Personality Disorders

Introduction to Personality Disorders

The 10 personality disorders mentioned in the DSM-5 involve pervasive and enduring personality styles that differ from cultural expectations and cause distress and/or conflict with others.

Learning Objectives

Differentiate among mood disorders and the three clusters of personality disorders identified in the DSM-5

Key Takeaways

Key Points

  • According to the DSM-5, personality disorders are characterized by patterns of cognition, behavior, and emotion that (1) differ from cultural norms, (2) cause distress and impairment, (3) apply across many contexts and over a long period of time, and (4) cannot be better explained by another mental disorder or by a physical or medical condition.
  • The DSM-5 includes 10 different personality disorders, grouped into three clusters based on common features.
  • Cluster A (“odd and eccentric”) includes paranoid personality disorder, schizoid personality disorder, and schizotypal personality disorder.
  • Cluster B (“dramatic, emotional, or erratic”) includes antisocial personality disorder, borderline personality disorder, histrionic personality disorder, and narcissistic personality disorder.
  • Cluster C (“anxious or fearful”) includes avoidant personality disorder, dependent personality disorder, and obsessive-compulsive personality disorder.
  • Management and treatment of personality disorders can be a challenging and controversial area since symptoms are long-lasting and affect multiple areas of functioning; substantial social stigma may also be a barrier to receiving treatment.

Key Terms

  • stigma: The disapproval and judgment of a person or group of people because they do not fit their community’s social norms.
  • ego-syntonic: A psychological term referring to behaviors, values, and feelings that align with an individual’s ideal self-image.
  • personality disorder: A state in which an individual displays patterns of cognition, behavior, and emotion that differ from cultural norms, cause distress and impairment, apply across many contexts, and have been exhibited over a long duration of time.
  • personality: The set of enduring behavioral and mental traits that distinguish an individual from other people.

Defining Personality Disorders

In the field of psychology, “personality” refers to the set of enduring behavioral and mental traits that distinguish an individual from other people. According to the DSM-5, “personality disorder” refers to when an individual displays a personality style (i.e., patterns of cognition, behavior, and emotion) that:

  1. differs significantly from the norms and expectations of their culture in two or more of the following areas: cognition, affect, interpersonal functioning, or impulse control;
  2. causes them and/or others around them “clinically significant” distress and impairment in important areas of functioning;
  3. is pervasive (i.e., applies across many contexts, such as school, work, and home) and enduring (i.e., has been exhibited over a long duration of time, since at least adolescence or early adulthood); and
  4. cannot be better explained by another mental disorder or be due to the direct physiological effects of a substance or general medical condition (e.g., head trauma).

The patterns found in personality disorders develop early and are inflexible. Someone diagnosed with a personality disorder may experience difficulties in cognition, emotion, impulse control, and interpersonal functioning. That said, though personality disorders are typically associated with significant distress or disability, they are also ego-syntonic, which means that individuals do not feel as though their values, thoughts, and behaviors are out of place or unacceptable. In other words, their thoughts and behaviors are consistent with their own ideal self-image.

The DSM-5: Grouping Personality Disorders

To be fully diagnosed, an individual must meet both the DSM-5’s general diagnostic criteria for a personality disorder (provided above) as well as the criteria for a specific disorder.

The DSM-5 lists ten different personality disorders, grouped into three clusters based on common features. Personality disorders are often researched within these clusters, since the disorders in a cluster exhibit many common disturbances.

Cluster A (odd and eccentric)

  • Paranoid personality disorder: Characterized by a pattern of irrational suspicion and mistrust of others and the interpretation of motivations as malevolent. The person is guarded, defensive, distrustful, suspicious, and always looking for evidence to confirm hidden plots and schemes.
  • Schizoid personality disorder: Characterized by a lack of interest and detachment from social relationships, and restricted emotional expression. The individual is apathetic, indifferent, remote, solitary, distant, and humorless. They neither desire, nor need, human attachments, and withdraw from relationships and prefer to be alone.
  • Schizotypal personality disorder: Characterized by a pattern of extreme discomfort interacting socially, and distorted cognitions and perceptions. One is eccentric, self-estranged, bizarre, absent, and exhibits magical thinking and strange beliefs.

Cluster B (dramatic, emotional, or erratic)

  • Antisocial personality disorder: A pervasive pattern of disregard for, and violation of, the rights of others, rooted in a lack of empathy. The person is impulsive, irresponsible, unruly, inconsiderate, and sometimes violent. They comply with social obligations only when they see personal benefit.
  • Borderline personality disorder: A pervasive pattern of instability in relationships, self-image, identity, behavior, and affect, often leading to self-harm and impulsivity. One is unpredictable, manipulative, unstable, and frantically fears abandonment and isolation. One shifts rapidly between loving and hating.
  • Histrionic personality disorder: A pervasive pattern of attention-seeking behavior and excessive emotions. One is dramatic, seductive, shallow, stimulus-seeking, and vain. One overreacts to minor events and is exhibitionistic.
  • Narcissistic personality disorder: A pervasive pattern of grandiosity, need for admiration, and a lack of empathy.

Cluster C (anxious or fearful)

  • Avoidant personality disorder: Pervasive feelings of social inhibition and inadequacy, and extreme sensitivity to negative evaluation. One is hesitant, self-conscious, embarrassed, anxious, and sees self as inept, inferior, or unappealing.
  • Dependent personality disorder: A pervasive psychological need to be cared for by other people. One is helpless, incompetent, submissive, immature, and sees self as weak or fragile.
  • Obsessive-compulsive personality disorder: Characterized by a rigid conformity to rules, perfectionism, and control. One maintains a rule-bound lifestyle, adheres closely to social conventions, sees the world in terms of regulations and hierarchies, and often follows directions and rules to the point of missing the purpose of the task.

Challenges of Personality Disorders

The disruptive nature of personality disorders, as well as the fact that their symptoms are long-lasting and affect multiple areas of functioning, means that these are possibly the most challenging group of disorders to manage. In addition, individuals with personality disorders may not even be able to recognize that their personality is causing distress or issues with other people.

Unfortunately, there is substantial social stigma and discrimination related to a diagnosis of a personality disorder. Community mental health services may view individuals with personality disorders as too complex or difficult to deal with and so directly or indirectly exclude them from receiving care.

Cluster A: Paranoid, Schizoid, and Schizotypal Personality Disorders

Cluster A personality disorders have a likely genetic component and are characterized by personality styles that are odd or eccentric.

Learning Objectives

Summarize the similarities and differences in diagnostic criteria, etiology, and treatment options among the Cluster A personality disorders

Key Takeaways

Key Points

  • Cluster A personality disorders include paranoid personality disorder, schizoid personality disorder, and schizotypal personality disorder. People with these disorders display a personality style that is odd or eccentric.
  • A person with paranoid personality disorder harbors a pervasive and unjustifiable suspiciousness and mistrust of others, is reluctant to confide in or become close to others, reads hidden threatening meaning into benign remarks or events, and takes offense and bears grudges easily.
  • A person with schizoid personality disorder lacks interest and desire to form relationships with others, is aloof and shows emotional coldness and detachment, is indifferent to approval or criticism of others, and lacks close friends or confidants.
  • A person with schizotypal personality disorder exhibits eccentricities in thought, perception, emotion, speech, and behavior; shows suspiciousness or paranoia; has unusual perceptual experiences; displays inappropriate emotions; and lacks friends or confidants.
  • Cluster A personality disorders are likely determined in part by genetics; researchers also believe early childhood experiences and parenting styles play a role.

Key Terms

  • anhedonia: The inability to experience pleasure from activities typically considered enjoyable.
  • Projection: In psychodynamic psychology, a defense mechanism in which an individual attributes their own unacceptable or unwanted attributes, thoughts, or emotions to other people.
  • comorbidity: The presence of one or more additional disorders (or diseases) co-occurring with a primary disorder or disease.

The DSM-5 recognizes 10 personality disorders, organized into 3 different clusters (A, B, and C). People with cluster A personality disorders display a personality style that is odd or eccentric; they are often described as having a pattern of acute discomfort in close relationships, cognitive or perceptual distortions, and eccentricities of behavior.

Cluster A disorders include paranoid personality disorder, schizoid personality disorder, and schizotypal personality disorder.

Paranoid Personality Disorder

Defining Paranoid Personality Disorder

Paranoid personality disorder (PPD) is a mental disorder characterized by paranoia and a pervasive, long-standing suspicion and general mistrust of others. Individuals with this personality disorder may be hypersensitive, easily feel slighted, and habitually relate to the world by vigilantly scanning the environment for clues or suggestions that might validate their fears or biases.

DSM-5 Diagnostic Criteria for Paranoid Personality Disorder

According to the DSM-5, to qualify for a diagnosis of paranoid personality disorder, at least 4 of 7 criteria must be met. These 7 criteria include that the person:

  1. suspects, without sufficient basis, that others are exploiting, harming, or deceiving him or her;
  2. is preoccupied with unjustified doubts about the loyalty or trustworthiness of friends or associates;
  3. is reluctant to confide in others because of unwarranted fear that the information will be used maliciously against him or her;
  4. reads hidden demeaning or threatening meanings into benign remarks or events;
  5. persistently bears grudges, i.e., is unforgiving of insults, injuries, or slights;
  6. perceives attacks on their character or reputation that are not apparent to others, and is quick to react angrily or to counterattack;
  7. has recurrent suspicions, without justification, regarding the fidelity of their spouse or sexual partner.

In addition, the person’s symptoms must not be due to schizophrenia or any other psychotic disorder.

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Paranoid personality disorder: People with paranoid personality disorder are characterized by a pervasive, long-standing suspicion and general mistrust of others.

Etiology of Paranoid Personality Disorder

Brain researchers have found a possible genetic predisposition to paranoid traits as well as a possible genetic link between paranoid personality disorder and schizophrenia.

Psychosocial theorists implicate the projection of negative internal feelings and parental modeling into fears of other people and/or situations.

Cognitive theorists believe the disorder to be a combination of both an underlying belief that other people are deceptive or malevolent as well as a lack of self-confidence.

Treatment of Paranoid Personality Disorder

Because of their reduced levels of trust, individuals with paranoid personality disorder can be challenging to treat. However, psychotherapy —in combination with antidepressants, antipsychotics, and anti- anxiety medications—can be useful if an individual is receptive to intervention.

Schizoid Personality Disorder

Defining Schizoid Personality Disorder

Schizoid personality disorder (SPD) is characterized by a lack of interest in social relationships as well as a tendency toward a solitary lifestyle, secrecy, emotional coldness, and apathy. At the same time, however, individuals with SPD may demonstrate a rich and elaborate internal fantasy world.

DSM-5 Diagnostic Criteria for Schizoid Personality Disorder

In order to be diagnosed with SPD, a person must lack the desire to form relationships with others, be aloof and show emotional coldness and detachment, be indifferent to others’ approval or criticism, and/or lack close friends and confidants. These symptoms must not be attributable to an autism spectrum disorder or to schizophrenia or another psychotic disorder.

Etiology of Schizoid Personality Disorder

Research has found that an individual is more likely to meet the criteria for SPD if they have a relative with schizophrenia or schizotypal personality disorder; this suggests that genetics play a partial role in heritability of this disorder. Twin studies also support this hypothesis.

Researchers hypothesize that the environment also plays a role—that unloving, neglectful, or excessively perfectionistic parenting might contribute to the development of this disorder.

Treatment of Schizoid Personality Disorder

Schizoid personality disorder has negative symptoms similar to those of schizophrenia (e.g., anhedonia, blunted affect, and low energy), and medications such as atypical antipsychotics may alleviate these symptoms. Those who seek treatment have the option of medication and/or therapy, and therapeutic interventions can be either short-term or long-term. Socialization groups may also help some people with schizoid personality disorder.

Schizotypal Personality Disorder

Defining Schizotypal Personality Disorder

Schizotypal personality disorder (STPD) is a personality disorder characterized by a need for social isolation, anxiety in social situations, odd behavior and thinking, and unconventional beliefs. People with this disorder feel extreme discomfort maintaining close relationships with people, so they generally avoid forming them altogether. Peculiar speech mannerisms and odd modes of dress are also diagnostic signs of this disorder. In some cases, people with STPD may react oddly in conversations, not respond, or talk to themselves. They also experience what are called “ideas of reference”—that is to say, they frequently misinterpret insignificant or coincidental events or situations as being highly and personally significant. Paranormal and superstitious beliefs are not uncommon. People with STPD frequently seek medical attention for anxiety or depression, but the underlying personality disorder often goes undiagnosed.

DSM-5 Diagnostic Criteria for Schizotypal Personality Disorder

To be diagnosed with STPD, at least five of the following symptoms must be present:

  • ideas of reference;
  • strange beliefs or magical thinking;
  • abnormal perceptual experiences;
  • strange thinking and speech;
  • paranoia;
  • inappropriate or constricted affect;
  • strange behavior or appearance;
  • lack of close friends; and
  • excessive social anxiety that does not abate and stems from paranoia rather than negative judgments about the self.

These symptoms must not be attributable to an autism spectrum disorder or to schizophrenia or another psychotic disorder.

Etiology of Schizotypal Personality Disorder

Rates of STPD are disproportionately higher among people who have a relative with schizophrenia than among those who have a relative with no or a different mental illness. This suggests that there is a genetic component to STPD and that it is also genetically linked to schizophrenia.

There is also evidence to suggest that parenting styles, early separation, and history of trauma or maltreatment. In particular, neglect, abuse, trauma, or family dysfunction during childhood can increase the risk of developing STPD. The exact nature of this relationship is unclear, but the impact is that people with STPD struggle with the childhood process of learning to interpret and respond appropriately to social cues.

Treatment of Schizotypal Personality Disorder

STPD is rarely seen as a primary reason for treatment in a clinical setting, but it has high rates of comorbidity with other mental disorders (i.e., it is often part of a dual diagnosis of STPD and a second disorder). When patients with STPD are prescribed medication, they are most often prescribed the same drugs used to treat patients suffering from schizophrenia.

According to personality psychologist Theodore Millon, schizotypal personality disorder is one of the easiest to identify but one of the most difficult to treat with psychotherapy. People with STPD usually underestimate the maladaptiveness of their social isolation and perceptual distortions; they tend to consider themselves to be simply eccentric, creative, or nonconformist. In addition, it is difficult to develop rapport with people who experience closeness and intimacy as more uncomfortable and anxiety-inducing. In most cases people with STPD do not respond to informality and humor.

Group therapy is recommended for people with STPD only if the group is well structured and supportive.

Cluster B: Antisocial, Borderline, Histrionic, and Narcissistic Personality Disorders

Cluster B personality disorders are characterized by personality styles that are impulsive, dramatic, highly emotional, and erratic.

Learning Objectives

Summarize the similarities and differences in diagnostic criteria, etiology, and treatment options among the Cluster B personality disorders

Key Takeaways

Key Points

  • Cluster B disorders include antisocial, histrionic, narcissistic, and borderline personality disorders. People with these disorders usually are impulsive, overly dramatic, highly emotional, and erratic.
  • A person with antisocial personality disorder continuously violates the rights of others; often lies, fights, and has problems with the law; can be deceitful and manipulative in order to gain profit or pleasure; and lacks feelings for others and remorse over misdeeds.
  • Borderline personality disorder is characterized by instability in self-image, mood, and behavior. The person cannot tolerate being alone; has unstable and intense relationships with others; and exhibits behavior that is impulsive, unpredictable, and sometimes self-damaging.
  • A person with histrionic personality disorder is excessively overdramatic, emotional, and theatrical; feels uncomfortable when not the center of others’ attention; exhibits inappropriately seductive or provocative behavior; and may alienate friends with demands for constant attention.
  • People with narcissistic personality disorder have an overinflated and unjustified sense of self-importance and are preoccupied with fantasies of success. They believe they are entitled to special treatment from others, take advantage of others, and lack empathy.

Key Terms

  • egocentrism: The constant following of one’s egotistical desires to an extreme.
  • conduct disorder: A psychological disorder diagnosed in childhood that presents itself through a persistent pattern of behavior in which the basic rights of others or major age-appropriate norms are violated.
  • serotonin: An indoleamine neurotransmitter (5-hydroxytryptamine) that is involved in depression and is crucial in maintaining a sense of well-being and security.

The DSM-5 recognizes 10 personality disorders, organized into 3 different clusters. Cluster B disorders include antisocial personality disorder, histrionic personality disorder, narcissistic personality disorder, and borderline personality disorder. People with these disorders usually are impulsive, overly dramatic, highly emotional, and erratic.

Antisocial Personality Disorder

Defining Antisocial Personality Disorder

Antisocial personality disorder (ASPD) is characterized by a pervasive pattern of disregard for (or violation of) the rights of others. There may be a poor moral sense or conscience and a history of crime, legal problems, impulsivity, and aggressive behavior. One of the most important features of ASPD is the individual’s lack of remorse or guilt for the acts they have committed. While many individuals break the law and engage in antisocial behavior, it is not appropriate to assume that antisocial behaviors indicate the antisocial personality disorder. Individuals with ASPD do not feel as though they are doing anything wrong, necessarily, and are able to internally justify all of their behaviors and actions.

Though the word “antisocial” is often used to indicate someone who does not like interacting with others, or may be shy or reserved, these characteristics have little to nothing to do with ASPD, and should not necessarily be associated. ASPD is sometimes referred to as psychopathy or sociopathy, though the criteria might be slightly different depending on the method of diagnosis.

DSM-5 Diagnostic Criteria for Antisocial Personality Disorder

The DSM-5 describes ASPD as a pervasive pattern of disregard for, and violation of, the rights of others occurring since age 15, as indicated by three (or more ) of the following:

  • Failure to conform to social norms with respect to lawful behaviors, as indicated by repeatedly performing acts that are grounds for arrest;
  • Deceitfulness, as indicated by repeated lying, use of aliases, or conning others for personal profit or pleasure;
  • Impulsivity or failure to plan ahead;
  • Irritability and aggressiveness, as indicated by repeated physical fights or assaults;
  • Reckless disregard for safety of one’s self or others;
  • Consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or honor financial obligations; and
  • Lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another.

The individual must be at least 18 years old; there must be evidence of conduct disorder with onset before age 15; and the occurrence of antisocial behavior must not exclusively be during the course of schizophrenia or a bipolar manic episode.

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Conduct Disorder: Features of conduct disorder (CD) are necessary for a diagnosis of ASPD. CD is childhood behavior disorder characterized by aggressive and destructive activities that violate social norms and the rights of others.

Etiology of Antisocial Personality Disorder

ASPD seems to be caused by a combination of both genetic  and environmental influences. Genetic influences draw on the temperament and the kind of personality a person is born with, and environmental influences include the way in which a person grows up and the experiences they have had. Traumatic events can lead to a disruption of the standard development of the central nervous system, which can generate a release of hormones that can change normal patterns of development. One of the neurotransmitters that have been discussed in individuals with ASPD is serotonin.

ASPD is seen in up to 30% of psychiatric outpatients. The prevalence of the disorder is even higher in selected populations, such as prisons, where there is a preponderance of violent offenders. Approximately 47% of male prisoners and 21% of female prisoners have ASPD. Similarly, the prevalence of ASPD is higher among patients in alcohol or other drug abuse treatment programs than in the general population. Furthermore, ASPD is diagnosed three times more frequently in men than in women.

Treatment of Antisocial Personality Disorder

ASPD is considered to be a difficult personality disorder to treat. Because of their very low or absent capacity for remorse, individuals with ASPD often lack sufficient motivation and fail to see the costs associated with antisocial acts. Those with ASPD may stay in treatment only as required by an external source, such as a parole. Residential programs that provide a carefully controlled environment of structure and supervision along with peer confrontation have been recommended. Various therapeutic approaches such as schema therapy and multisystemic therapy (MST) have been indicated as potential avenues for treatment.

No medications have been approved by the FDA to treat ASPD, although certain psychiatric medications (such as antipsychotic, antidepressant, or mood-stabilizing medications) may alleviate conditions sometimes associated with the disorder.

Borderline Personality Disorder

Defining Borderline Personality Disorder

The central features of borderline personality disorder (BPD) are a pattern of impulsivity and instability in mood, interpersonal relationships, and self-image. These patterns emerge in early adulthood and persist throughout the lifetime, though they can improve with treatment. One tell-tale symptom is intense fear of abandonment, which underlies the unstable relationships characteristic of BPD. People with BPD often engage in idealization and devaluation of others, alternating between high positive regard and great disappointment. If they sense any indication of negative emotion, criticism, or abandonment, they will completely devalue that once-idealized person and may even seek to hurt them. Other symptoms may include intense anger and irritability, self-mutilation, and suicidal behavior.

DSM-5 Diagnostic Criteria for Borderline Personality Disorder

According to the DSM-5, a diagnosis of borderline personality disorder needs to meet at least five of the following criteria, and can only be diagnosed after the age of 18:

  • Frantic efforts to avoid real or imagined abandonment (not including suicidal behavior);
  • A pattern of unstable and intense interpersonal relationships that alternate between extremes of idealization and devaluation;
  • Identity disturbance: markedly and persistently unstable self-image or sense of self;
  • Impulsivity in at least two areas that are potentially self-damaging (not including suicidal behavior), such as excessive spending, unprotected sex, substance abuse, reckless driving, and/or binge eating;
  • Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior;
  • Affective instability due to a marked reactivity of mood, such as intense episodic dysphoria, irritability, or anxiety lasting between a few hours and a few days;
  • Chronic feelings of emptiness;
  • Inappropriate, intense anger or difficulty controlling anger; and
  • Transient, stress -related paranoid ideation or severe dissociative symptoms.

Etiology of Borderline Personality Disorder

The causes of BPD are complex and not fully agreed upon. Most researchers agree that a history of childhood trauma can be a contributing factor. Recently, more attention has been given to investigating the role played by congenital brain abnormalities, genetics, neurobiological factors, and environmental factors other than trauma.

Sixty-five percent of the variability in symptoms among different individuals with BPD can be explained by genetic differences. There are also some brain abnormalities associated with BPD. The hippocampus tends to be smaller in those who suffer from this disorder, as it is in people with post-traumatic stress disorder ( PTSD ). However in BPD, unlike PTSD, the amygdala also tends to be smaller. Since the amygdala is a major structure involved in managing negative emotions, this may explain the intense fear, sadness, anger, and shame experienced by people with BPD. The prefrontal cortex tends to be less active in people with BPD, especially when recalling memories of abandonment.

Treatment of Borderline Personality Disorder

Psychotherapy is the primary treatment for borderline personality disorder. Treatments should be based on the needs of the individual, rather than upon the general diagnosis of BPD. Various forms of therapeutic treatments include dynamic deconstructive psychotherapy (DDP), mentalization-based treatment (MBT), transference-focused psychotherapy, dialectical behavior therapy (DBT), general psychiatric management, and schema-focused therapy. While DBT is the therapy that has been studied the most, empirical research and case studies have shown that most of these treatments are effective for treating BPD.

Medications are useful for treating comorbid (co-occurring) disorders such as depression and anxiety. Short-term hospitalization has not been found to be more effective than community care for improving outcomes or long-term prevention of suicidal behavior in those with BPD.

Stigma and Controversy Surrounding Borderline Personality Disorder

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Instability in Emotions and Relationships: A central feature of BPD is markedly unstable relationships and sense of self, as well as an intense fear of abandonment.

There is an ongoing debate about the terminology of this disorder, especially the word “borderline”. The concern is that the diagnosis of BPD stigmatizes people and supports discriminatory practices by suggesting that the personality of the individual is flawed.

There are many stigmatizing features of BPD, including emotional instability, intense unstable interpersonal relationships, a need for intimacy, and a fear of rejection. As a result, people with BPD often evoke intense emotions in those around them. Pejorative terms are often used to describe people with BPD (such as difficult, treatment resistant, manipulative, demanding, and attention-seeking) and may become a self-fulfilling prophecy, as the negative treatment of these individuals triggers further self-destructive behavior.

Women are three times more likely to be diagnosed with BPD, corroborating the false stereotype of the “hyper-emotional, unstable woman” that will not conform to traditional female roles. In fact, a large criticism of BPD from a feminist perspective is that the diagnosis forces women into traditional gender roles for fear of being stereotyped. Many survivors of childhood abuse who are diagnosed with BPD are re-traumatized by negative responses from healthcare providers. Some argue that people diagnosed with BPD should instead be diagnosed with PTSD, as this would acknowledge the impact of abuse on the person’s behavior. Others argue that that a diagnosis of PTSD does not encompass all aspects of the disorder and is neurologically and characteristically different than BPD.

Histrionic Personality Disorder

Defining Histrionic Personality Disorder

Histrionic personality disorder (HPD) is a personality disorder characterized by a pattern of excessive attention-seeking emotions, usually beginning in early adulthood, including inappropriately seductive behavior and an excessive need for approval. Histrionic people are lively, dramatic, vivacious, enthusiastic, and flirtatious. People with HPD have a high need for attention, make loud and inappropriate appearances, exaggerate their behaviors and emotions, and crave stimulation. They may exhibit sexually provocative behavior, express strong emotions with an impressionistic style, and can be easily influenced by others. HPD is diagnosed four times more often in women as it is in men, which critics argue suggests a culturally-based gender bias.

DSM-5 Diagnostic Criteria for Histrionic Personality Disorder

According to the DSM-5, a diagnosis of histrionic personality disorder is indicated by at least five of the following:

  • The person is uncomfortable in situations in which he or she is not the center of attention;
  • Interaction with others is often characterized by inappropriate sexually seductive or provocative behavior;
  • The person displays rapidly shifting and shallow expression of emotions;
  • The person consistently uses physical appearance to draw attention to self;
  • The person has a style of speech that is excessively impressionistic and lacking in detail;
  • The person shows self-dramatization, theatricality, and exaggerated expression of emotion;
  • The person is suggestible, i.e., easily influenced by others or circumstances;
  • The person considers relationships to be more intimate than they actually are.

Etiology of Histrionic Personality Disorder

Little research has been done to find evidence as to what causes histrionic personality disorder and where it stems from. There are a few theories, however, that relate to the lineage of its diagnosis. Psychoanalytic theories incriminate authoritarian or distant attitudes by one (mainly the mother) or both parents, along with conditional love based on expectations the child can never fully meet.

Another theory suggests that histrionic personality disorder and antisocial personality disorder could have a possible relationship to one another. Research has found two-thirds of patients diagnosed with histrionic personality disorder also meet criteria similar to that of the antisocial personality disorder. Some family history studies have found that histrionic personality disorder, as well as borderline and antisocial personality disorders, tends to run in families, but it is not clear if this is due to genetic or environmental factors.

Treatment of Histrionic Personality Disorder

Treatment is often prompted by depression associated with dissolved romantic relationships. Medication does little to affect the personality disorder, but may be helpful with symptoms such as depression. The primary forms of treatment for HPD itself involve psychotherapy, including cognitive therapy.

Narcissistic Personality Disorder

Defining Narcissistic Personality Disorder

Narcissistic personality disorder (NPD) is a personality disorder in which a person is excessively preoccupied with personal adequacy, power, prestige, and vanity, and is mentally unable to see the destructive damage they are causing to themselves and others. People with NPD are characterized by exaggerated feelings of self-importance. They have a sense of entitlement and demonstrate grandiosity in their beliefs and behavior. They have a strong need for admiration, but lack feelings of empathy.

It is estimated that this condition affects one percent of the population, with rates greater for men. First formulated in 1968, NPD was historically called megalomania and is a form of severe egocentrism.

DSM-5 Diagnostic Criteria for Narcissistic Personality Disorder

Symptoms of this disorder, as defined by the DSM-5, include significant impairments in self functioning (such as excessive reference to others for self-definition and self-esteem regulation; exaggerated self-appraisal; goal-setting based on gaining approval from others; personal standards that are unreasonably high; etc.) along with impairments in interpersonal functioning (such as lack of empathy; over- or underestimating one’s own effect on others; superficial relationships that exist to serve self-esteem regulation; etc.). They must also experience feelings of grandiosity (including entitlement or self-centeredness) and attention seeking behavior.

Etiology of Narcissistic Personality Disorder

The cause of this disorder is unknown; however, Groopman and Cooper (2006) listed the following factors identified by various researchers as possibilities:

  • An oversensitive temperament (personality traits) at birth.
  • Excessive admiration that is never balanced with realistic feedback.
  • Excessive praise for good behaviors or excessive criticism for bad behaviors in childhood.
  • Overindulgence and overvaluation by parents, other family members, or peers.
  • Being praised for perceived exceptional looks or abilities by adults.
  • Severe emotional abuse in childhood.
  • Unpredictable or unreliable caregiving from parents.
  • Learning manipulative behaviors from parents or peers.
  • Valued by parents as a means to regulate their own self-esteem.

Recent research has identified a structural abnormality in the brains of those with NPD, specifically noting less volume of gray matter in the left anterior insula. This brain region relates to empathy, compassion, emotional regulation, and cognitive functioning.

Treatment of Narcissistic Personality Disorder

People rarely seek therapy for NPD, partly because many NPD sufferers deny they have a problem. Most, if not all, cannot see the destructive damage they cause to themselves and to others and usually only seek treatment at the insistence of relatives and friends.

Psychotherapy is generally used to treat NPD. Schema therapy, a form of therapy developed by Jeffrey Young that integrates several therapeutic approaches (psychodynamic, cognitive, behavioral etc.), also offers an approach for the treatment of NPD. Anger, rage, impulsivity, and impatience can be worked on with skill training. Group treatment has its benefits as the effectiveness of receiving peer feedback rather than the clinician’s may be more accepted.

Cluster C: Avoidant, Dependent, and Obsessive-Compulsive Personality Disorders

Cluster C personality disorders are characterized by personality styles that are nervous and fearful.

Learning Objectives

Summarize the similarities and differences in diagnostic criteria, etiology, and treatment options among the Cluster C personality disorders

Key Takeaways

Key Points

  • Cluster C disorders include avoidant personality disorder, dependent personality disorder, and obsessive-compulsive personality disorder. People with these disorders often appear to be nervous and fearful.
  • A person with avoidant personality disorder is socially inhibited and oversensitive to negative evaluation; feels inadequate and views self as socially inept and unappealing; and avoids relationships with others unless guaranteed to be accepted unconditionally.
  • A person with dependent personality disorders allows others to take over and run their life; is submissive, clingy, and fears separation; cannot make decisions without advice and reassurance from others; lacks self-confidence; cannot do things on their own; and feels uncomfortable or helpless when alone.
  • A person with obsessive-compulsive personality disorder feels a pervasive need for perfectionism that interferes with the ability to complete tasks; is preoccupied with details, rules, order, and schedules; is excessively devoted to work at the expense of leisure and friendships; and is rigid and inflexible.

Key Terms

  • heritability: The condition of being passed down through genes.
  • temperament: A person’s normal manner of thinking, behaving, or reacting.
  • miserliness: The property of being very covetous, stingy, or cautious with money.

The DSM-5 recognizes 10 personality disorders, organized into 3 different clusters. Cluster C disorders include avoidant personality disorder, dependent personality disorder, and obsessive-compulsive personality disorder (which is not the same thing as obsessive-compulsive disorder). People with these disorders often appear to be nervous and fearful.

Avoidant Personality Disorder

Defining Avoidant Personality Disorder

Avoidant personality disorder is characterized by a pervasive pattern of social inhibition, feelings of inadequacy, extreme sensitivity to negative evaluation, and avoidance of social interaction. Individuals afflicted with the disorder tend to describe themselves as ill at ease, anxious, lonely, and generally feel unwanted and isolated from others. They often consider themselves to be socially inept or personally unappealing and avoid social interaction for fear of being ridiculed, humiliated, rejected, or disliked. Avoidant personality disorder is usually first noticed in early adulthood.

There is controversy as to whether avoidant personality disorder is a distinct disorder from generalized social phobia, and it is contended by some that they are merely different conceptualizations of the same disorder, where avoidant personality disorder may represent the more severe form. Generalized social phobia and avoidant personality disorder have similar diagnostic criteria and may share a similar causation, subjective experience, course, treatment, and underlying personality features, such as shyness.

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Avoidant Personality Disorder: Avoidant personality disorder is characterized by a pervasive pattern of social inhibition, feelings of inadequacy, extreme sensitivity to negative evaluation, and avoidance of social interaction. The disorder may begin in childhood or early adulthood.

DSM-5 Diagnostic Criteria for Avoidant Personality Disorder

To be diagnosed with avoidant personality disorder, symptoms must begin by early adulthood and occur in a range of situations. Four of seven following symptoms should be present:

  • Avoids occupational activities that involve significant interpersonal contact because of fears of criticism, disapproval, or rejection;
  • Is unwilling to get involved with people unless they are certain of being liked;
  • Shows restraint within intimate relationships because of the fear of being shamed or ridiculed;
  • Is preoccupied with being criticized or rejected in social situations;
  • Is inhibited in new interpersonal situations because of feelings of inadequacy;
  • Views self as socially inept, personally unappealing, or inferior to others;
  • Is unusually reluctant to take personal risk or to engage in any new activities because they may prove embarrassing.

Etiology of Avoidant Personality Disorder

Causes of avoidant personality disorder are not clearly defined and may be influenced by a combination of social, genetic, and psychological factors. The disorder may be related to temperamental factors that are inherited. Specifically, various anxiety disorders in childhood and adolescence have been associated with a temperament characterized by behavioral inhibition, including features of being shy, fearful, and withdrawn in new situations. These inherited characteristics may give an individual a genetic predisposition towards avoidant personality disorder. Childhood emotional neglect and peer group rejection are both associated with an increased risk for the development of avoidant personality disorder.

Treatment of Avoidant Personality Disorder

Treatment of avoidant personality disorder can employ various techniques, such as social skills training, cognitive therapy, exposure treatment to gradually increase social contacts, group therapy for practicing social skills, and sometimes drug therapy (such as antidepressants and anti-anxiety medication). A key issue in treatment is gaining and keeping the patient’s trust, as people with avoidant personality disorder will often start to avoid treatment sessions if they distrust the therapist or fear rejection. The primary purpose of both individual therapy and social skills group training is for individuals with the disorder to begin challenging their exaggerated negative beliefs about themselves.

Dependent Personality Disorder

Defining Dependent Personality Disorder

Dependent personality disorder is characterized by a pervasive psychological dependence on other people. This personality disorder is a long-term (chronic) condition in which people depend on others to meet their emotional and physical needs, with only a minority achieving normal levels of independence. The difference between a ‘dependent personality’ and a ‘dependent personality disorder’ is somewhat subjective, which makes diagnosis sensitive to cultural influences such as gender role expectations.

DSM-5 Diagnostic Criteria for Dependent Personality Disorder

The diagnosis for dependent personality disorder includes the pervasive and excessive need to be taken care of which leads to submissive and clinging behavior and fears of separation. In order to be diagnosed, the person must allow others to take over and run their life; is submissive, clingy, and fears separation; cannot make decisions without advice and reassurance from others; lacks self-confidence; cannot do things on their own; and/or feels uncomfortable or helpless when alone. Symptoms must begin by early adulthood and be present in a variety of contexts.

Etiology of Dependent Personality Disorder

Dependent personality disorder occurs in about 0.6% of the general population, and occurs more frequently in females. A 2004 twin study suggests a heritability of.81 for developing dependent personality disorder. Because of this, there is significant evidence that this disorder runs in families. Children and adolescents with a history of anxiety disorders and physical illnesses are more susceptible to acquiring this disorder. A study in 2012 found that two-thirds of this disorder stemmed from genetics while one-third came from the environment

Treatment of Dependent Personality Disorder

Various forms of psychotherapy are used to treat dependent personality disorder, often with the goal of assisting the patient in becoming more independent and making independent decisions related to their life. Various medications may also be used to treat comorbid (co-occurring) disorders, such as depression or anxiety.

Obsessive-Compulsive Personality Disorder

Defining Obsessive-Compulsive Personality Disorder

Obsessive-compulsive personality disorder (OCPD) is characterized by a general pattern of concern with orderliness, perfectionism, excessive attention to details, mental and interpersonal control, and a need for control over one’s environment, at the expense of flexibility, openness, and efficiency. Workaholism and miserliness are also seen often in those with this personality disorder. Rituals are performed to the point of excluding leisure activities and friendships. Persons affected with this disorder may find it hard to relax, always feeling that time is running out for their activities and that more effort is needed to achieve their goals. They may plan their activities down to the minute—a manifestation of the compulsive tendency to keep control over their environment.

OCPD is distinct from obsessive-compulsive disorder (OCD), which is an anxiety (rather than a personality) disorder, and the relation between the two is contentious. Some, but not all, studies have found high comorbidity rates between the two disorders, and both may share outside similarities (for example, rigid and ritual-like behaviors). Hoarding, orderliness, and a need for symmetry and organization are often seen in people with either disorder. However, attitudes toward these behaviors differ between people affected with either of the disorders: for people with OCD, these behaviors are unwanted and seen as unhealthy, being the product of anxiety-inducing and involuntary thoughts. For people with OCPD, these behaviors are experienced as rational and desirable, being the result of, for example, a strong adherence to routines, a natural inclination towards cautiousness, or a desire to achieve perfection.

DSM-5 Diagnostic Criteria for Obsessive-Compulsive Personality Disorder

In order to be diagnosed with OCPD, symptoms must appear by early adulthood and in multiple contexts. At least four of the following should be present:

  • Is preoccupied with details, rules, lists, order, organization, or schedules to the extent that the major point of the activity is lost.
  • Shows perfectionism that interferes with task completion (e.g., is unable to complete a project because his or her own overly strict standards are not met).
  • Is excessively devoted to work and productivity to the exclusion of leisure activities and friendships (not accounted for by obvious economic necessity).
  • Is overconscientious, scrupulous, and inflexible about matters of morality, ethics, or values (not accounted for by cultural or religious identification).
  • Is unable to discard worn-out or worthless objects even when they have no sentimental value.
  • Is reluctant to delegate tasks or to work with others unless they submit to exactly his or her way of doing things.
  • Adopts a miserly spending style toward both self and others; money is viewed as something to be hoarded for future catastrophes.
  • Shows rigidity and stubbornness.

Etiology of Obsessive-Compulsive Personality Disorder

Researchers have set forth both genetic and environmental theories for what causes OCPD. Under the genetic theory, people with a form of a particular gene (the DRD3 gene) are more likely to develop OCPD and depression, particularly if they are male. However, genetic factors may lie dormant until triggered by events in the lives of those who are predisposed to OCPD. These events could include trauma faced during childhood, such as physical, emotional, or sexual abuse, or other psychological trauma. Under the environmental theory, OCPD is seen as a learned behavior.

Treatment of Obsessive-Compulsive Personality Disorder

Treatment for OCPD includes psychotherapy, cognitive-behavioral therapy, behavior therapy, or self-help. Medication may also be prescribed. In behavior therapy and cognitive-behavioral therapy, a patient discusses with a psychotherapist ways of changing compulsions into healthier, productive behaviors.

Treatment is complicated if the patient does not accept that they have OCPD or does not view their thoughts or behaviors as problematic. Medication alone is generally not indicated for this personality disorder, but fluoxetine has been prescribed with success. Selective serotonin reuptake inhibitors (SSRIs) may be useful in addition to psychotherapy.