KEY THEME

The personality disorders are characterized by inflexible, maladaptive patterns of thoughts, emotions, behavior, and interpersonal functioning.

KEY QUESTIONS

Like every other person, you have your own unique personality—the consistent and enduring patterns of thinking, feeling, and behaving that characterize you as an individual. As we described in Chapter 11, your personality can be described as a specific collection of personality traits. Your personality traits are relatively stable predispositions to behave or react in certain ways. In other words, your personality traits reflect different dimensions of your personality.

By definition, personality traits are consistent over time and across situations. But that’s not to say that personality traits are etched in stone. Rather, the psychologically well-adjusted person possesses a fair degree of flexibility and adaptiveness. Based on our experiences with others, we are able to modify how we display our personality traits so that we can think, feel, and behave in healthier and more appropriate ways.

In contrast, someone with a personality disorder has personality traits that are inflexible and maladaptive across a broad range of situations. However, the behavior of people with personality disorders goes well beyond that of a normal individual who occasionally experiences an emotional melt-down or who is grumpier, more aloof, or more self-centered than most people.

The personality disorders involve pervasive patterns of perceiving, relating to and thinking about the self, other people, and the environment that interfere with long-term functioning (Oltmanns & Balsis, 2011). And, these maladaptive behaviors are not restricted to isolated episodes or specific circumstances. Rather, these maladaptive patterns of emotions, thought processes, and behavior tend to be very stable over time. The patterns also deviate markedly from the social and behavioral expectations of the individual’s culture. Usually, personality disorders become evident during adolescence or early adulthood. Personality disorders are evident in about 10 percent of the general population (Lenzenweger, 2008).

Many researchers believe that personality disorders reflect conditions in which “normal” personality traits are taken to an abnormal extreme (Samuel & others, 2010; Trull & Widiger, 2008). For example, it’s normal to feel uneasy or sad when separated from a loved one. In a personality disorder, however, these responses reach pathological extremes. Rather than uneasiness, a person might experience intense feelings of desperation and intense anxiety. And rather than sadness, the person might experience unbearably intense feelings of abandonment and emptiness.

Despite the fact that the maladaptive personality traits consistently cause personal or social turmoil, people with personality disorders often blame others for their difficulties. Even if they are aware of their maladaptive personality patterns, they typically don’t think there’s anything wrong with them. In other words, they are unable to see that their inflexible style of thinking and behaving is at the root of their personal and social difficulties. Consequently, people with personality disorders often don’t seek help.

DSM-5 identifies ten distinct personality disorders, summarized in TABLE 14.7. These disorders are organized into three basic clusters: odd, eccentric personality disorders; dramatic, emotional, erratic personality disorders; and anxious, fearful personality disorders. However, this classification system is problematic (American Psychiatric Association, 2012b, c). For example, many people display the characteristics of more than one personality disorder, making diagnosis difficult.

For the first time, DSM-5 includes a second approach to classifying personality disorders. It involves assessing people on two dimensions: (1) a severity scale, which assesses the degree of impairment in personality functioning; and (2) a trait scale, which rates the person on pathological personality traits, such as the tendency to be antagonistic, emotionally unstable, impulsive, or manipulative. DSM-5 includes both the older and the newer approaches as a compromise between differences of opinion as to which is more useful.

In this section, we’ll focus our discussion on two of the more serious personality disorders, antisocial personality disorder and borderline personality disorder. These two disorders are also among the most thoroughly researched. Because the older method of diagnosis is used more commonly among clinicians than the newer one, we will refer to it throughout our discussion.

Often referred to as a psychopath or sociopath, the individual with antisocial personality disorder has the ability to lie, cheat, steal, and otherwise manipulate and harm other people. And when caught, the person shows little or no remorse for having caused pain, damage, or loss to others (Patrick, 2007). It’s as though the person has no conscience or sense of guilt. This pattern of blatantly disregarding and violating the rights of others is the central feature of antisocial personality disorder (DSM-5, 2013). Although many people associate violence with antisocial personality disorder, a history of violence is not necessary for the diagnosis (DSM-5, 2013). In fact, there is evidence that some psychopaths succeed in high-status, competitive professions such as in business or politics where a ruthless personality might be useful (Boddy & others, 2010; Lilienfeld & others, 2012). Researchers have also noted a relative lack of anxiety in these individuals, especially those most likely to harm others for their own benefit (De Brito & Hodgins, 2009; Neumann & others, 2013). Approximately 4 percent of the general population displays the characteristics of antisocial personality disorder, with men far outnumbering women (Grant & others, 2004).

More recently, researchers have argued that the definitions of psychopath and sociopath are different from the criteria for antisocial personality disorder, despite the fact that all three are often used interchangeably. Jack Pemment (2013) explains that sociopaths have a sense of morality, but it differs from that of others in their community. Their particular sense of morality can lead sociopaths to commit deviant, and sometimes criminal, acts. Psychopaths, on the other hand, lack any sense of morality and do not have normal emotional responses. For example, unlike others, psychopaths do not startle when presented with disturbing images, such as a weapon aimed at them or a victim of a violent assault (Levenston & others, 2000).

Evidence of the maladaptive personality patterns associated with antisocial personality disorder is often seen in childhood or early adolescence (Diamantopoulou & others, 2010; Hiatt & Dishion, 2008). In many cases, the child has repeated run-ins with the law or school authorities. Behaviors that draw the attention of authorities can include cruelty to animals, attacking or harming adults or other children, theft, setting fires, and destroying property. During childhood and adolescence, this pattern of behavior is typically diagnosed as conduct disorder. The habitual failure to conform to social norms and rules often becomes the person’s predominant life theme, which continues into adulthood (Patrick, 2007).

Deceiving and manipulating others for their own personal gain is another hallmark of individuals with antisocial personality disorder. With an uncanny ability to look you directly in the eye and speak with complete confidence and sincerity, they will lie in order to gain money, sex, or whatever their goal may be. When confronted with their actions, they respond with indifference or offer some superficial rationalization to justify their behavior. Often, they are contemptuous about the feelings or rights of others, blaming the victim for his or her stupidity. This quality makes antisocial personality disorder especially difficult to treat because clients often manipulate and lie to their therapists, too (McMurran & Howard, 2009).

Because they are consistently irresponsible, individuals with antisocial personality disorder often fail to hold a job or meet financial obligations. Losing or quitting one job after another, defaulting on loans, and failing to make child support payments are common occurrences. Their past is often checkered with arrests and jail sentences. High rates of alcoholism and other forms of substance abuse are also strongly associated with antisocial personality disorder (Hasin & others, 2011; Fridell & others, 2008). However, by middle to late adulthood, the antisocial tendencies of such individuals tend to diminish.

Borderline individuals are the psychological equivalent of third-degree-burn patients. They simply have no emotional skin. Even the slightest touch or movement can create immense suffering.

This is how Marsha Linehan (2009) describes the chaotic, unstable world of people with borderline personality disorder (BPD). Borderline personality disorder is characterized by impulsiveness and chronically unstable emotions, relationships, and self-image. Moods and emotions are intense, fluctuating, and extreme, often vastly out of proportion to the triggering incident, and seemingly uncontrollable. The person with borderline personality disorder unpredictably swings from one mood extreme to another. Inappropriate, intense, and often uncontrollable episodes of anger are another hallmark of this disorder (Berenson & others, 2011).

Relationships with others are as chaotic and unstable as the person’s moods. The person with borderline personality disorder has a chronic, pervasive sense of emptiness. Above all, she is desperately afraid of abandonment and alternately clings to others and pushes them away. Because her sense of identity is so fragile, she constantly seeks reassurance and self-definition from others. When it is not forthcoming, she may erupt in furious anger or abject despair.

Relationships careen out of control as the person shifts from inappropriately idealizing the newfound lover or friend to viewing them with complete contempt or hostility. She sees herself, and everyone else, as absolutes: ecstatic or miserable, perfect or worthless (Arntz & ten Haaf, 2012; de Montigny-Malenfant & others, 2013).

Often, the deep despair and inner emptiness that people with BPD experience are outwardly expressed in self-destructive behavior (Linehan & Dexter-Mazza, 2008). “Cutting” or other acts of self-mutilation, threats of suicide, and suicide attempts are common, especially in response to perceived rejection or abandonment. Underscoring the seriousness of borderline personality disorder is a grim statistic: As many as 10 percent of those who meet the BPD criteria eventually commit suicide, an extremely high percentage that is about 50 times the suicide rate for the general population (American Psychiatric Association, 2001; Qin, 2011).

Borderline personality disorder is often considered to be the most serious and disabling of the personality disorders. People with this disorder often also suffer from depression, substance abuse, and eating disorders (Mercer & others, 2009; Walter & others, 2009). And because they often lack control over their impulses, self-destructive, impulsive behavior is common, such as gambling, reckless driving, drug abuse, or sexual promiscuity.

Along with being among the most severe of the personality disorders, borderline personality disorder is also the most commonly diagnosed. A recent survey found that BPD was more prevalent than previously thought. Estimates suggest that BPD affects about 6 percent of the population, or possibly some 18 million Americans (Grant & others, 2008). The researchers also found the highest prevalence of borderline personality disorder among women, people in lower income groups, and Native American men, while the lowest incidence was among women of Asian descent.

WHAT CAUSES BORDERLINE PERSONALITY DISORDER?

As with the other personality disorders, multiple factors have been implicated. Because people with borderline personality disorder have such intense and chronic fears of abandonment and are terrified of being alone, some researchers believe that a disruption in attachment relationships in early childhood is an important contributing cause (Barone & others, 2011). Dysfunctional family relationships are common: Many borderline patients report having experienced neglect or physical, sexual, or emotional abuse in childhood (Ball & Links, 2009; Watson & others, 2006).

A more comprehensive theory, called the biosocial developmental theory of borderline personality disorder, has been proposed by psychologist Marsha Linehan (1993; Crowell & others, 2009). According to this view, borderline personality disorder is the outcome of a unique combination of biological, psychological, and environmental factors. Some children are born with a biological temperament that is characterized by extreme emotional sensitivity, a tendency to be impulsive, and the tendency to experience negative emotions. Linehan believes that borderline personality disorder results when such a biologically vulnerable child is raised by caregivers who do not teach him how to control his impulses or help him learn how to understand, regulate, and appropriately express his emotions (Crowell & others, 2009).

In some cases, Linehan believes, parents or caregivers actually shape and reinforce the child’s pattern of frequent, intense emotional displays by their own behavior. For example, they may sometimes ignore a child’s emotional outbursts and sometimes reinforce them. In Linehan’s theory, a history of abuse and neglect may be present but is not a necessary ingredient in the toxic mix that produces borderline personality disorder. Despite the difficulties faced by people suffering from borderline personality disorder, treatments developed by Linehan and her colleagues have been shown to help patients to manage this mental illness (see Bohus & others, 2000).