromes; seven of
those denote moderate conditions and three denote severe
conditions.
The MCMI-III/ also includes 14 personality disorder scales that
are subdivided into 11 basic scales
assessing schizoid, avoidant, depressive, dependent, histrionic,
narcissistic, antisocial, sadistic,
compulsive, masochistic, and negativistic (with the latter also
referred to as passive-aggressive)
and 3 severe personality pathologies assessing schizotypal,
borderline, and paranoid features.
Despite the theoretical appeal and innovativeness of the MCMI/
tests, there have been some
concerns due to the modest, and in some cases poor, empirical
support for some of the scales on
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the inventory (e.g., Retzlaff, 1996; Saulsman, 2011). This has
led some in the field to suggest that

the MCMI-II/ and MCMI-III/ have failed to meet the basic
standards of admissibility for a test in
a court of law (known as the Daubert standard), especially when
considering the valid assessment
of personality disorders (Rogers, Salekin, & Sewell, 1999).
Moreover, researchers have suggested
that there are problems with the base rate data in the MCMI/
that is used to facilitate diagnoses,
and as a result some revisions have been suggested (Grove &
Vrieze, 2009). It has also been noted
that although the original MCMI/ had reasonable validity, the
MCMI-III/ has not received the
same empirical scrutiny; therefore, it is less clear whether the
newest version is valid (see Craig &
Olson, 2005, Craig, 2008).
Common Features of Each Assessment
Although the measures presented here adopt distinct
assumptions and have many unique scales,
there are nevertheless overlapping features. All are self-report
inventories with symptom-specific
items that require the respondent to respond using some kind of
a scale (either true/false or Lik-
ert). In all cases, scores are then compared to normative
samples for interpretation, and the inter-
pretation takes into account the test-taking approach of the
respondent (i.e., the validity scale
profile). Another common feature is that the measures
essentially tap the same broad groupings
of psychopathology. For example, in a recent study, researchers
factor analyzed (grouped) item
responses of psychiatric inpatients, those with substance abuse
disorders, and even those drawn
from forensic settings. For both the MMPI--2-RF and the
MCMI-III/, the measures captured
the extent to which the disorders are (1) internalizing, (2)

externalizing, (3) reflective of paranoia/
thought disturbance, and (4) pathologically introverted (van der
Heijden, Egger, Rossi, & Derk-
sen, 2012). Thus, irrespective of the measure, there appears to
be some fundamental overlap
with respect to the constructs being assessed (i.e., the disorders
themselves are a constant, and
the various measures essentially reflect that). This suggests that
the more noteworthy difference
between the various measures may involve the validity scales,
rather than the scales assessing
psychopathology.
Validity scales are typically embedded within the inventories
and assess the extent to which the
respondent may have approached the test in a manner other than
an honest and forthright one.
This is particularly important because these measures are often
administered in settings where
the individual has much to gain or lose based on the outcome of
the assessment. For example, in
psychiatric settings, the respondent may want to receive
services and may, therefore, exaggerate
symptoms or problematic personality functioning to gain access
to services. Or they may want to
avoid an involuntary hospitalization, thereby resulting in a
minimization tendency. Thus, the use
of validity scales to gauge the respondent’s test-taking approach
is critical to interpreting the test.
The MMPI--2 has the most comprehensive set of validity
indicators, including multiple measures
of defensiveness (defensiveness and lie scales), a measure of
superlative responding (answering
as you think a well-adjusted person might respond), multiple
measures of exaggeration (items

infrequently endorsed either in the general population or in
clinical settings), infrequent somatic
symptoms, measures of inconsistent responding, and a measure
to assess for the tendency to
primarily give true or false responses. Of course, having the
most validity measures does not nec-
essarily equate with having the best validity indicators, and this
is the focus of the next research
feature.
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CHAPTER 10 10.4 Case Illustrations
10.4 Case Illustrations
In this section, we provide some case examples to illustrate the
personality disorders, the mea-sures used to assess them, and
how the theoretical models are applied to explain their occur-
rence. In some instances, multiple theoretical perspectives will
be applied to illustrate how
the same data can be explained from different perspectives—
and, in some instances, with equal
plausibility.
Case 1: Bob G.
Bob G., a 32-year-old, single Caucasian male, presented for a
psychiatric interview at the behest
of his supervisor, who had received numerous complaints from
the residents of a building where
Bob is employed. The complaints essentially involve Bob being
nonresponsive to requests and
attempts to interact (i.e., Bob goes out of his way to isolate
himself from the residents, to the

point of undermining some of his duties). Bob had previously
worked the night shift and had had
many fewer interactions with the residents, but because of a
new rotating schedule, he was now
required to work the day shift sometimes.
Family background indicates that Bob has minimal interactions
with his family of origin. His father
is now deceased, but had been diagnosed with schizophrenia.
His mother is in out-of-state assisted
living. Bob also has a sister who provided collateral
information, saying that Bob has always been a
social isolate and somewhat odd. He was also described by his
sister as smart, and he did reason-
ably well in school.
Bob reported that his best friend was a former college
roommate, whom he had not seen since
his freshman year, when they shared a dormitory room for one
semester. He characterized their
relationship as mostly “focused on work,” and stated that they
typically “gave each other space”
so that they could accomplish their schoolwork.
Bob is single and has not had any dates or expressed any
interest in dating. He does describe him-
self as heterosexual, but when asked about his relationships
with women, he simply noted that he
has some fellow security officers who work on other floors who
are female. Bob also noted that he
perspires easily and heavily, and therefore he tends to keep to
himself so as not to offend others
(especially women) with the smell. (Note: No odor was detected
during the interview.) This is one
of the reasons he does not like to socialize with others. He also
described himself as someone who

is “serious” and “all business.” Thus, he does not like to waste
time with idle chatter. He reported
few socialization experiences outside the work setting. In fact,
even in the work setting, he did not
appear to know many people; when he described having lunch
with colleagues he described it as
“uncomfortable” and noted that he typically eats in the cafeteria
with others, but does not speak
to them. Bob noted that he can usually tell what others are
thinking, and so there is little need to
actually speak to them.
He denied the use of any alcohol or drugs and denied any legal
history. He also denied any formal
psychiatric history. As noted, family psychiatric history only
involves his father, who was diagnosed
with schizophrenia.
With respect to behavioral observations, Bob presented as
somewhat awkward socially, he rarely
made eye contact, and his gaze often moved about the room. He
sat with his hands clenched and
only spoke when asked a question, but he was cooperative. He
was dressed in his security guard
uniform, which was kempt. Although Bob denied the experience
of hallucinations, he did appear
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to become overly engrossed in common stimuli in the interview
room (e.g., staring at the walls
and the desk for prolonged periods of time). He occasionally

engaged in some odd hand gestures,
where he seemed to be blocking out stimulation that was not
apparent to the interviewer. Verbal-
izations were nonlinear (tangential and circumstantial) and
difficult to follow at times. He would
begin to answer a question, but then become engrossed in
another topic. For example, when
asked about his intense focus on the blue painted wall, he
reported being lost in thought, contem-
plating the complexities of the depths of our oceans, and the
undiscovered and even magical qual-
ities of that part of the world. Affective expression was
generally flat throughout the interview.
One other odd verbalization is also worth highlighting. Bob
stated that he became aware of the
current complaints from work because he “sensed” that others
might be upset with him and
believed that it was not uncommon for others to be speaking
about him behind his back. He also
expressed concern that the various executives who have offices
where he works are likewise talk-
ing about him and may even be considering terminating his
position because of Bob’s decision
not to attend church on Sundays. When asked directly if the
executives would know about Bob’s
non-work-related behavior, he acknowledged that they would
not likely know about this, but that
if they did, they would strongly disapprove. Despite these
concerns, Bob was unsure as to why
he needed this evaluation, stating that he is doing fine and has
not noticed any changes in his
behavior.
Data From Standardized Measures

Bob completed the MMPI--2. The validity profile indicated a
mildly defensive response set, as
Bob either minimized his problems or demonstrated poor insight
with respect to his difficul-
ties. Nevertheless, the basic scales are interpretable. Several of
the clinical scales were elevated,
including scales 8, 6, and 0, indicating disordered thinking,
eccentric behaviors, poor contact with
reality, withdrawal, alienation, suspiciousness, the tendency to
displace blame on others, mis-
taken beliefs, introversion, social withdrawal, and aloofness. No
other basic scales were elevated.
With respect to the PSY-5 scales, Bob was elevated on
Psychoticism (PSYC), indicating discon-
nection from reality and odd beliefs and perceptions, and
Introversion/Low Positive Emotionality
(INTR), indicating few positive emotions and social withdrawal.
Critical Thinking Questions:
• Referring to the DSM-5 criteria presented earlier in this
chapter, which personality disorder (if
any) best fits Bob? What might be the pros and cons of
administering the following measures
to assess Bob: (a) The MCMI-III/? (b) The Rorschach using the
Exner scoring system?
Consider one of the theoretical perspectives presented in this
text, and try to explain the
etiology for Bob’s behavior and presentation (i.e., how did he
become the way he is now?).
Diagnosing Bob
Bob’s presentation in the clinical interview and MMPI--2 test
scores suggest a personality disor-

der, most likely schizotypal PD. Importantly, there appear to be
problems in functioning, as Bob
has been having problems at work and relationships are largely
absent. His behavior is different
from that of most others, and he may cause those around him to
experience distress, even though
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he does not. Moreover, data from the clinical interview indicate
that Bob’s behavior has been
constant through much of his life, and it appears to manifest in
all areas of his life. Thus, if there is
a problem, it is likely to be one of personality.
Data to suggest schizotypal PD include the presence of odd
beliefs, such as being able to “sense”
things (i.e., magical or delusional thinking), and also possible
paranoid ideation, as indicated by
his concerns regarding the executives talking about him and
planning to fire him for not attending
church (something his employers would not know about, let
alone have an interest in). There may
have been some evidence of hallucinations, including smelling
an odor that was not detectable
and seeing things in the walls that preoccupied his thoughts and
engendered odd hand gestures.
Bob’s affect was flat, he presented as asocial, and he appeared
aloof and alienated, with few,
if any, social contacts. Bob’s profile of scores on the MMPI--2
highlights many of these same
themes (i.e., disordered thinking, odd perceptions, alienation,

and aloof presentation), thereby
providing further corroboration for the diagnosis.
Theoretical Approaches to Bob’s Case
A number of different theoretical accounts can be forwarded
based on the theoretical models
reviewed in previous chapters. For example, from the
neurobiological perspective, it is noted
that Bob’s father was diagnosed with schizophrenia, thereby
suggesting that Bob would have an
increased genetic risk for a similar disorder, such as a cluster A
personality disorder. Research also
suggests that the traits seen in the cluster A personality
disorders can be the result of physiologi-
cal hard wiring, whereby one is less responsive to
environmental stimuli and learning experiences
(e.g., Raine, 1988).
Bob also evidenced some mild but pervasive delusional
ideation, with some evidence of paranoia.
Freud believed that paranoia resulted from a combination of two
defense mechanisms that are
unconsciously engaged in order to address homosexual thoughts
and feelings (note that Bob has
no dating history and no interest in any type of relationship
with women). Freud might argue that
Bob deals with unacceptable homosexual ideation by first using
reaction formation, such that the
thought “I, a man, love other men,” becomes the opposite, in the
form of “I, a man, hate other
men.” Freud argued that this, too, was an unacceptable thought,
so projection is used, thereby
changing “I, a man, hate other men” to “Other men hate me.”
The behavioral model might suggest that Bob was not properly

reinforced for “normal” behavior
early in life, and therefore he engaged in increasingly bizarre
behavior for reinforcement (possibly
attention). It might also be argued that many of Bob’s beliefs,
such as his “decision” to avoid oth-
ers (especially women) because of his odor, is a preferred
interpretation of reality, as the alter-
native is that others have little or no interest in him, and this is
a far less favorable (reinforcing)
interpretation (cf. Roberts, 1991).
The cognitive perspective has also weighed in on odd or
delusional thinking, as researchers have
demonstrated the presence of reasoning biases in those with
delusional ideation. For example,
deluded schizophrenics were found to request less information
relative to non-deluded psychi-
atric patients before reaching a decision, and despite having less
information, they expressed
greater certainty in their decisions (Huq, Garety, & Hemsley,
1988; see also Garety, Hemsley, &
Wessely, 1991). Thus, it would be predicted that Bob would
require less evidence to come to his
conclusion that the executives were conspiring to fire him for
non-work–related behavior, and the
cognitive model would predict that he would have greater
certainty in this delusional narrative
(see also McGuire, Junginger, Adams, Burright, & Donovick,
2001).
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Case 2: Samantha K.
Samantha K. is a 26-year-old mother of one who was recently
arrested by police for prostitution.
However, because police thought she was acting in an atypical
manner, they brought her to the
regional psychiatric hospital for evaluation. Samantha was
arrested in Atlanta, but she resides in
Baltimore. She reported having traveled to Atlanta to visit
friends when her 5-year-old son, who
was staying with an ex-boyfriend in Baltimore, became ill with
pneumonia and had to be hospital-
ized. Samantha stated that the reason she had turned to
solicitation was so that she could earn
enough money to immediately travel back to Baltimore and pay
for her son’s medical services.
She was quite convinced that her actions were fully justified,
and she said she would do it again
if placed in the same position (“I don’t regret anything I’ve
done, and you would have done the
same thing if you were in those circumstances”).
Although she denied any significant legal history, records
indicate a series of arrests for petty
theft and marijuana possessions charges, dating back to when
Samantha was 14. Despite the
large number of charges, few resulted in convictions. In those
instances where she was convicted,
Samantha had lengthy explanations to justify her actions, and
she typically put the blame on
either the circumstances or the actions of others.
Samantha has no psychiatric history. She completed high
school, and although she scored reason-
ably high on aptitude tests, her grades were average and she did
not continue education after high
school. Samantha has held a number of service-related jobs,

such as hostessing at restaurants and
sales in clothing stores, but she has rarely held a job for more
than a few months; she moves on
when she gets bored with the position. She has also been fired
twice for suspicion of stealing on
the job, but no charges were pressed.
Samantha’s parents divorced when she was 4 years old, after
many years of verbal and physi-
cal assaults. Samantha stayed with her mother and had little to
no contact with her father. She
described her mother as having many different boyfriends, but
no stable relationships. Because
her mother worked, she reported “essentially raising myself.”
Samantha is somewhat estranged
from her family, who also reside in Baltimore. According to
several members of her family, Saman-
tha will call a couple of times per year, but it is usually to
request money or a favor. These requests
involve lengthy justifications and sometimes even business
schemes that have never come to frui-
tion. Because she owes many people money, many
acquaintances and family members have cut
off ties with Samantha.
Samantha is an attractive woman, who presents as somewhat
charming at first. However, her
interpersonal style comes across as manipulative, and it’s not
always clear if she is telling the
truth. She appears relatively calm and collected interpersonally,
but will sometimes verbalize
aggression. The clinical interview was complicated by the fact
that Samantha repeatedly changed
topics after several questions on any one topic. She also
perseverated on her son’s health, but
despite saying she was concerned about her son, she did not

appear concerned (at least her out-
ward appearance did not indicate it).
When asked about her son and the rationale for leaving him
behind in Baltimore, Samantha
explained that she wanted to give her son some quality time
with her ex-boyfriend; however, it
was unclear as to why her son would benefit from or even desire
this contact, given that Samantha
dated her ex-boyfriend prior to her son’s birth (i.e., her son
didn’t know Samantha’s ex-boyfriend
prior to this trip).
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Data From Standardized Measures
Samantha completed the MMPI--2. The validity profile
indicated that she was highly defensive;
she demonstrated a tendency to under-report and minimize
problems. The observed defensiveness
can undermine the interpretation of the clinical scales, as low
scores do not necessarily denote the
absence of psychopathology, but may instead be the result of
excessive under-reporting. However,
any significant elevations that do emerge can be interpreted.
One clinical scale was elevated: scale 4. Elevations on this scale
are often associated with poor
judgment, irresponsible behavior and attitudes, hostility, and
the displacement of blame onto
others.

Two of the five personality subscales from the MMPI--2 were
also elevated, most notably the
AGGR scale, which refers to the use of aggression, hostility,
and intimidation to facilitate goal
attainment. The second elevation was on DISC, which suggests
the presence of risk taking and
impulsivity and little regard for following rules. Finally, the
MMPI--2 supplemental scale assessing
over-controlled hostility was also elevated, suggesting that
although Samantha usually responds
appropriately to provocation, she is likely to sometimes
evidence an exaggerated anger response,
even in the absence of provocation.
The NEO-PI was also completed, but this measure resulted in no
significant elevations, aside from
Samantha’s endorsement of items indicating that she is very
friendly (agreeableness) and dutiful
(conscientiousness). The scores on this face-valid measure
appeared to reflect a more socially
desirable response set, but there are no formal validity measures
on the NEO™-PI.
Critical Thinking Questions
• Referring to the DSM-5 criteria presented earlier in this
chapter, which personality disorder
(if any) best fits Samantha? What might be the pros and cons of
administering the following
measures to assess Samantha: (a) The MMPI--2? (b) The NEO/-
PI? Consider one of the
theoretical perspectives presented in this text, and try to explain
the etiology for Samantha’s
behavior and presentation (i.e., how did she become the way she
is now?).

Diagnosing Samantha
Samantha’s test scores and her presentation in the clinical
interview converge on a diagnosis of
antisocial personality disorder. A recurrent theme in the
evaluation was her less-than-genuine
presentation. She under-reported her problems, was defensive
on the standardized measures,
and even provided misleading information regarding her
criminal history. Even the fact that she
has a lengthy criminal history is indicative of this diagnosis.
Samantha also did not evidence any
remorse for her actions, opting instead to blame the
circumstances on others; she even stated
that she would act in the same way if given the opportunity to
do so again.
Samantha has superficial relationships and she tends to take
advantage of others. She presents as
aggressive and even hostile at times, though she can be quite
charming when trying to get what
she wants. Samantha’s actions also suggest that she is impulsive
and has been an underachiever
for most of her life.
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Given Samantha’s less-than-genuine presentation and
defensiveness on the MMPI--2, it is not
surprising that she only endorsed more favorable characteristics
on the face-valid NEO/-PI. The

MMPI--2 scores converge with many of the above descriptions,
with elevations on scale 4, as
well as other scales assessing problems managing aggression
and impulsivity. Importantly, even
though Samantha does not feel distress, she appears to be
creating distress in those around her.
There is also clear evidence of dysfunction, with a poor work
history, legal and drug problems, and
few stable relationships.
Theoretical Approaches to Samantha’s Case
The physician Philippe Pinel introduced the concept “manie
sans délire” to refer to individuals
who appeared to think clearly, but who would nevertheless
behave in a manner that would sug-
gest disturbance. Similarly, the physician James Prichard coined
the term “moral insanity” to char-
acterize mental illness where emotional experiences are
disturbed, but intellectual capacities are
intact. These terms arguably provide some of the earliest
writings relating to the modern-day
concept of antisocial PD (see also Berrios, 1996).
More recently, antisocial tendencies have been referred to using
the terms sociopath and psycho-
path, and this highlights two distinct etiologies for the
associated behaviors, a behavioral (or social
learning) account and a physiological account.
The term sociopath implies problematic learning, which can
include parental neglect (i.e., failure
to reinforce appropriate behavior and punish inappropriate
behavior) and/or poor parenting (i.e.,
reinforcing inappropriate behavior and punishing appropriate
behavior). Thus, from this account,

Samantha’s unstable home, and the report that she raised
herself, would be consistent with prob-
lematic learning experiences early in life, resulting in the
antisocial tendencies. Sociopathy also
involves problematic factors outside the family-of-origin, such
as poverty and the presence of
delinquent peers. Samantha came from a single-parent home,
and given her current shortcomings
with respect to finances, we can assume that she has and
continues to struggle financially. The
case history also indicates involvement with the law and
extensive experience with drugs begin-
ning at an early age, thus delinquent peers were also likely.
The above-described factors could also be accounted for by
social learning theory, whereby
Samantha observed and subsequently modeled her mother’s
numerous superficial relationships
and aggressive behavior toward her ex-husband. Similarly, her
delinquent peers would have
served as targets to model, and their substance abuse and other
criminal behavior would eventu-
ally lead to Samantha demonstrating these same behaviors.
The term psychopath has also been linked to antisocial
personality disorder, but here the implica-
tion is the presumed physiological underpinnings of the
disorder. That is, in contrast to the above
models, which emphasize environmental factors, the
psychopathy model focuses on inherited
genetic factors.
Psychopaths are thought to have innate, temperamental features
that predispose them to be
impulsive decision-makers, risk takers, and individuals who do
not profit from learning experi-

ences (e.g., Cleckley, 1982; Hare, 1978; Lykken, 1957; Raine,
1987; see also Lykken, 1995, and
Raine, 1993, for reviews). For example, mild electric shocks
(positive punishments) appear to
be less effective at eliminating behaviors for psychopaths, and
this problematic learning may be
especially prominent when there are no delays in responding
(i.e., impulsive responding). Some
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CHAPTER 10Summary
research suggests that the cause of these and other related
problems are the result of a dys-
function in the prefrontal cortex, which is the region of the
brain governing decision-making,
responsiveness to rewards and punishments, and impulsivity
(see Crews & Boettiger, 2009). This
extensive literature suggests that psychopaths are essentially
wired differently than others, mak-
ing them less responsive to reinforcers and punishers, which
then inhibits proper learning and the
internalization of moral standards. Researchers have also
forwarded more complex physiological
accounts, though even these models are in keeping with the
traditional literature, while also impli-
cating motivated behavior through classic approach-avoidance
models presented earlier in this
text (see Arnett, 1997). From this perspective, it is somewhat
irrelevant whether Samantha had
opportunities to learn or model appropriate behavior, as it
would be assumed that she would not
profit from these experiences to develop proper, internalized

moral standards. Thus, Samantha
would feel justified in her behavior even when it breaks the law
or is contrary to moral standards.
Summary
Personality disorders have traditionally been studied separate
from normal personality, and, as a result, researchers have
developed distinct systems of categorization and unique mea-
sures to assess them. The dominant model for identifying
personality disorders in the United
States is represented by the DSM-5, which identifies 10
personality disorders (schizoid, schizo-
typal, paranoid, histrionic, narcissistic, antisocial, borderline,
obsessive-compulsive, avoidant,
and dependent), along with the specific symptoms associated
with each diagnosis. In addition to
the diagnosis-specific criteria, the identification of a personality
disorder requires that there be a
number of other, more general, criteria, such as the presence of
dysfunction, distress, danger, and
deviance from social/cultural standards. These criteria are
neither necessary nor sufficient, but
the more criteria that are present, the more likely the observed
traits will constitute a personality
disorder. The prevalence rates vary considerably for the
personality disorders, and there are also
marked differences based on gender.
Although widely used, the DSM-5 and its predecessors are not
the only classification system, and
many researchers argue that a more parsimonious and accurate
approach would be one in which
the models used to characterize normal personality functioning
(e.g., the Five Factor Model) are
applied to the personality disorders. This approach would then

signal a quantitative rather than a
qualitative distinction between normal and disordered
personality. Other critics of the DSM have
argued that it is not simply the diagnostic system that is a
problem; rather, they question the very
existence of the psychiatric disorders themselves.
Some of the most commonly used measures of personality and
other psychiatric disorders
include the MMPI--2, the PAI-, and the MCMI-III/. These
measures are uniquely qualified to
assess disorders because they also have validity scales that
assess the respondent’s test-taking
approach. This is important because in clinical settings there are
often external contingencies that
can increase the incidence of over- or under-reporting biases,
and these have to be understood
in order to interpret the data. Using information from these tests
(and others), along with the
patient’s case history, allows the clinician to diagnose the
individual. Moreover, the theories pre-
sented in earlier chapters can then be used to conceptualize the
patient and how their pathology
developed.
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CHAPTER 10Key Terms
Key Terms
abnormal personality A variant of normal
personality that can be defined as an extreme
of the basic personality traits.

antisocial personality disorder A personal-
ity disorder characterized by universal and
longstanding practice of complete disregard
for social norms and often a history of illegal
behavior.
avoidant personality disorder A personality
disorder characterized by social inhibition and
fear and hypersensitivity to negative evalua-
tions from others.
borderline personality disorder A personality
disorder characterized by instability of affect
and relationships, with the individual making
dramatic attempts to avoid perceived abandon-
ment by others.
cluster A personality disorders Personality dis-
orders that involve odd or eccentric behavior,
resulting in decreased socialization and often
increased isolation.
cluster B personality disorders Personality
disorders that involve dramatic or emotional
behavior and conflict, instability, and exploita-
tion in relationships.
cluster C personality disorders Personality
disorders that involve fear, anxiety, and limited
interpersonal relationships.
comorbidity The co-occurrence of different
disorders.
danger When certain behaviors or traits are

risky or harmful to either the individual or to
others.
Daubert standard The basic criteria of admis-
sibility for a test in a court of law.
dependent personality disorder A personality
disorder characterized by a pervasive need to
be cared for by others.
deviance The statistical infrequency of a
behavior in the general population; a lower
frequency is typically associated with abnormal
behavior.
Diagnostic and Statistical Manual of Mental
Disorders, Fifth Edition (DSM-5) The most
recent manual of the APA (2103), which has
eliminated the multi-axial system of categoriz-
ing diagnoses (used in previous DSM editions)
and aligned itself more closely with the World
Health Organization’s (WHO) International Clas-
sification of Diseases (ICD).
distress Negative feelings or reactions felt by
an individual or those around them as a result
of certain behaviors or traits.
dysfunction The extent to which a behavior or
trait leads to problematic functioning in daily
living.
histrionic personality disorder A personality
disorder characterized by dramatic and exag-
gerated emotional presentation that is almost
theatrical in nature.

International Classification of Diseases, 11th
Revision (ICD-11) The version of the World
Health Organization’s (WHO) International Clas-
sification of Diseases that will be released in
2015. The ICD is used worldwide for diagnoses.
longstanding When a problematic behavior or
trait has been present for a significant portion
of an individual’s life.
narcissistic personality disorder A personal-
ity disorder characterized by grandiose self-
presentation and a need to be admired.
Lec81110_10_c10_283-312.indd 311 5/21/15 12:40 PM
CHAPTER 10Key Terms
obsessive-compulsive personality disorder A
personality disorder characterized by preoccu-
pation with details and trivial rules, stubborn-
ness, and rigid moral standards.
other specified personality disorder A diagno-
sis that can be given to individuals who do not
fit into the cluster personality categories but
still exhibit personality patterns that result in
deviance, dysfunction, distress, and/or danger.
paranoid personality disorder A personality
disorder characterized by persistent and univer-
sal distrust and suspiciousness of others.

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