The Personality Disorders
T HE C ONCEPT OF P ERSONALITY D ISORDER
Cross-situationally consistent and persistent features are described as traits. Each person
possesses several traits, the combination of which describes personality.
A personality disorder is an enduring pattern of inner experience and behavior that deviates
markedly from the expectations of the individual’s culture, is pervasive and inflexible, has an
onset in adolescence or early adulthood, is stable over time, and leads to distress or
People with personality disorders show a restricted range of traits and are more likely to be
characterized by a single dominant, dysfunctional trait.
The personality disorders include conditions that cause distress primarily for other people.
Personality disorders are associated with various forms of personal impairment and extensive
The DSM-5 provides six formal criteria in defining personality disorders:
o The pattern of behavior must be manifested in at least two of the following areas:
cognition, emotions, interpersonal functioning, or impulse control.
o The enduring pattern of behavior must be rigid and consistent across a broad range of
personal and social situations.
o This behavior should lead to clinically significant distress in social, occupational, or other
important areas of functioning.
o It requires stability and long duration of symptoms, with onset in adolescence or earlier.
o The behavior cannot be accounted for by another mental disorder.
o The behavioral patterns are not the result of substance abuse.
DSM-5 lists the specific personality disorders per three broad clusters:
o Odd and eccentric disorders (paranoid, schizoid, and schizotypal);
o Dramatic, emotional, or erratic disorders (antisocial, borderline, histrionic, and
o Anxious and fearful disorders (avoidant, dependent, and obsessive-compulsive).
In addition to these three clusters, the manual also includes personality change
due to another medical condition and other specified personality disorder and
unspecified personality disorder.
Depending on the sample and method of diagnosis, prevalence rates vary considerably. Cluster A disorders are most prevalent in men who had never married. Cluster B disorders are
most prevalent in poorly educated men. Cluster C disorders are most common among those
who had graduated from high school but who had never married.
In 2001-2001, 14.8 percent of American adults met the diagnostic criteria for at least one DSM-
IV-TR personality disorder.
The risk of having avoidant, dependent, and paranoid personality disorders was greater for
females than for males, whereas the risk of having APD was greater for males than for females.
39 percent of people with a personality disorder receive treatment for their mental health or
substance abuse difficulties.
For many people with personality disorder, their functioning is egosyntonic; that is, they do not
view it as problematic. Most other mental disorders are generally considered egodystonic; they
cause distress and are viewed as problematic by the individual sufferer.
D IAGNOSTIC ISSUES
The personality disorders have lower reliability of their diagnosis, poorly understood etiology
and weak treatment efficacy.
Personality disorders might be better viewed as constellations of traits, each of which lie along a
continuum, rather than as disorders that people simply have or do not have.
Others suggest that the diagnostic criteria for some personality disorders are gender biased.
GENDER AND CULTURAL ISSUES
DSM-5 requires diagnosticians to ensure that the client’s functioning does not simply reflect
normative responding in the client’s culture.
Sex role stereotypes may influence the clinician’s determination of the presence of personality
o Borderline personality disorder and histrionic personality disorder has long been
diagnosed more commonly in females than in males.
RELIABILITY OF DIAGNOSIS
Personality disorders require a very thorough and careful consideration of the potential
disorder’s pervasiveness and severity, as well as the client’s personality style and motivation.
Most personality disorders can be reliably diagnosed given enough information and effort.
All personality disorders, except for narcissistic personality disorder and paranoid personality
disorder, showed “fair to good” test-retest reliability. As well, there is at least “fair to good”
inter-rater reliability for all personality disorders. COMORBIDITY AND DIAGNOSTIC OVERLAP
Comorbidity should be used to describe the co-occurrence in the same person of two or more
Overlap refers to the similarity of symptoms in two or more different disorders.
Patients diagnosed as borderline have been found to have schizotypal features, and
considerable overlap has been observed between borderline diagnoses and other personality
Schizotypal personality disorder is associated with bother borderline personality disorder and
narcissistic personality disorder.
There is a high level of comorbidity between the construct of histrionic personality disorder and
borderline, narcissistic, and dependent personality disorder.
Over half of the individuals diagnosed with personality disorders meet the criteria for at least
one mental disorder.
H ISTORICAL P ERSPECTIVE
Historically, there has been greater attention to what we now call antisocial personality
disorder, or the related condition psychopathy, than to any other personality disorder.
Based on Machiavelli’s writings, the term machiavellianism has become synonymous with
callous, manipulative, and deceptive personality characteristics.
o In addition to subclinical narcissism and subclinical psychopathy, make up the “Dark
Pinel described a condition called manie sans délire, or madness without delirium.
James Pritchard coined the term moral insanity to delineate a mental condition characterized by
an absence of morality.
o The “moral principles of the mind” were “perverted or depraved” in these men.
Koch gave the opinion that a more appropriate term would be psychopathic inferiority. The
condition of psychopathy stemmed from a type of biological abnormality.
In the early part of the twentieth century, sociologists replaced the term psychopath with the
descriptor sociopath, reflecting the idea that the condition involved an “anti-society” view of
During and after the 1940s, many causal theories were published, from learning theorists,
psychoanalysts, and psychophysiologists. To this day there have been no firm conclusions about the factors that cause personality
Psychoanalysts see personality disorder as resulting from disturbances in the parent-child
relationship, particularly in problems related to separation-individuation.
o Difficulties in this process result in either an inadequate sense of self or problems in
dealing with other people.
This evidence has served to bolster other environmental theories of personality disorders.
Attachment theory asserts that children learn how to relate to others, particularly in
affectionate ways, by the way in which their parents relate to them.
o When the bond is poor, children will lack confidence in relations with others and leads
to deficits in developing intimacy. As well, they are an antecedent to violence and
antisocial patterns in children.
Evidence appears to support the role of disrupted attachments in the etiology of these
Rates of childhood maltreatment among individuals with personality disorders are generally
Borderline personality disorder was more consistently associated with childhood abuse and
neglect than were other disorders.
Cognitive strategies or schemas are said to develop early in life, and in personality-disordered
individuals these schemas become rigid and inflexible.
o People cope with their schemas in ways that may have been adaptive when they were
children trying to survive in a damaging environment, but they continue coping in this
same manner into adulthood.
o These people come from families who consistently invalidate the emotional experiences
of the child and oversimplify the ease with which life’s problems can be solved.
o They learn that the way to get their parents’ attention is through a display of major
Parents may also model inappropriate personal styles themselves, and there is considerable
evidence that modelling is a powerful influence on children’s behavior.
Parents may inappropriately reward or punish behavior and the expression of attitudes. o Parents of children who engage in antisocial behavior have been shown to reward or
punish their children non-contingently.
Biological theorists have claimed that there is either brain dysfunction or a genetic or hormonal
basis for these conditions.
Specific disturbances in neurotransmitter systems in the brain characterize particular types of
Different biological processes are associated with four dimensions (i.e., cognitive-perceptual
organization, impulsivity-aggression, affective stability, and anxiety-inhibition) that together
o Disruptions in the biological underpinnings of these four factors might be expected to
produce the unique personality disorders.
Both schizophrenia and schizotypal personality disorder occurred exclusively in children of
parents with schizophrenia.
o Children of parents with schizophrenia also were at increased risk for avoidant
personality disorder but not paranoid personality disorder.
o These relationships were particularly strong for males.
There is a familial vulnerability to schizophrenia spectrum disorders that is observable before
The personality disorder group showed reduced prefrontal volume and poorer frontal
functioning compared to both other groups.
Studies have implicated dysregulated responding of the prefrontal areas of the brain as well as
fronto-limbic dysfunction in the form of overactivation of the amygdala in borderline patients.
The median “heritability coefficient” for 12 personality disorder scales was .75.
Childhood personality disorders may have a substantial genetic component.
SUMMARY OF ETIOLOGY
There is clear correlational evidence of biological, family, and learning processes, and there is
some support for psychodynamic accounts.
With respect to Cluster A disorders, the most prominent observations are genetic links with
both schizophrenia and mood disorders.
For Cluster B disorders, the two etiological factors that have received the best support are
biological factors and attachment problems.
Investigations of causal factors specifically with Cluster C disorders have been very limited. In general, causes of the personality disorders remain murky.
C LUSTER A: O DD AND E CCENTRIC D ISORDERS
PARANOID PERSONALITY DISORDER
Pervasive suspiciousness concerning the motives of other people and a tendency to interpret
what others say and do as personally meaningful in a negative way are the primary features of
someone with paranoid personality disorder.
Individuals with paranoid personality tend to be hypervigilant, and they take extreme
precautions against potential threats from others.
They are typically humorless and eccentric, and are seen by others as hostile, jealous, and
preoccupied with power and control.
They have numerous problems in relationships. Frequently, patients become socially isolated,
and this seems only to add to their persecutory ideas.
A genetic link with schizophrenia has been proposed. It has even been suggested that paranoid
personality disorder may be a subtype or “cousin” of schizophrenia.
o The main difference in paranoid personality and paranoid schizophrenia is the severity
of the paranoid belief.
In schizophrenia, the paranoid belief is sufficiently bizarre and ingrained that it
is considered “psychotic”—a delusion.
In paranoid personality, the individual’s paranoid beliefs are non-bizarre, within
the realm of possibility, and pertain to general suspiciousness.
There is significant diagnostic overlap between paranoid personality and both avoidant and
borderline personality disorders.
Paranoid personality disorder is one of the most commonly diagnosed personality disorders in
Only a very small proportion of individuals with this disorder would seek or accept treatment.
SCHIZOID PERSONALITY DISORDER
Individuals with this condition seem completely uninterested in having any sort of intimate
involvement with others, and they display little in the way of emotional responsiveness.
Individuals with schizoid personality disorder are typically loners who are cold and indifferent
toward others. They seem not to enjoy relationships of any type.
o Most do not have the skills necessary for effective social interaction. The impact on diagnostic practices of the changes from DSM-III to DSM-III-R revealed that the
frequency of schizoid diagnoses increased significantly.
This diagnostic category has been the focus of little methodologically sound research.
This disorder may be more related to asocial disorders than paranoid personality disorder or
schizotypal personality disorder.
SCHIZOTYPAL PERSONALITY DISORDER
The major presenting feature of individuals with the schizotypal personality disorder is
eccentricity of thought and behavior; many are extremely superstitious.
Schizotypal patients are typically socially isolated.
Their thinking tends to be permeated by odd beliefs. They typically believe in magical thinking
and paranormal phenomena and may see such skills in themselves.
This condition has some similarities with schizophrenia. The difference lies in the severity and
quality of the symptoms.
o They are not usually considered to be so eccentric as to meet the criteria for delusional
or hallucinatory psychotic experiences.
Biological research has found strong similarities between patients with schizotypal personality
disorder and those with schizophrenia.
Many family members of patients with schizophrenia exhibit schizotypal symptoms.
While the symptoms of SPD remain the same, the severity of the symptoms varies depending on
sex and age.
Diagnostic overlap between schizotypal disorder and other Cluster A disorders is considerable.
Low doses of antipsychotic drugs relieve the cognitive problems and social anxiety apparent in
these patients, and antidepressant medication has also produced positive effects.
Generally the long-term prognosis for schizotypal patients is poor.
C LUSTER B: D RAMATIC , E MOTIONAL , OR E RRATIC D ISORDERS
It’s been suggested that antisocial patients belong to a separate category of personality
ANTISOCIAL PERSONALITY DISORDER AND PSYCHOPATHY: A CONFUSION OF
Not all patients with antisocial personalities commit crimes, although most of them who are so
diagnosed by clinicians have a criminal record. The behavioral features of APD predispose these patients to crime, and unlawfulness is one of
the examples that DSM-5 provides of the disregard that those with antisocial personalities
display toward others.
DESCRIPTION OF THE DISORDER
Individuals thus identified have been referred to as psychopaths, sociopaths, or dissocial
personalities, with these terms sometimes being used interchangeably.
APD and psychopathy are not the same disorder. Only a small proportion of individuals who
qualify for an APD diagnosis are psychopathic, whereas most individuals who are psychopathic
would qualify for an APD diagnosis.
o APD and psychopathy have an asymmetric relationship.
The Psychopathy Checklist—Revised specifies both behavior and personality as features to be
o Personality and lifestyle instability are necessary and sufficient for a diagnosis.
o The PCL-R emotional/affective criteria are highly reliable if the rater has the appropriate
The essential feature of APD is a pervasive pattern of disregard for and violation of the rights of
others that begins in childhood or early adolescence and continues into adulthood.
The DSM-5 criteria for APD are a highly reliable set of indicators of a socially deviant lifestyle;
however, they are not the best criteria for tapping the core features of psychopathy.
ANTISOCIAL PERSONALITY DISORDER (APD)
The DSM-5 criteria for the diagnosis of APD include seven exemplars reflecting the violation of
the rights of others: nonconformity, callousness, deceitfulness, irresponsibility, impulsivity,
aggressiveness, and recklessness.
Reflecting a polythetic approach, three or more of the above symptoms must be met for the
diagnosis to be applied.
The DSM-5 reports lifetime prevalence rates for APD between 0.2 percent and 3.3 percent for
both males and females.
In Canadian prisons using DSM-III-R, approximately 40 percent of offenders were diagnosed as
ETIOLOGY OF APD
Social and family factors were initial explanations with the view being that parental behaviors
can influence the development of antisocial functioning.
A minority of youth become involved in rule breaking and delinquent behavior at an early age
and this is sustained throughout their lifespan in one form or another. Research also suggests the importance of familial/parental factors and genetic features as risk
factors for developing APD.
Heritability estimates for measure of antisocial behavior/aggression ranges from 44 to 72
There appear to be neuropsychological markers that, in combination with specific
environmental circumstances, interact to make children vulnerable to developing an antisocial
lifestyle and personality.
The fearlessness hypothesis claims that those with APD have a higher threshold for feeling fear
than do other people. There appears to be an attentional mechanism that reduces the fear
respond in individuals with APD.
o Schmauk suggested that these individuals might have learned to be either indifferent to
physical punishment or oppositional to such attempts at controlling them.
Oppositional behavior refers to a tendency to do the opposite of what is being asked of the
Psychopaths suffer from a generalized information processing deficiency involving the
automatic directing of attention to stimuli that are peripheral to ongoing directed behavior.
o Once engaged in reward-based behavior, the psychopath is less likely to attend to other
cues to modulate his or her ongoing response.
o The antisocial and criminal behavior exhibited by those diagnosed as having APD
involves schema-based deficits not requiring automatic attentional cuing.
COURSE AND PROGNOSIS OF APD
The average duration of APD, from the onset of the first symptom to the end of the last, was 19
years. The remittance over time of symptoms has been described as the burnout factor.
When APD and substance use are comorbid conditions, the post-release performance is poorer
than in those offenders who have only one or the other disorder.
TREATMENT FOR APD
Programs delivered in the previ