Definition: patterns of thought, feeling, and behavior beyond the normal range of psychological variation
First edition: included a list and description of personality disorders
TR = text revision
Make diagnosis more objective: ensures a common vocabulary for describing problems, which should make discussions and analyses more useful; especially important for research
Insurance billing: so care for the patient will be reimbursed
Axis III: injuries, poisoning, and brain diseases that impair mental functioning such as Alzheimer’s
Axis IV: unemployment, bereavement, recent divorce
Axis V: hold a job, maintain a relationship
Figure 18.1
Five general characteristics
Affect social relationships: other people are required for the symptoms (inflexible, deceitful) to be expressed
Stable over time: disorders are about as stable as personality itself
Ego-syntonic: The people who have them do not think anything is wrong; only applies to some personality disorders.
Clinical impression: based on unstructured interviews and clinical intuition and experience; most common
Open and flexible: adjust diagnosis criteria if necessary; use common sense
Unreliable: differences in experience and accuracy, interviews, application of criteria, and ultimately diagnosis
Self-report scales: ask people whether they exhibit signs of personality disorders
Advantages: inexpensive, easy to obtain, scores can be easily compared with other information, valid (same as S data)
Disadvantages: lack of insight about symptoms or unwillingness to respond accurately
Structured interviews: series of questions designed to maintain objectivity while zeroing in on relevant characteristics; often seen as the gold standard for diagnosis
Advantages: better reliability than clinical impression, requires minimal training
Disadvantages: rigid structure may inhibit client’s ability to talk about real problems, similar to self-report (lack of insight or honesty)
Advantages and disadvantages (based on limited information, biased opinion) of I data
Oltmanns & Turkheimer article in the reader: Person perception and personality pathology
Cluster B disorders tend to be the most stable
Schizotypal personality disorder: an extreme pattern of odd beliefs and behaviors, and of difficulties relating to others
9 basic indicators (5 needed for diagnosis)
Ideas of reference: seeing irrelevant or innocuous events as pertaining to the self
Magical thinking, bizarre fantasies, believing in odd phenomenon
Strange perceptual experiences
Odd speech or thinking
Suspiciousness or paranoia
Inappropriate or flattened emotions
Odd, peculiar, or eccentric actions or appearance
Failure to develop friendships and a lack of social ties other than to one’s immediate family
Anxiety being around other people that does not go away
9 basic indicators (5 needed for diagnosis)
Ideas of reference: seeing irrelevant or innocuous events as pertaining to the self
Magical thinking, bizarre fantasies, believing in odd phenomenon
Strange perceptual experiences
Odd speech or thinking
Suspiciousness or paranoia
Inappropriate or flattened emotions
Odd, peculiar, or eccentric actions or appearance
Failure to develop friendships and a lack of social ties other than to one’s immediate family
Anxiety being around other people that does not go away
About 3% of the population
Slightly more common in males
Schizoid personality disorder: an extreme pattern of seeming indifferent to others and cold, bland style of behavior
Over 3% of the population
Equally common in men and women
Paranoid personality disorder: an extreme pattern of suspicion, hostility, and resentment
About 5% of the population
More common in women
Histrionic personality disorder: an extreme pattern of attention-getting behavior and shallow but dramatically expressed emotions
2%–3% of the population
Equally common in men and women, but with different manifestations: examples: women get attention with revealing clothing; men get attention by being macho or overly-masculine
Narcissistic personality disorder (NPD): an extreme pattern of arrogant, exploitative behavior combined with a notable lack of empathy
Needs the admiration of others (even if it’s not genuine)
Exploits others: expects special treatment and feels justified in taking advantage of others to get what he feels he deserves
Lack of empathy: because no one else really matters
Adolf Hitler was a textbook case, also Mussolini and Stalin
Less than 1% of the population
More common in males
Activity 18-1. Narcissistic personality disorder and Charles Manson
Activity 18-2. Case history of Hitler
Antisocial personality disorder: an extreme pattern of deceitful, manipulative, and sometimes dangerous behavior
Illegal activities: such as vandalism, theft, and drug dealing
Risky behaviors: such as reckless driving, drug abuse, and dangerous sexual practices
Ted Bundy
3.5% of the population
More common in men, declines with age
Borderline personality disorder (BPD): an extreme and sometimes dangerous pattern of emotional instability, emotional emptiness, confused identity, and tendencies toward self-harm
Must have at least 5 of 9 characteristics for diagnosis
Rapid mood shifts: with little or no cause
Uncontrollable anger: also often with little or no cause
Self-destructive acts: suicide, self-mutilation; recent understanding of cutting and self-harm is that it short-circuits the build-up of anxiety and other negative emotion; 8%–10% commit suicide
Self-damaging behaviors: including drug abuse, compulsive gambling, eating disorders, shoplifting, etc.; undermining oneself at the moment of success
Identity disturbance: not knowing who they are and how they appear to others, lack of understanding of own values, goals, sexual identity, and actions
Chronic emptiness: feeling bored, don’t have satisfying and enjoyable activities, don’t have meaningful relationships
Unstable relationships: confusing, chaotic, noisy, and unpredictable relationships; often view people as all good or all bad (splitting)
Fear of abandonment: put great effort into trying to avoid abandonment
Confusion and feelings of unreality: feeling extremely upset can make people unable to think straight
Possible origins: genetic risk factor combined with early family environment that doesn’t teach children how to understand and regulate emotions; problems with the endogenous opioid system that regulates natural painkillers
Dialectical behavioral therapy: teaches skills for emotional self-control
2%–6% of the population
Equally common in men and women
Activity 18-3. Thoughts from a man with borderline personality disorder
Dependent personality disorder: an extreme pattern of relying on others to take care of one’s needs and make decisions, combined with a bitter kind of agreeableness
Fear disagreeing with others: and having to think on their own
Rare (½ of 1%)
More common among women
Avoidant personality disorder: fear of failure, criticism, or rejection leads to avoidance of normal activities
Expect the absolute worst from others: criticism, contempt, rejection
Deep cravings for affection and social acceptance: but they inhibit emotional expression toward others and others cannot get close to them
About 2.5% of the population
Similar prevalence in men and women
Obsessive-Compulsive Personality Disorder (OCPD): an extreme pattern of rigidly conscientiousness behavior, including an anxious and inflexible adherence to rules and rituals, perfectionism, and a stubborn resistance to change
Not the same as obsessive compulsive disorder: less severe because it does not include specific compulsions
Must have at least 4 of 8 characteristics for diagnosis
Overconcern with rules and details: may forget the real point; inflexibility in following the rules; not able to see the big picture (when rules don’t apply, when a flawed detail is not important)
Perfectionism: difficult to work with; difficult to finish anything
Workaholism: work long hours but don’t get much done
Inflexibility of thinking and behaving: apply values, ethics, and principles mindlessly
Packrat behavior: unable to throw anything away because they think they might need it later
Inability to delegate: because no one else will do it right
Somewhat ego-syntonic: for some symptoms but not others; some of these characteristics may be useful
About 8% of the population (most common personality disorder)
Equal prevalence among males and females
Activity 18-4. Thoughts from a woman with dependent personality disorder
Activity 18-5. Thoughts from a woman with avoidant personality disorder
No clear-cut requirements for diagnosing a personality disorder: only some of the symptoms need to be present
All disorders seem to be associated with an inability to hold thoughts in active, working memory: which prevents finding different ways to solve problems
Prototypes: ideal exemplars; real objects may match a prototype more or less well, even while differing from each other
Biosocial learning model: arrange personality disorders according to three dimensions; not consistently supported by empirical research
Circumplex models: similar to those for goals and emotions
The Big Five: one of the best supported and most accepted structures; seen by some as the foundation of most of the variation in personality
Table 18.1
Almost all disorders include high neuroticism.
Useful to see similarities and differences across disorders
Main goals: be more in line with modern research; correct important shortcomings (disorganized and unclear criteria for diagnosis, categorical classifications)
Retain 6 of 10 disorders: antisocial, avoidant, borderline, narcissistic, obsessive-compulsive, schizotypal
Ratings of 5 maladaptive personality traits: part of clinical assessment
Negative affectivity: anxiety, depression, suspicion
Detachment: tendency to withdraw from and avoid emotional contacts with others
Antagonism: including deceitfulness, grandiosity, callousness, and manipulativeness
Disinhibition: lack of self-control leading to impulsive behavior
Psychoticism: tendency to have bizarre thoughts or experiences, and to exhibit eccentric behavior
Advantage of these ratings: maps onto the Big Five: negative affectivity & neuroticism; detachment and low extraversion; antagonism and low agreeableness; disinhibition and low conscientiousness; psychoticism and openness
Assess whether personality functioning is seriously impaired: if so, assess degree of dysfunction
Avoids making a single diagnosis
The current DSM as 365 diagnoses.
Pathologizing behaviors: describing them as the result of mental illness; there are disadvantages to describing so many behaviors as pathological
Describing behavior as the result of mental illness is too easy: because there is a diagnosis for almost everything
Pathologizing tells us almost nothing about the nature of mental health: Mental health means more than not having any of the symptoms listed in the DSM-IV.
Improving mental health requires an understanding of normal personality: not just mental illness and personality disorders; this is one motivator of positive psychology
The DSM labels are misleading: sometimes a little, sometimes a lot; because no one fits the exact criteria for any category, people often have characteristics of several categories, and they are difficult to apply consistently and reliably
Can limit understanding: by leading to not taking the person’s feelings, outlook, and rights seriously and decreasing empathy
Labels can be useful: for knowing what characteristics and behaviors tend to go together
Labels are necessary: for describing clients, for research purposes, for discussing disorders with precision
Table 18.2
Disorders may be thought of as exaggerated versions of traits that are advantageous when in the normal range.
