What are Personality Disorders? - Chapter 12

What is the categorical approach to Personality Disorders in DSM-IV-TR and DSM-5?

A personality disorder (PD) is a disorder characterized by persistent, inflexible, maladaptive thought patterns and behaviors that develop in adolescence or early adulthood and significantly impair functioning.

The DSM-IV-TR organized personality disorders into three categories: (1) Odd/Eccentric Personality Disorders, (2) Dramatic/Emotional Personality Disorders, and (3) Fearful/Anxious Personality Disorders.

What problems are there with the categorical approach?

There is evidence for a dimensional approach to personality disorders. Everyone experiences certain characteristics associated with personality disorders, such as mood swings. Therefore, personality disorders can be called extreme forms of personality dimensions rather than disorders. There is a lot of overlap, certain characteristics are reflected in several personality disorders. A number of personality disorders are rare, and it is therefore not helpful to describe them as an independent category. Lastly, personality disorders are often not very stable over time. This also suggests that a dimensional approach is more appropriate.

What is the DSM-5’s Alternative Model?

The alternative diagnostic model contains three discrete types of personality ratings:

1. Level of Personality Functioning: Disturbances in self and interpersonal functioning are at the core of personality disorders, with the severity of the impairment giving an indication of whether the individual has more than one personality disorder;
2. Personality Trait Domains and Facets: Five personality trait domains are specified: negative affectivity, detachment, antagonism, disinhibition, and psychoticism on which a patient is scored; and
3. Personality Disorder Types: Diagnosis is based on the previous two steps: Antisocial PS, Avoidant PD, Borderline PD, Narcissistic PD, Obsessive Compulsive PD, and Schizotypal PD.

What are personality disorders and how are these diagnosed?

The DSM-5 criteria for personality disorders in general are:

• A persistent, rigid pattern of thoughts and behavior that differs significantly from the expectations of the culture in which the person lives, manifested in at least two of the following areas: cognition, affectivity, interpersonal functioning, and impulse control.
• The pattern is constant and long-lasting and can be traced back to adolescence or childhood;
• The pattern leads to distress or limitations in social, work-related or other areas of life; and
• The symptoms are not better explained by other mental disorders or due to the effects of a substance or other medical condition.

What are Odd/Eccentric Personality Disorders (Cluster A)?

The eccentric personality disorder cluster contains three subtypes:

1. Paranoid PD
2. Schizoid PD
3. Schizotypal PD

What is Paranoid Personality Disorder?

A paranoid PD is characterized by a persistent pattern of suspicion and mistrust of others. Innocent comments are interpreted as threatening and the intentions of others as malicious. The DSM-5 criteria for this PS are:

A general distrust of others insofar as their motives are perceived as malicious, indicated by at least four of the following:

• Suspicions that others are abusing, hurting, or deceiving him/her
• Fixation on unwarranted doubts about reliability from friends
• Unwilling to trust others, due to a fear that the information could be used against him/her
• Sees hidden threats in non-threatening words or events
• Carries lasting grudges
• Sees attacks on his/her character or status that others do not see and quickly reacts angrily
• Has persistent suspicions about the fidelity of the sexual partner
• The symptoms are not only present during a psychotic disorder

What is Schizoid Personality Disorder?

Individuals with schizoid PD are often described as 'loners' who do not express a normal range of emotions and experience little reward from activities. The DSM-5 criteria for this PD are:

A persistent pattern of separation from social relationships and a limited range of emotion expression in relational situations, indicated by at least four of the following:

• Dislikes or does not want close relationships,
• Prefers solitary activities
• Has little or no pleasure in sexual experiences with another
• Takes no pleasure in activities
• Has no close friends or confidants other than immediate family
• Insensitive to praise or criticism from others
• Emotional coolness, detachment, or flat expression
• The symptoms are not only present during another psychotic disorder.

What is a Schizotypal Personality Disorder?

A schizotypal PD is characterized by eccentric behavior, manifested in odd thinking and communication patterns. The DSM-5 criteria for this PD are:

An enduring pattern of social and relationship deficits, evidenced by difficulty with and diminished ability to form close relationships, and disturbances and idiosyncrasies in behavior, manifested in at least five of the following:

• Beliefs or perceptions that are irrelevant or insignificant
• Strange beliefs that influence behavior that do not fit the subcultural norms
• Strange perceptions of what is happening around the person
• Vague thoughts and words
• Suspicious or paranoid ideas
• Inappropriate or limited emotion expression,
• Eccentric behaviour or appearance
• Has no close friends or confidants other than immediate family
• High social anxiety despite familiarity
• This pattern is not part of schizophrenia or any other psychotic disorder

A problem with this PD is that it has high comorbidity with the other personality disorders, mainly paranoid PD and avoidant PD. In addition, there is evidence that schizotypal PD is strongly related to schizophrenia and is also a risk factor for it.

What are Dramatic/Emotional Personality Disorders (Cluster B)?

The dramatic/emotional personality disorder cluster contains four subtypes:

1. Antisocial PD
2. Borderline PD
3. Narcissistic PD
4. Histrionic PD

Many personality disorders are characterized by impulsivity. The DSM-5 describes a number of impulse-based problems separately:

• Intermittent Explosive Disorder: This involves episodes of inability to control aggressive impulses, often resulting in criminal offenses.
• Kleptomania: Inability to control impulses to steal objects.
• Pyromania: There are recurring patterns of arson for pleasure, satisfaction or relaxation.

What is Antisocial Personality Disorder?

An antisocial PD is characterized by impulsive behavior and lack of remorse and is strongly linked to criminal behavior. The terms sociopath and psychopath are also used to describe this disorder. The DSM-5 criteria for this PD are:

A pattern of indifference to and violation of the rights of others manifested in at least three of the following since age 15:

• Failure to conform to social norms and frequent illegal behavior
• Lying, impersonating or deceiving others for personal gain
• Inability to plan ahead or impulsiveness
• Irritability and aggression leading to physical fights
• Indifference to the safety of self and others
• Consistent irresponsible behaviour
• Lack of remorse
• The person is at least 18 years old
• The antisocial behavior is not associated with symptoms of schizophrenia or mania

Research from 1998 suggests that ADHD is a risk factor for developing antisocial PD. However, more recent research shows that there is only a weak link between ADHD and antisocial personality disorders.

Antisocial personality disorders are strongly associated with criminal and antisocial behavior. Predictors of criminal and antisocial behavior are: conduct disorder, persistent aggressive behavior before age 11, fighting and hyperactivity, low IQ and low self-esteem, persistent lying, running away from home, vandalism, truancy, unstable family life, school failure, smoking/alcohol use /drug use/problems with the police/sex before the age of 15, having a parent with an antisocial PD and having a background of violence, poverty and conflict in the family.

What is Borderline Personality Disorder?

Borderline PD is described in the DSM-5 as the long-term instability of relationships, self-esteem, and behaviors with high impulsiveness beginning in early adulthood, manifested in at least five of the following:

• Desperate efforts to avoid real or imagined abandonment
• A pattern of unstable and intense interpersonal relationships, fluctuating between praise and depreciation
• Constantly unstable self-image and identity distortion
• Potential impulsivity to self-harm in at least two areas, such as sex, substance abuse, or reckless driving
• Recurrent suicidal behaviour or self-mutilation
• Emotional instability due to mood reactivity
• Inappropriate, intense fear or difficulty controlling anger
• Stress-related paranoid idealization or severe dissociative symptoms

What is Narcissistic Personality Disorder?

Narcissistic PD is described in the DSM-5 as a persistent pattern of grandiosity, need for admiration, lack of empathy, beginning in early adulthood, manifested in at least five of the following:

• A great, exaggerated sense of self-importance and self-development
• Preoccupation with illusions of unlimited success, power, beauty, or ideal love
• Believe that he/she is special and can only be understood by people of equal 'specialness'
• demands excessive admiration
• Has unreasonable expectations of beneficial treatment
• Exploit others for personal gain
• Lacks compassion and can't identify the needs and feelings of others
• Often jealous of others and believes others are jealous of him/her
• Is conceited and shows self-righteous behavior and attitudes

What is Histrionic Personality Disorder?

A histrionic PS is characterized by seeking attention and feeling uncomfortable or unhappy when an individual is not the centre of attention. The DSM-5 describes this PS as a continuous pattern of high emotionality, attention seeking, beginning in early adulthood, manifested in at least five of the following:

• Feeling unhappy in situations where he/she is not the centre of attention
• Excessive, sexually suggestive or provocative behavior in interactions with others
• Show rapid swings and superficial expressions of emotions
• Often uses personal appearance to draw attention to self
• Has an excessively impressionistic and devoid of detail manner of speaking
• Is self-dramatic, very theatrical and uses exaggerated emotion expression
• Is easily influenced by others
• Feels relationships as much more intimate than they really are

What are Anxious/Fearful Personality Disorders (Cluster C)?

The anxious personality disorder cluster contains three subtypes:

1. Avoidant PD
2. Dependent PD
3. Obsessive Compulsive PD

What is an avoidant personality disorder?

Avoidant PS is described by the DSM-5 as a persistent pattern of social restraint, feelings of inadequacy, and hypersensitivity to criticism, beginning in early adulthood, manifested in at least four of the following:

• Avoiding activities that involve a lot of interpersonal contact because of fear of criticism or rejection
• Not wanting to approach others unless there is assurance of approval and being liked
• Restraint in intimate relationships because of fear of ridicule or embarrassment
• Fixation on disapproval or rejection in social situations
• Inhibition in new relationships due to feelings of inadequacy
• Feeling socially incompetent, unattractive or less than others
• Strongly reluctant to participate in new activities because of possible embarrassment

Some clinicians believe that avoidant PD and social anxiety disorder can be grouped together in a broader social anxiety spectrum.

What is Dependent Personality Disorder?

Dependent PD is described in the DSM-5 as an unavoidable and extreme need to be cared for, leading to submissive and clingy behaviors and separation anxiety beginning in early adulthood, manifested in at least five of the following:

• Inability to make everyday decisions without unnecessarily high levels of advice and validation from others;
• Needing others to take on most of the responsibilities of daily life;
• Difficulty expressing disagreement with someone for fear of losing support;
• Difficulty doing or initiating things yourself;
• Feeling uncomfortable or scared when left alone because of a fear of not being able to take care of themselves;
• Urgently seeking a new supportive relationship when the previous one ends;
• Being unrealistically obsessed with fear of being left alone to fend for oneself.

What is Obsessive Compulsive Personality Disorder?

Obsessive Compulsive PS is described in the DSM-5 as a persistent pattern of preoccupation with orderliness, perfection, and mental and interpersonal control, at the expense of flexibility, openness, and efficiency, beginning in early adulthood, seen in at least four of the following things:

• An obsession with details, rules, lists, organization, or schedules that loses the core of the activity
• Perfectionism that interferes with task completion
• Excessive dedication to work up to self-prohibition from social and recreational activities
• Inflexibility in morals, ethics and values
• Inability to throw away worn-out or worthless objects despite having no emotional value
• Reluctant to pass things on to others unless they want to do it exactly as he/she asks
• Hoards money and is reluctant to use it
• Is rigid and stubborn.

What is the prevalence of personality disorders?

There is uncertainty about the actual prevalence of personality disorders, due to issues with (1) the reliability of diagnosis, (2) potential gender bias in the diagnosis of certain disorders and (3) the weak temporal stability of personality disorders. Data from various studies show that the prevalence in the general population is between 10% and 14%.

There are several risk factors for developing a PD, including being part of a low socioeconomic class, living in the inner city, being a young adult, and being divorced, widowed, or never married. In addition, being physically, verbally or sexually abused in childhood is a risk factor for developing a PD, especially borderline PD.

What is the aetiology of personality disorders?

What psychodynamic approaches are there?

It is reasoned that causes of paranoid and schizoid personality disorders lie in the relationship with the parents. In a paranoid PD, the parents would be demanding, distant, rigid, and dismissive. In a schizoid PD, parents would have rejected or even abused the child, as a result of which the child cannot give or receive love.

How are cluster A disorders related to schizophrenia?

There is evidence that cluster A personality disorders are strongly related to schizophrenia and together form a schizophrenia spectrum disorder. For example, a genetic link has been discovered between cluster A disorders and schizophrenia. In addition, the brain abnormalities and physiological abnormalities in cluster A disorders are very similar to those found in schizophrenia. Limitations in cognitive and executive functioning are also comparable in cluster A disorders and schizophrenia.

What is the aetiology of Odd/Eccentric Personality Disorders (Cluster A)?

One of the best predictors of antisocial PD is a diagnosis of childhood conduct disorder. More specifically, there are three pathways that predict antisocial PD:

1. An overtly aggressive path that progresses from bullying to fighting to serious violence;
2. A hidden aggressive path that progresses from lying and stealing to serious property damage;
3. An authority conflict path that develops through varying degrees of oppositional and defiant behavior.

There are several developmental factors that contribute to having an antisocial PD. It seems that modeling and imitation lead to the learning of antisocial behavior. Psychodynamic approaches argue that the absence of parental love in childhood creates an inability in the child to trust others. Twin and adoption studies indicate that genetic factors influence the development of and antisocial PD. The heritability is between 40% and 69%. However, these studies also show that environmental factors play an important role.

Cognitive models postulate that individuals with antisocial personality disorders have developed dysfunctional schemas, which are dysfunctional beliefs that perpetuate problematic behaviors. An example of such a schema is the "abandoned and abused child" mode, in which the child develops feelings of pain, fear of abandonment, and inferiority, among other things.

Finally, there are physiological and neurological factors to mention. First, individuals with antisocial personality disorders show a reduced anxiety response. Second, they respond to emotional or distressing stimuli with slower autonomic arousal, suggesting they can ignore threatening stimuli more easily than most people. Third, often no fear response can be learned in aversive conditioning. In addition, there is reduced prefrontal brain function.

What is the aetiology of Dramatic/Emotional Personality Disorders (Cluster B)?

There are several risk factors for developing a borderline PS. Most relate to childhood difficulties, especially problematic parenting, such as physical verbal and sexual abuse, rejection, or unloving parents.

There is evidence for a genetic component in the development of borderline PS. Low levels of serotonin and dopamine dysfunction can also contribute to the development of the disorder. Neuroimaging techniques also show that, among other things, there are abnormalities in the frontal lobe and the limbic system in patients with borderline PS. The disorder often occurs together with bipolar disorder, which means that they are also placed together in a bipolar disorder spectrum.

There are several psychological theories that attempt to explain borderline personality disorders. Some forms of psychodynamic theory, such as object relations theory, argue that patients have received inadequate support and love from important persons such as parents, resulting in an insecure ego, leading to lack of self-confidence and fear of rejection. This theory also states that individuals with weak egos use the splitting defence mechanism, meaning they view people, events, or things in a black and white way. In their experience, people are good or bad, without a grey area in between.

Psychodynamic theories state that individuals with narcissistic PD have childhood experiences with cold, dismissive parents who rarely expressed praise for their child. Therefore, clients try to look for confirmation.

This PS is strongly associated with an antisocial PD. However, individuals with a narcissistic PS can be distinguished from an antisocial PS by their sense of grandiosity and self-importance. Little is known about the aetiology of histrionic personality disorders. The dramatic displays of emotion and attention-seeking behavior would be manifestations of an underlying conflict. Psychodynamic theories differ on the causes of the underlying conflict.

What is the aetiology of Anxious/Fearful Personality Disorders (Cluster C)?

An avoidant PS is strongly associated with, among other things, introversion, neuroticism, low self-esteem, pessimism and with increased emotional reactivity to threat. There also appears to be a genetic component, the chance of an avoidant PS being two to three times greater if it runs in the family. The disorder is closely related to social anxiety disorder, which would allow them to be grouped together under a broader social anxiety spectrum.

Psychodynamic theories have developed aetiology models for dependent PD that are very similar to those for depression, as symptoms of dependent PD are reduced by taking medications used to treat depression. For example, object-relationship theorists argue that dependence and fear of rejection come from neglect or loss of a parent in childhood. In addition, a dependent PD often has comorbidities with various anxiety disorders.

There is very little research on the aetiology of obsessive-compulsive personality disorder. It is known that underlying vulnerability factors are often related to a parenting style with psychological manipulation and guilt induction. An interesting fact is that the comorbidity of an obsessive-compulsive PS with OCD is only 22%, while there is a large overlap between these two disorders.

How can personality disorders be treated?

There are several factors that make treating personality disorders difficult:

• Individuals with personality disorders are often unaware that their behavior is problematic and often do not know that they may need treatment
• Individuals with personality disorders are often predisposed to many other psychiatric disorders. This makes treatment difficult because individuals are more disturbed and require more intensive treatment, many personality disorders consist of ingrained behaviors that are likely to create difficulties in the future that can trigger symptoms of other disorders, and many personality disorders have characteristics that make individuals manipulative and distrustful, making  it hard to establish a good relationship with the therapist
• it is difficult to pinpoint exactly what is disturbed in personality disorders and therefore difficult to treat; and the characteristics differ per person

In general, it can be said that an individual must acquire certain life skills, learn emotional control strategies, and learn the skill of mentalization.

What drug treatments can be used?

Drug treatments are usually used in personality disorders to treat the comorbid disorders, such as anxiety disorders. It has been found that antidepressants are effective in cluster C symptoms and drugs for aggression and impulsivity in cluster B symptoms.

What are psychodynamic and insight approaches?

Psychodynamic theories often describe problematic relationships with parents to explain personality disorders. Insight is seen as an important mechanism in treatment, namely exploring and resolving these experiences in development. Object-relations psychotherapy is a treatment that seeks to strengthen the individual's weak ego so that they can identify issues in their lives without constantly moving from one extreme view to another.

What is Dialectical Behavioral Therapy?

Dialectical Behavioral Therapy is a client-centred therapy that seeks to provide clients with an understanding of their dysfunctional ways of thinking about the world that is particularly successful in borderline personality disorders. There are four phases:

1. Identifying dangerous and impulsive behaviors and helping the client deal with these behaviors
2. Helping the client to moderate extreme emotions
3. Improving the client's self-confidence and coaching the client in dealing with relationships
4. Promoting positive emotions

How can cognitive behaviour therapy be used?

CBT in personality disorders involves exploring logic errors and dysfunctional schemas underlying the personality disorders. Specifically, with borderline PD, the therapist should be aware that the client must be treated with empathy because of sensitivity to criticism. In addition, in these patients, it is beneficial to change the dysfunctional schemas by "re-educating" the client to build an emotional connection with the client in order to challenge the dysfunctional schemas.

40% to 50% of clients recover after treatment with CBT.

What is schema-focused cognitive therapy?

Schema-focused cognitive therapy or schema therapy is used to address dysfunctional ways of thinking and maladaptive cognitive schemas that develop during childhood. This ultimately leads to a reduction in belief in the schemas and the development of alternative perspectives.