The disorders you’ve learned about previously, in this chapter and in Chapter 15, disrupt people’s typical styles of behavior. Rather than being their usual selves, people become intensely anxious, or gloomily depressed, or begin hearing voices. Now we’ll consider a different type of disorder—one in which the disorder is the person’s typical style of behavior.

Personality disorders are chronic styles of thinking, behavior, and emotion that severely lower the quality of people’s personal relationships. These personal styles create conflict with others and, in the long run, harm the person with the disorder. People with personality disorders may not realize that the problems they experience in relationships are caused by their own behavior; as a result, they tend to blame others for interpersonal conflict.

People with personality disorders are particularly likely to experience difficulties when under stress. Stress can occur in different situations of a person’s life: work, relations with parents, social relationships, dealing with financial problems, and so forth. In general, it is good to be “flexible” when dealing with stress; that is, to develop different strategies for coping with different types of stress (Cheng & Cheung, 2005). However, people with personality disorders are relatively inflexible; their personal style is consistent across different situations. As a result, they do not cope with stress as effectively as most other people (Bijttebier & Vertommen, 1999).

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Why do psychologists say that some personality styles are “disorders” rather than merely saying that a person is “unusual” or “quirky” or “difficult”? The term disorder implies that the personality style is directly harmful to mental health. Psychologist Theodore Millon (2004) explains that people with personality disorders contribute to their own psychological distress in a number of ways:

When the DSM is used to diagnose people, personality disorders are found to be remarkably prevalent. A large survey in the United States, involving a representative sample of more than 9000 adults, found that roughly 1 out of every 11 adults exhibits a diagnosable personality disorder (Lenzenweger et al., 2007).

Identifying and distinguishing among personality disorders is a tricky task. DSM-5 contains two different classifications of the disorders; one maintains older classifications, and the other is a new, simpler model. We will rely here on the newer model, which recognizes six types of personality disorder: (1) antisocial, (2) avoidant, (3) borderline, (4) obsessive-compulsive, (5) narcissistic, and (6) schizotypal personality disorder. Each, as you will see, is a distinctive pattern of personality processes—an interconnected system of thoughts, feelings, and interpersonal behaviors (Shedler et al., 2010).

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ANTISOCIAL PERSONALITY DISORDER. Antisocial personality disorder is defined by a set of negative personality traits. People with antisocial personalities are manipulative (using others to achieve their own goals), callous (not caring about harm to others), hostile (often angry and vengeful), and are risk takers (engaging calmly in dangerous behaviors). They lack empathy; that is, they are unconcerned about the feelings, rights, and safety of others. If a person displays these traits consistently, and they harm the individual’s interpersonal relationships, then the person meets DSM criteria for antisocial personality disorder.

The center point of antisocial personality disorder, at a deeper psychological level, is what Sigmund Freud called a weak superego (Meloy, 2007) and what contemporary psychological scientists refer to as moral reasoning (Raine & Yang, 2006). Most people adhere to moral rules that prevent them from harming others and motivate them to perform behaviors that are good for society. In antisocial personality disorder, these rules seem to be absent; people lack an inner “voice of conscience.” Even after harming another person, an individual with antisocial personality disorder experiences no guilt or remorse. Such people can be dangerous to themselves, to society at large, and to the therapists who try to help them. One therapist reports an antisocial personality disorder client saying, after numerous therapy sessions, “You know a lot about me, Doc, and sometimes when people know too much they get killed” (Meloy, 2007, p. 779).

People who fit the diagnostic category antisocial personality disorder are not all the same. The category is broad and, within it, researchers have identified distinct subgroups of people with somewhat different personalities (Poythress et al., 2010). One subgroup has a high level of a trait called psychopathy (Hare & Neumann, 2008). Psychopathy is a personality style defined not only by the hostility toward others and lack of guilt that characterize antisocial personality disorder in general, but also by a tendency to lie to others and manipulate them. Psychopaths are “social predators who charm [and] manipulate … leaving a broad trail of broken hearts, shattered expectations, and empty wallets” (Hare, 1999, p. xi). Many of the serial killers who have plagued recent world history displayed psychopathic characteristics (LaBrode, 2007). Psychopathy is less prevalent among women than men (Cale & Lilienfeld, 2002). By contrast, a different subgroup shows signs of antisocial personality disorder (a callous lack of empathy) but not psychopathy (manipulativeness and lying; Poythress et al., 2010).

AVOIDANT PERSONALITY DISORDER. Consider the case of “Ms. K,” a 24-year-old pursuing a degree in nursing (Gilbert & Gordon, 2013; following quotes pp. 115–116). Ms. K entered psychotherapy to address “a lifetime of significant interpersonal passivity.” She reported “low positive mood throughout her adolescence and young adult life,” and chronic feelings of inadequacy that caused her to be unable to express opinions to professional associates or to friends. A tendency to avoid other people “had been present her entire life,” her therapist reported, “and affected all areas of functioning.”

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Ms. K’s is a case of avoidant personality disorder, which is characterized by feelings of social inadequacy and low self-esteem, as well as preoccupation with the possibility of being evaluated negatively by others (Sanislow, Bartolini, & Zoloth, 2012). These feelings and thoughts contribute to a style of behavior that is shy, withdrawn, and inhibited. People’s insecurity about themselves causes them to miss out on social contact with others.

Research suggests that, among people with avoidant personality disorder, feelings of insecurity are particularly acute in a certain type of situation: when others might be criticizing them. In one study (Bowles et al., 2013), participants were asked to imagine themselves working busily on particular projects and receiving feedback from others. In one experimental condition, the feedback was fully supportive (“I’m really impressed”). In another, it was ambiguous with a suggestion of criticism (“Don’t spread yourself too thin”). More so than other individuals, people with avoidant personality disorder felt badly about themselves after being exposed to the ambiguous feedback.

BORDERLINE PERSONALITY DISORDER. You encountered borderline personality disorder at the outset of this chapter, in our opening vignette. The 17-year-old girl who attacked herself—and who, as an adult, became the eminent clinical psychologist Marsha Linehan—was a sufferer.

Borderline personality disorder is the most commonly diagnosed personality disorder, with a prevalence rate of 2 to 3% of the adult population (Gunderson & Links, 2008). Borderline personality disorder is difficult to describe precisely; professionals are not in complete agreement on its defining characteristics. However, it has the following main features:

This combination of symptoms is exceptionally stressful. Borderline individuals report feeling lonely, worthless, and overwhelmed by the stresses of life (Zanarini at al., 1998). They experience a spectrum of negative emotions and have difficulty controlling those emotions. Borderline individuals dwell on, or go over and over, their emotions. As a result, feelings of anger, anxiety, and despair can last for weeks and disrupt their lives (Conklin, Bradley, & Westen, 2006).

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People with borderline personality disorder sometimes take desperate steps to escape this stress. One step is self-harm—that is, deliberately harming oneself physically. Some individuals cut themselves or burn themselves with lit cigarettes. Why would anyone engage in self-destructive behavior? Borderline individuals often report that self-harm temporarily relieves their anxieties (Linehan, 1993). Although the behavior is harmful in the long run, its short-term effect is to reduce tension and distract people from the daily worries that commonly overwhelm them (Brown, Comtois, & Linehan, 2002).

Another tragic step taken by many borderline patients is suicide. Suicide is a risk associated with many mental health problems; different forms of distress and despair can drive people to the ultimate, final escape from life’s problems (Nordentoft, Mortensen, & Pedersen, 2011). Borderline patients, however, are particularly at risk. The majority of borderline patients attempt suicide, and 10% of individuals with borderline personality disorder die from their attempts (Soloff et al., 2005). Research sheds light on the reasons behind this act. Interviewers spoke with women who had tried unsuccessfully to take their own lives. They indicated that a primary reason for suicide was to make other people better off (Brown et al., 2002). Individuals with borderline personality disorder perceived themselves as a burden on others and tried to take their own lives to relieve others of this burden.

NARCISSISTIC PERSONALITY DISORDER. Narcissistic personality disorder is a personality pattern in which individuals are excessively self-centered. They pay little attention to the thoughts and feelings of others, focusing instead on themselves and how to enhance their own self-image. According to the DSM, this personality pattern qualifies as a disorder when it occurs repeatedly across time and place and lowers the quality of the interpersonal relationships that an individual is able to form.

Narcissistic individuals possess personality characteristics that are contradictory (Morf & Rhodewalt, 2001). On the one hand, they hold views of themselves that seem extraordinarily positive. Narcissists crave attention and, when they get it, talk about how great they are. On the other hand, their opinion of themselves seems “fragile.” If you know a narcissist, you might get the impression that, down deep, the person isn’t confident in all the great things he’s saying about himself. This uncertainty, in fact, is why he craves attention. Narcissists need to find other people to support their grandiose, yet fragile, views of self. The political dictator who surrounds himself with “yes men” illustrates these personality dynamics.

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OBSESSIVE COMPULSIVE PERSONALITY DISORDER. As you may recall, Chapter 15 discusses obsessive-compulsive disorder (OCD), in which people experience obsessions (recurring thoughts about danger and harm) and engage in compulsions (repetitive actions taken to prevent the dangers and harms). People with OCD repeatedly check locks, arrange household items in a strict order, or engage in other such compulsive behavior.

More than a century ago, the French psychologist Pierre Janet observed this OCD—and something in addition. He noticed some personality characteristics that seemed to predict the onset of OCD symptoms. Individuals who were highly perfectionistic, he judged, were more likely to develop obsessions and compulsions later in life (Mancebo et al., 2005).

The observations of Janet, and many subsequent psychologists and psychiatrists, led to the recognition of obsessive-compulsive personality disorder (OCPD). People with OCPD are, as Janet observed, highly perfectionistic. They also seek order and control over activities, stick rigidly to rules for behavior, and pay extraordinary attention to small details (Mancebo et al., 2005). OCPD individuals are so highly devoted to work that they commonly are, in practice, less devoted to family and friends (Van Noppen, 2010). Unlike individuals with OCD, who generally are aware of their psychological problems, people with OCPD often see their dysfunctional behavior as perfectly normal.

Research reveals a strong relation between the personality disorder, OCPD, and the anxiety disorder, obsessive-compulsive disorder. The populations of people with OCPD and OCD overlap significantly, and individuals with perfectionistic OCPD tendencies are relatively less likely to benefit from therapy for obsessive-compulsive symptoms (Garyfallos et al., 2010; Pinto et al., 2011).

SCHIZOTYPAL PERSONALITY DISORDER. Schizotypal personality disorder is characterized by two predominant features. One is its distinctive patterns of thinking (Chemerinski et al., 2013). In this disorder, individuals have odd beliefs that diverge from those of most members of society; individuals may, for example, believe in “paranormal” phenomena, such as the ability of thoughts alone to control physical objects. They also may exhibit odd mannerisms, styles of dressing and speaking that differ from most other people, and suspiciousness of other people. People with schizotypal personality disorder are, in short, individuals whom you might call “eccentric.”

The second distinctive feature is that people with schizotypal personality disorder have few close friends (e.g., Bergman et al., 1996). Their odd personal style, combined with their suspicions of others, appear to undermine their capacity to form close personal relationships with people outside of their immediate families. Many people with the disorder lead lives that are socially isolated from others.

The odd beliefs that characterize this personality disorder are related to schizophrenia; the name itself, “schizotypal,” suggests that the disease is a type of schizophrenia. However, research on brain mechanisms in the two disorders suggests that they are distinct (Haznedar et al., 2004).

Table 16.2 summarizes the characteristics of the six disorders we have reviewed.

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Nature and nurture both contribute to the development of personality disorders. Genes and environmental experience play significant roles and interact with one other. Research on antisocial personality disorder illustrates this general point.

GENE–ENVIRONMENTAL INTERACTION AND ANTISOCIAL PERSONALITY DISORDER. A meta-analysis of twin studies—in other words, a statistical summary of numerous past twin studies—reveals the substantial impact of both genetic and environmental factors on antisocial behavior. Genes were found to account for 41% of overall individual differences in antisocial conduct. Environmental factors thus explained the majority of the differences between people: 59% (Rhee & Waldman, 2002).

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This twin-study finding establishes that both nature and nurture—genes and the environment—play important roles. But it does not tell us what those roles are. To determine this, researchers examine how genes and environmental experiences affect the workings of the brain. A landmark study of antisocial behavior (Caspi et al., 2002) shows how genes and the environment interact in affecting brain functioning and antisocial conduct.

In this study, researchers (Caspi et al., 2002) focused on two factors, one environmental and one genetic:

These two factors have opposing effects within the brain. Childhood maltreatment is a highly stressful event that causes neurotransmitter activity to increase. The gene causes neurotransmitter activity to decrease; in particular, it enables the brain to return to a normal activity level after a stressful event occurs. Research findings show that these two factors combine in their influence on antisocial behavior. Among children who did not experience maltreatment, genetic variations did not make much difference. No matter what their genetic makeup, children who do not experience maltreatment are unlikely to develop antisocial personalities (Figure 16.7). However, among children who do experience maltreatment, genes make a big difference. Some of these children are quite likely to become antisocial adults, whereas others, who have a different genetic makeup, are not. Children who experience maltreatment, but who also possess genes that produce a biochemical that quickly restores their normal level of activity after stress, are “resilient” in the face of maltreatment (see Chapter 14); they are less likely to become antisocial adults.

ANTISOCIAL AND PSYCHOPATHIC DISORDERS AND THE BRAIN. In addition to neurotransmitters, researchers studying the biology of antisocial personality disorder and psychopathy also investigate neurons, the brain’s cells. They compare people with different personality styles and search for neural differences.

A challenge is figuring out where in the brain to search. Psychological findings provide a clue. As you learned, the main psychological component of antisocial behavior is deficits in empathy and moral reasoning. Psychopathic individuals also display a lack of guilt feelings. Brain regions that already are known to be involved in these thoughts and feelings, then, are the place to look when conducting brain research.

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In one study (Gregory et al., 2012), researchers examined a population of men who had been convicted of violent crimes (e.g., murder). Within this population, they identified one subgroup with antisocial personality disorder and psychopathic personality qualities, and a second with antisocial personality disorder but without psychopathic qualities. Brain scans revealed differences between the groups. The psychopathic group had lower brain volume in parts of the brain that are active when people (1) evaluate others’ ongoing social behavior and emotions (a region in the brain’s frontal cortex) and (2) relate ongoing behavior to personal memories and stored knowledge of social rules (a region in the temporal lobe). These brain regions are needed to understand when, and why, one’s own behavior violates social rules, and thus to experience emotions such as embarrassment and guilt (Gregory et al., 2012). The brain-level findings thus complement mind-level analyses of psychopathic persons.

BORDERLINE PERSONALITY DISORDER AND THE BRAIN. Brain research sheds light on the biological underpinnings of other personality disorders, including borderline personality disorder. Researchers (Koenigsberg et al., 2009) asked two groups of people—(1) borderline patients and (2) individuals without the disorder—to control their emotions while viewing a series of pictures with emotional content. The researchers took brain images while participants performed this task.

Brain activity in the groups differed. Variations were seen within the anterior cingulate cortex (Figure 16.8), a region known to be involved in emotional control (Ochsner et al., 2004). Compared with other people, in borderline patients, this brain region was less active (Koenigsberg et al., 2009).

What does this result say about borderline personality disorder and the brain? Actually, it’s hard to know precisely without additional research. There are two possibilities. Borderline patients may inherit a brain structure that is less developed and active. This would cause them to have less ability to control their emotions. Alternatively, it’s possible that borderline patients less frequently try to control their emotions. This could cause them to have less neural development in regions of the brain involved in emotional control (Giuliani, Drabant, & Gross, 2011). Behavioral activities (such as controlling emotions) can change the brain (see Chapter 3).

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When it comes to formulating therapy, personality disorders pose unique challenges. The disorders consist of emotional and behavioral patterns that are highly ingrained. There is no quick-and-easy way to alter fundamental personality styles that have been exhibited for years.

Despite the challenge, the need for therapy is compelling. In antisocial personality disorder, sufferers may inflict harm on others. In borderline personality disorder, people often inflict harm on themselves. Therapists need to act quickly to minimize the harm that these disorders can bring.

PSYCHOANALYTIC THERAPY AND COGNITIVE THERAPY. For many years, the primary psychotherapy for personality disorders was psychoanalysis (Waldinger, 1987). Psychoanalytic therapists focused on clients’ unconscious defense mechanisms (mental strategies to protect against anxiety; see Chapter 13) and their interpersonal relationship with the therapist. They judged that transference—a process in which a patient unconsciously responds to the therapist as a significant figure from earlier in his or her life (see Chapter 15)—is central to therapeutic insight and improvement.

More recently, many therapists have employed cognitive therapy for personality disorders (Beck, Freeman, & Davis, 2004). In comparison to psychoanalysis, cognitive therapy places greater emphasis on conscious processes. Therapists believe clients are consciously aware of personal beliefs that contribute to their chronic psychological distress, and they try to modify these cognitions in therapy.

In addition, like psychoanalysts, cognitive therapists attend closely to the interpersonal relationship they have with their clients. In therapy for personality disorders, therapists must become familiar with a client’s life as a whole and must build a therapeutic relationship strong enough that the client will come to accept the therapist’s suggestions for significant personal change (Beck et al., 2004).

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DIALECTICAL BEHAVIOR THERAPY. Psychoanalysis and cognitive therapy were not originally designed to treat personality disorders. Instead, they have been adapted to the need of the personality disorder client. We’ll now consider a therapy designed specifically to benefit clients with a personality disorder, specifically, borderline personality disorder.

Dialectical behavior therapy is a treatment for borderline personality disorder developed by the psychologist Marsha Linehan (1993). Her therapy combines principles of behavior therapy with principles of Eastern and Western philosophy.

A primary philosophical principle is dialectic. Dialectic is a form of argument—that is, a way of resolving disagreements—that has been known for thousands of years. In dialectical argument, one identifies opposing points of view and then searches for a single viewpoint that reconciles them. Rather than “sticking to your guns,” you think flexibly and remain open to changing your opinions. Linehan and colleagues explain (Lynch et al., 2007) how dialectic works when patients harm themselves. Rather than merely arguing that self-harm is bad, therapists recognize two opposing facts: Self-injury is (1) harmful in the long run (it creates scars and risks severe bodily damage), but (2) has short-term benefits (it temporarily relieves emotional turmoil, as borderline patients report; Kemperman, Russ, & Shearin, 1997). The therapist acknowledges the validity of both points and then reconciles them by searching for a new way to remove emotional distress that avoids the long-term harm of self-injury (Lynch et al., 2007). Dialectical thinking counteracts the tendency among borderline patients to engage in black-and-white thinking.

A second philosophical principle is acceptance. The term is used as in Zen Buddhism, where it refers to recognizing, and accepting, that some aspects of the world are unchangeable. This principle shifts the therapist’s focus. Rather than constantly striving for therapeutic change, the dialectical behavior therapist teaches clients to accept themselves, and their circumstances, as they are.

Linehan grafts these philosophical principles onto standard cognitive and behavior therapy practices. As in behavior therapy (see Chapter 15), the dialectical therapist strives to increase clients’ skills in problem solving and to reduce their anxiety. This is accomplished through both individual psychotherapy and group settings in which clients can develop and test their interpersonal skills (Linehan, 1993).

Good news for people with borderline personality disorder is that dialectical behavior therapy works. Numerous research studies comparing dialectical therapy to other treatments document that dialectic behavior therapy uniquely improves the emotional lives and behavioral experiences of borderline patients (Lynch et al., 2007). Critically, dialectical therapy also substantially reduces their risk of suicide (Linehan et al., 2006).