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Chapter 13 Introduction

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CHAPTER 13

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TOPIC OVERVIEW

“Odd” Personality Disorders

Paranoid Personality Disorder

Schizoid Personality Disorder

Schizotypal Personality Disorder

“Dramatic” Personality Disorders

Antisocial Personality Disorder

Borderline Personality Disorder

Histrionic Personality Disorder

Narcissistic Personality Disorder

“Anxious” Personality Disorders

Avoidant Personality Disorder

Dependent Personality Disorder

Obsessive-Compulsive Personality Disorder

Multicultural Factors: Research Neglect

Are There Better Ways to Classify Personality Disorders?

The “Big Five” Theory of Personality and Personality Disorders

“Personality Disorder—Trait Specified”: Another Dimensional Approach

Putting It Together: Disorders of Personality—Rediscovered and Reconsidered

Personality Disorders

While interviewing for the job of editor of a start-up news Web site, Frederick said, “This may sound self-serving, but I am extraordinarily gifted. I am certain that I will do great things in this position. I and the Osterman Post will soon set the standard for journalism and blogging in the country. Within a year, we’ll be looking at the Huffington Post in the rearview mirror.” The committee was impressed. Certainly, Frederick’s credentials were strong, but even more important, his self-confidence and boldness had wowed them.

A year later, many of the same individuals were describing Frederick differently—arrogant, self-serving, cold, ego-maniacal, draining. He had performed well as editor (though not as spectacularly as he seemed to think), but that performance could not outweigh his impossible personality. Colleagues below and above him had grown weary of his manipulations, his emotional outbursts, his refusal ever to take the blame, his nonstop boasting, and his grandiose plans. Once again Frederick had outworn his welcome.

To be sure, Frederick had great charm, and he knew how to make others feel important, when it served his purpose. Thus he always had his share of friends and admirers. But in reality they were just passing through, until Frederick would tire of them or feel betrayed by their lack of enthusiasm for one of his self-serving interpretations or grand plans. Or until they simply could take Frederick no longer.

Bright and successful though he was, Frederick always felt entitled to more than he was receiving—to higher grades at school, greater compensation at work, more attention from girlfriends. If criticized even slightly, he reacted with fury and was certain that the critic was jealous of his superior intelligence, skill, or looks. At first glance, Frederick seemed to have a lot going for him socially. Typically, he could be found in the midst of a deep, meaningful romantic relationship—in which he might be tender, attentive, and seemingly devoted to his partner. But Frederick would always tire of his partner within a few weeks or months and would turn cold or even mean. Often he started affairs with other women while still involved with the current partner. The breakups—usually unpleasant and sometimes ugly—rarely brought sadness or remorse to him, and he would almost never think about his former partner again. He always had himself.

Each of us has a personality—a set of uniquely expressed characteristics that influence our behaviors, emotions, thoughts, and interactions. Our particular characteristics, often called personality traits, lead us to react in fairly predictable ways as we move through life. Yet our personalities are also flexible. We learn from experience. As we interact with our surroundings, we try out various responses to see which feel better and which are more effective. This is a flexibility that people who suffer from a personality disorder usually do not have.

personality disorder An enduring, rigid pattern of inner experience and outward behavior that repeatedly impairs a person’s sense of self, emotional experiences, goals, capacity for empathy, and/or capacity for intimacy.

People with a personality disorder display an enduring, rigid pattern of inner experience and outward behavior that impairs their sense of self, emotional experiences, goals, capacity for empathy, and/or capacity for intimacy (APA, 2013). Put another way, they have personality traits that are much more extreme and dysfunctional than those of most other people in their culture, leading to significant problems and psychological pain for themselves or others.

Frederick appears to display a personality disorder. For most of his life, his extreme narcissism, grandiosity, and insensitivity have led to poor functioning in both the personal and social realms. They have caused him to repeatedly feel angry and unappreciated, deprived him of close personal relationships, and brought considerable pain to others. Witness the upset and turmoil felt by Frederick’s coworkers and girlfriends.

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The symptoms of personality disorders last for years and typically become recognizable in adolescence or early adulthood, although some start during childhood (APA, 2013). These disorders are among the most difficult psychological disorders to treat. Many people with the disorders are not even aware of their personality problems and fail to trace their difficulties to their maladaptive style of thinking and behaving. Surveys indicate that between 10 and 15 percent of all adults in the United States have a personality disorder (APA, 2013; Sansone & Sansone, 2011).

Early notions of personality In the popular nineteenth-century theory of phrenology, Franz Joseph Gall (1758–1828) suggested that the brain consists of distinct portions, each responsible for some aspect of personality. Phrenologists tried to assess personality by feeling bumps and indentations on a person’s head.

It is common for a person with a personality disorder to also suffer from another disorder, a relationship called comorbidity. As you will see later in this chapter, for example, many people with avoidant personality disorder, who fearfully shy away from all relationships, also display social anxiety disorder. Perhaps avoidant personality disorder predisposes people to develop social anxiety disorder. Or perhaps social anxiety disorder sets the stage for the personality disorder. Then again, some biological factor may create a predisposition to both the personality disorder and the anxiety disorder. Whatever the reason for the relationship, research indicates that the presence of a personality disorder complicates a person’s chances for a successful recovery from other psychological problems (Fok et al., 2014).

DSM-5, like its predecessor, DSM-IV-TR, identifies 10 personality disorders (APA, 2013). Often these disorders are separated into three groups, or clusters. One cluster, marked by odd or eccentric behavior, consists of the paranoid, schizoid, and schizotypal personality disorders. A second cluster features dramatic behavior and consists of the antisocial, borderline, histrionic, and narcissistic personality disorders. The final cluster features a high degree of anxiety and includes the avoidant, dependent, and obsessive-compulsive personality disorders.

These 10 personality disorders are each characterized by a group of very problematic personality symptoms. For example, as you will soon see, paranoid personality disorder is diagnosed when a person has unjustified suspicions that others are harming him or her, has persistent unfounded doubts about the loyalty of friends, reads threatening meanings into benign events, persistently bears grudges, and has recurrent unjustified suspicions about the faithfulness of a life partner.

The DSM’s listing of 10 distinct personality disorders is called a categorical approach. Like a light switch that is either on or off, this kind of approach assumes that (1) problematic personality traits are either present or absent in people, (2) a personality disorder is either displayed or not displayed by a person, and (3) a person who suffers from a personality disorder is not markedly troubled by personality traits outside of that disorder.

It turns out, however, that these assumptions are frequently contradicted in clinical practice. In fact, the symptoms of the personality disorders listed in DSM-5 overlap so much that clinicians often find it difficult to distinguish one disorder from another (see Figure 13.1), resulting in frequent disagreements about which diagnosis is correct for a person with a personality disorder. Diagnosticians sometimes even determine that particular people have more than one personality disorder (APA, 2013). This lack of agreement has raised serious questions about the validity (accuracy) and reliability (consistency) of the 10 DSM-5 personality disorder categories.

Figure 13.1: figure 13.1 Prominent and central features of the personality disorders in DSM-5 The symptoms of the various personality disorders often have significant overlap, leading to frequent misdiagnoses or to multiple diagnoses for a given client.

Given this state of affairs, many theorists have challenged the use of a categorical approach to personality disorders. They believe that personality disorders differ more in degree than in type of dysfunction and should instead be classified by the severity of personality traits rather than by the presence or absence of specific traits—a procedure called a dimensional approach (Morey, Skodol, & Oldham, 2014). In a dimensional approach, each trait is seen as varying along a continuum extending from nonproblematic to extremely problematic. People with a personality disorder are those who display extreme degrees of problematic traits—degrees not commonly found in the general population (see Table 13.1).

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Given the inadequacies of a categorical approach and the growing enthusiasm for a dimensional one, the framers of DSM-5 initially proposed significant changes in how personality disorders should be classified. They proposed a largely dimensional system that would allow many additional kinds of personality problems to be classified as personality disorders and would require clinicians to assess the severity of each problematic trait exhibited by a person who receives a diagnosis of personality disorder. However, this proposal itself produced enormous concern and criticism in the clinical field, leading the framers of DSM-5 to change their mind and to retain, for now, a classic 10-disorder categorical approach in the new DSM. At the same time, the framers acknowledged the likely future direction of personality disorder classifications by also describing an alternative dimensional approach (Anderson et al., 2014).

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Most of the discussions in this chapter are organized around the 10-disorder categorical approach currently used in DSM-5. Later in the chapter, however, we will examine possible alternative—dimensional—approaches of the future, including the one presented in DSM-5.

Why do you think personality disorders are particularly subject to so many efforts at amateur psychology?

As you read about the various personality disorders, you should be clear that diagnoses of such disorders can be assigned too often. We may catch glimpses of ourselves or of people we know in the descriptions of these disorders and be tempted to conclude that we or they have a personality disorder. In the vast majority of instances, such interpretations are incorrect. We all display personality traits. Only occasionally are they so maladaptive, distressful, and inflexible that they can be considered disorders.

Summing Up

PERSONALITY DISORDERS AND DSM-5 People with a personality disorder display an enduring, rigid pattern of inner experience and outward behavior. Their personality traits are much more extreme and dysfunctional than those of most other people in their culture, resulting in significant problems for them or those around them. It has been estimated that as many as 10 to 15 percent of adults have such a disorder. DSM-5 uses a categorical approach that lists 10 distinct personality disorders. In addition, the framers of DSM-5 have proposed a dimensional approach to the classification of personality disorders, an approach that they assigned for further study and possible inclusion in a future revision of the DSM.