Chapter 13: Personality Disorders
• Personality disorder (PDs) are a heterogeneous group of
disorders that are coded on Axis II of the DSM. They are regarded
as long-standing, pervasive, and inflexible patterns of behaviour
and inner experience that deviate from the expectations of a
person’s culture and that impair social and occupational
functioning. Some, but not all, can cause emotional distress.
Classifying Personality Disorders: Clusters, Categories, and Problems
• The reliability of personality disorders diagnoses, then, has
improved because of two developments: (1) the publication of
specific diagnostic criteria; and (2) the development of
structured interviews specially designed for assessing personality
Assessing Personality Disorders
• Some key points need to be made about the assessment of
personality disorders. A significant challenge is that many
disorders are egosyntonic: the person with a personality disorder
is typically unaware that a problem exists and may not be
experiencing significant personal distress; that is, they lack
insight into their own personality.
• Another significant challenge is that a substantial proportion of
patients are deemed to have a personality disorder not otherwise
specified (PDNOS) and these patients do not fit into existing
personality disorder diagnostic categories.
• This framework, known as the PSY-5, consists of dimensions
assessing negative emotionality/neuroticism, lack of positive
emotionality, aggressiveness, lack of constraint, and
• PSY-5 and the NEO-PI(R) were strong, significant unique
predictors of the symptoms of 10-personality disorders.
• Perhaps the most widely used measure of personality disorder
symptoms is the Millon Clinical Multiaxal Inventory, now in its
third edition. The MCMI-III is a 175-item true-false inventory at an
eighth grade reading level that was revised to parallel DSM-IV.
• The update 2009 version of the MCMI-III has new norms and
additional scoring. It now includes “therapy-guiding facet scales”
(e.g. interpersonal style, cognitive style) known as the Grossman
Facet Scales that further characterize the person who answered
the MCMI-III. These facet scales were added to facilitate Milon
and Grossman’s (2007) new treatment approach known as personalized therapy.
Personality Disorder Clusters
• Personality disorders are grouped into three clusters:
1. Individuals in cluster A (paranoid, schizoid, and schizotypal)
seem odd or eccentric. These disorders reflect oddness, and
avoidance of social contact.
2. Those in cluster B (borderline, histrionic, narcissistic, and anti-
social) seem dramatic, emotional, or erratic. Behaviours are
extrapunitive and hostile.
3. Those in cluster C (avoidant, dependent, and obsessive-
compulsive) appear fearful.
• The odd/ eccentric cluster comprises three diagnoses: paranoid,
schizoid, and schizotypal PDs. The symptoms of these disorders
bear some similarity to the symptoms of schizophrenia,
especially to the less severe symptoms of its prodromal and
Paranoid Personality Disorder
• The individual with paranoid personality disorder (PPD) is
suspicious of others.
• PPD occurs most frequently in men and co-occurs most
frequently with schizotypal, borderline, and avoidant personality
Schizoid Personality Disorder
• People with schizoid personality disorder do not appear to desire
or enjoy social relationships and usually have no close friends.
They appear dull, bland, and aloof and have no warm, tender
feelings for others. They rarely report strong emotions, have no
interest in sex, and experience few pleasurable activities.
• Comorbidity is highest for schizotypal, avoidant, and paranoid
Schizotypal Personality Disorder
• The concept of the schizotypal personality grew up of Danish
studies of the adopted children of schizophrenic parents.
Although some of these children developed full-blown schizophrenia as adults, an even larger number developed what
seemed to be an attenuated form of schizophrenia.
• People with schizotypal personality disorder usually have the
interpersonal difficulties of the schizoid personality and
excessive social anxiety that does not diminish as they get to
• Those with schizotypal personality disorder may also have odd
beliefs or magical thinking and recurrent illusions.
Etiology of the Odd/Eccentric Cluster
• Family studies of paranoid personality disorders for the most part
find higher than average rates in the relatives of people with
schizophrenia or delusional disorder.
• Family studies have shown that the relatives of people with
schizophrenia are at increased risk for this disorder.
• The lowest heritability estimate was found for schizotypal
personality disorder and the largest heritability estimate was
found for anti-social personality disorder.
• The diagnoses in the dramatic/erratic cluster – borderline,
histrionic, narcissistic, and anti-social personality disorders –
include clients with a wide variety of symptoms, ranging from
variable behaviour to inflated self-esteem, exaggerated
emotional displays, and anti-social behaviour.
Borderline Personality Disorder
• The core features of this disorder are impulsivity and instability
in relationships, mood, and self-image.
• Emotions are erratic and can shift abruptly, particularly from
passionate idealization to contemptuous anger. BPD sufferers are
argumentative, irritable, sarcastic, quick to take offence, and
very hard to live with.
• Individuals with BPD have not developed a clear and coherent
sense of self and remain uncertain about their values, loyalties,
and career choices. They cannot bear to be alone, have fears of
abandonment, and demand attention.
• BPD typically begins in early adulthood, has a prevalence of 1%
to 2% and is more common in women than in men.
• Comorbidity is found with substance abuse, posttraumatic stress
disorder, eating disorders, and personality disorders from the odd eccentric cluster.
• Object-relations theory, an important variant of psychoanalytic
theory, is concerned with the way children incorporate (or
introject) the values and images of important people, such as
their parents. In other words, the focus is on the manner in which
children identify with people to whom they have strong
• Splitting: dichotomizing objects into all good or all bad and failing
to integrate positive and negative aspects of another person or
the self into a whole. This tendency causes extreme difficulty in
regulating emotions because the person with BPD sees the
world, including himself or herself in black-and-white terms.
• The diagnosis of histrionic personality formerly called hysterical
personality is applied to people who are overly dramatic and
attention-seeking. They often use features of their physical
appearance, such as unusual clothes, makeup, or hair colour, to
draw attention to themselves. These individuals, although
displaying emotion extravagantly, are though to be emotionally
shallow. They are self-centred, overly concerned with their
attractiveness, and uncomfortable when not the centre of
• People with a narcissistic personality disorder (NPD) have a
grandiose view of their own uniqueness and abilities. To say that
they are self-centred is an understatement. They require almost
constant attention and excessive admiration and believe that
only high-status people can understand them.
• The prevalence of NPD is less than 1%. It most often co-occurs
Etiology of Narcissistic Personality Disorder
• Heinz Kohut established a variant of psychoanalysis known as
self-psychology. According to Kohut, the self emerges early in life
as bipolar structure with an immature grandiosity at one pole
and a dependent overidealization of other people at the other. A
failure to develop healthy self-esteem occurs when parents do