58 Personality Disorders

The purpose of this module is to define what is meant by a personality disorder, identify the five domains of general personality (i.e., neuroticism, extraversion, openness, agreeableness, and conscientiousness), identify the six personality disorders proposed for retention in the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) (i.e., borderline, antisocial, schizotypal, avoidant, obsessive-compulsive, and narcissistic), summarize the etiology for antisocial and borderline personality disorder, and identify the treatment for borderline personality disorder (i.e., dialectical behavior therapy and mentalization therapy).

Neuroticism (Emotional Instability) Fearful, apprehensive, angry, bitter, pessimistic, glum, timid, embarrassed, tempted, urgency, helpless, fragile		Emotional Stability relaxed, unconcerned, cool, even-tempered, optimistic, self-assured, glib, shameless, controlled, restrained, clear-thinking, fearless, unflappable
Extraversion cordial, affectionate, attached, sociable, outgoing, dominant, forceful, vigorous, energetic, active, reckless, daring, high-spirited, excitement-seeking		Introversion cold, aloof, indifferent, withdrawn, isolated, unassuming, quiet, resigned, passive, lethargic, cautious, monotonous, dull, placid, anhedonic
Openness (unconventionality) dreamer, unrealistic, imaginative, aberrant, aesthetic, self-aware, eccentric, strange, odd, peculiar, creative, permissive, broad-minded		Closedness (conventionality) practical, concrete, uninvolved, no aesthetic interest, constricted, unaware, alexythymic, routine, predictable, habitual, stubborn, pragmatic, rigid, traditional, inflexible, dogmatic
Agreeableness gullible, naive, trusting, confiding, honest, sacrificial, giving, docile, cooperative, meek, self-effacing, humble, soft, empathetic		Antagonism skeptical, cynical, suspicious, paranoid, cunning, manipulative, deceptive, stingy, selfish, greedy, exploitative, oppositional, combative, aggressive, confident, boastful, arrogant, tough, callous, ruthless
Conscientiousness perfectionistic, efficient, ordered, methodical, organized, rigid, reliable, dependable, workaholic, ambitious, dogged, devoted, cautious, ruminative, reflective		Disinhibition lad, negligent, haphazard, disorganized, sloppy, casual, undependable, unethical, aimless, desultory, hedonistic, negligent, hasty, careless, rash

Some of the DSM-5 personality disorders are confined largely to traits within one of the basic domains of personality. For example, obsessive-compulsive personality disorder is largely a disorder of maladaptive conscientiousness, including such traits as workaholism, perfectionism, punctilious, ruminative, and dogged; schizoid is confined largely to traits of introversion (e.g., withdrawn, cold, isolated, placid, and anhedonic); borderline personality disorder is largely a disorder of neuroticism, including such traits as emotionally unstable, vulnerable, overwhelmed, rageful, depressive, and self-destructive (watch the 1987 movie, Fatal Attraction, starring Glenn Close, for a nice portrayal of this personality disorder); and histrionic personality disorder is largely a disorder of maladaptive extraversion, including such traits as attention-seeking, seductiveness, melodramatic emotionality, and strong attachment needs (see the 1951 film adaptation of Tennessee William’s play, Streetcar Named Desire, starring Vivian Leigh, for a nice portrayal of this personality disorder).

It should be noted though that a complete description of each DSM-5 personality disorder would typically include at least some traits from other domains. For example, antisocial personality disorder (or psychopathy) also includes some traits from low neuroticism (e.g., fearlessness and glib charm) and extraversion (e.g., excitement-seeking and assertiveness); borderline includes some traits from antagonism (e.g., manipulative and oppositional) and low conscientiousness (e.g., rash); and histrionic includes some traits from antagonism (e.g., vanity) and low conscientiousness (e.g., impressionistic). Narcissistic personality disorder includes traits from neuroticism (e.g., reactive anger, reactive shame, and need for admiration), extraversion (e.g., exhibitionism and authoritativeness), antagonism (e.g., arrogance, entitlement, and lack of empathy), and conscientiousness (e.g., acclaim-seeking). Schizotypal personality disorder includes traits from neuroticism (e.g., social anxiousness and social discomfort), introversion (e.g., social withdrawal), unconventionality (e.g., odd, eccentric, peculiar, and aberrant ideas), and antagonism (e.g., suspiciousness).

The APA currently conceptualizes personality disorders as qualitatively distinct conditions; distinct from each other and from normal personality functioning. However, included within an appendix to DSM-5 is an alternative view that personality disorders are simply extreme and/or maladaptive variants of normal personality traits, as suggested herein. Nevertheless, many leading personality disorder researchers do not hold this view (e.g., Gunderson, 2010; Hopwood, 2011; Shedler et al., 2010). They suggest that there is something qualitatively unique about persons suffering from a personality disorder, usually understood as a form of pathology in sense of self and interpersonal relatedness that is considered to be distinct from personality traits (APA, 2012; Skodol, 2012). For example, it has been suggested that antisocial personality disorder includes impairments in identity (e.g., egocentrism), self-direction, empathy, and capacity for intimacy, which are said to be different from such traits as arrogance, impulsivity, and callousness (APA, 2012).

Validity

It is quite possible that in future revisions of the DSM some of the personality disorders included in DSM-5 and DSM-IV-TR will no longer be included. In fact, for DSM-5 it was originally proposed that four be deleted. The personality disorders that were slated for deletion were histrionic, schizoid, paranoid, and dependent (APA, 2012). The rationale for the proposed deletions was in large part because they are said to have less empirical support than the diagnoses that were at the time being retained (Skodol, 2012). There is agreement within the field with regard to the empirical support for the borderline, antisocial, and schizotypal personality disorders (Mullins-Sweat, Bernstein, & Widiger, 2012; Skodol, 2012). However, there is a difference of opinion with respect to the empirical support for the dependent personality disorder (Bornstein, 2012; Livesley, 2011; Miller, Widiger, & Campbell, 2010; Mullins-Sweat et al., 2012).

Little is known about the specific etiology for most of the DSM-5 personality disorders. Because each personality disorder represents a constellation of personality traits, the etiology for the syndrome will involve a complex interaction of an array of different neurobiological vulnerabilities and dispositions with a variety of environmental, psychosocial events. Antisocial personality disorder, for instance, is generally considered to be the result of an interaction of genetic dispositions for low anxiousness, aggressiveness, impulsivity, and/or callousness, with a tough, urban environment, inconsistent parenting, poor parental role modeling, and/or peer support (Hare, Neumann, & Widiger, 2012). Borderline personality disorder is generally considered to be the result of an interaction of a genetic disposition to negative affectivity interacting with a malevolent, abusive, and/or invalidating family environment (Hooley, Cole, & Gironde, 2012).

To the extent that one considers the DSM-5 personality disorders to be maladaptive variants of general personality structure, as described, for instance, within the Five-Factor Model, there would be a considerable body of research to support the validity for all of the personality disorders, including even the histrionic, schizoid, and paranoid. There is compelling multivariate behavior genetic support with respect to the precise structure of the Five-Factor Model (e.g., Yamagata et al., 2006), childhood antecedents (Caspi, Roberts, & Shiner, 2005), universality (Allik, 2005), temporal stability across the lifespan (Roberts & DelVecchio, 2000), ties with brain structure (DeYoung, Hirsh, Shane, Papademetris, Rajeevan, & Gray, 2010), and even molecular genetic support for neuroticism (Widiger, 2009).

Treatment

Personality disorders are relatively unique because they are often “ego-syntonic;” that is, most people are largely comfortable with their selves, with their characteristic manner of behaving, feeling, and relating to others. As a result, people rarely seek treatment for their antisocial, narcissistic, histrionic, paranoid, and/or schizoid personality disorder. People typically lack insight into the maladaptivity of their personality.

One clear exception though is borderline personality disorder (and perhaps as well avoidant personality disorder). Neuroticism is the domain of general personality structure that concerns inherent feelings of emotional pain and suffering, including feelings of distress, anxiety, depression, self-consciousness, helplessness, and vulnerability. Persons who have very high elevations on neuroticism (i.e., persons with borderline personality disorder) experience life as one of pain and suffering, and they will seek treatment to alleviate this severe emotional distress. People with avoidant personality may also seek treatment for their high levels of neuroticism (anxiousness and self-consciousness) and introversion (social isolation). In contrast, narcissistic individuals will rarely seek treatment to reduce their arrogance; paranoid persons rarely seek treatment to reduce their feelings of suspiciousness; and antisocial people rarely (or at least willfully) seek treatment to reduce their disposition for criminality, aggression, and irresponsibility.

Nevertheless, maladaptive personality traits will be evident in many individuals seeking treatment for other mental disorders, such as anxiety, mood, or substance use. Many of the people with a substance use disorder will have antisocial personality traits; many of the people with mood disorder will have borderline personality traits. The prevalence of personality disorders within clinical settings is estimated to be well above 50% (Torgersen, 2012). As many as 60% of inpatients within some clinical settings are diagnosed with borderline personality disorder (APA, 2000). Antisocial personality disorder may be diagnosed in as many as 50% of inmates within a correctional setting (Hare et al., 2012). It is estimated that 10% to 15% of the general population meets criteria for at least one of the 10 DSM-IV-TR personality disorders (Torgersen, 2012), and quite a few more individuals are likely to have maladaptive personality traits not covered by one of the 10 DSM-5 diagnoses.

The presence of a personality disorder will often have an impact on the treatment of other mental disorders, typically inhibiting or impairing responsivity. Antisocial persons will tend to be irresponsible and negligent; borderline persons can form intensely manipulative attachments to their therapists; paranoid patients will be unduly suspicious and accusatory; narcissistic patients can be dismissive and denigrating; and dependent patients can become overly attached to and feel helpless without their therapists.

It is a misnomer, though, to suggest that personality disorders cannot themselves be treated. Personality disorders are among the most difficult of disorders to treat because they involve well-established behaviors that can be integral to a client’s self-image (Millon, 2011). Nevertheless, much has been written on the treatment of personality disorder (e.g., Beck, Freeman, Davis, & Associates, 1990; Gunderson & Gabbard, 2000), and there is empirical support for clinically and socially meaningful changes in response to psychosocial and pharmacologic treatments (Perry & Bond, 2000). The development of an ideal or fully healthy personality structure is unlikely to occur through the course of treatment, but given the considerable social, public health, and personal costs associated with some of the personality disorders, such as the antisocial and borderline, even just moderate adjustments in personality functioning can represent quite significant and meaningful change.

Nevertheless, manualized and/or empirically validated treatment protocols have been developed for only one personality disorder, borderline (APA, 2001).

Of course, this diagnostic overlap and complexity did not prevent researchers and clinicians from developing dialectical behavior therapy and mentalization therapy. A further reason for the weak progress in treatment development is that, as noted earlier, persons rarely seek treatment for their personality disorder. It would be difficult to obtain a sufficiently large group of people with, for instance, narcissistic or obsessive–compulsive disorder to participate in a treatment outcome study, one receiving the manualized treatment protocol, the other receiving treatment as usual.

Conclusions

It is evident that all individuals have a personality, as indicated by their characteristic way of thinking, feeling, behaving, and relating to others. For some people, these traits result in a considerable degree of distress and/or impairment, constituting a personality disorder. A considerable body of research has accumulated to help understand the etiology, pathology, and/or treatment for some personality disorders (i.e., antisocial, schizotypal, borderline, dependent, and narcissistic), but not so much for others (e.g., histrionic, schizoid, and paranoid). However, researchers and clinicians are now shifting toward a more dimensional understanding of personality disorders, wherein each is understood as a maladaptive variant of general personality structure, thereby bringing to bear all that is known about general personality functioning to an understanding of these maladaptive variants.

Check Your Knowledge

To help you with your studying, we’ve included some practice questions for this module. These questions do not necessarily address all content in this module. They are intended as practice, and you are responsible for all of the content in this module even if there is no associated practice question. To promote deeper engagement with the material, we encourage you to create some questions of your own for your practice. You can then also return to these self-generated questions later in the course to test yourself.

Vocabulary

Antisocial

A pervasive pattern of disregard and violation of the rights of others. These behaviors may be aggressive or destructive and may involve breaking laws or rules, deceit or theft.

Avoidant

A pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation.

Borderline

A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity.

Dependent

A pervasive and excessive need to be taken care of that leads to submissive and clinging behavior and fears of separation.

Five-Factor Model

Five broad domains or dimensions that are used to describe human personality.

Histrionic

A pervasive pattern of excessive emotionality and attention seeking.

Narcissistic

A pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy.

Obsessive-compulsive

A pervasive pattern of preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness, and efficiency.

Paranoid

A pervasive distrust and suspiciousness of others such that their motives are interpreted as malevolent.

Personality

Characteristic, routine ways of thinking, feeling, and relating to others.

Personality disorders

When personality traits result in significant distress, social impairment, and/or occupational impairment.

Schizoid

A pervasive pattern of detachment from social relationships and a restricted range of expression of emotions in interpersonal settings.

Schizotypal

A pervasive pattern of social and interpersonal deficits marked by acute discomfort with, and reduced capacity for, close relationships as well as perceptual distortions and eccentricities of behavior.

References

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How to cite this Chapter using APA Style:

Crego, C. & Widiger, T. (2019). Personality disorders. Adapted for use by Queen’s University. Original chapter in R. Biswas-Diener & E. Diener (Eds), Noba textbook series: Psychology. Champaign, IL: DEF publishers. Retrieved from http://noba.to/67mvg5r2

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