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15.8 Personality Disorders: Going to Extremes

Think for a minute about high school acquaintances whose personalities made them stand out—not necessarily in a good way. Was there an odd person who didn’t seem to make sense, wore strange outfits, sometimes wouldn’t respond in conversation—or would respond by bringing up weird things like astrology or mind reading? Or perhaps a drama queen, someone whose theatrics and exaggerated emotions turned everything into a big deal? And don’t forget the neat freak, the perfectionist obsessed with control, who had the perfectly organized locker, precisely arranged hair, and sweater with zero lint balls. One way to describe such people is to say they simply have personalities, the unique patterns of traits we explored in the Personality chapter. But sometimes personality traits can become so rigid and confining that they blend into mental disorders. Personality disorders are enduring patterns of thinking, feeling, or relating to others or controlling impulses that deviate from cultural expectations and cause distress or impaired functioning. Personality disorders begin in adolescence or early adulthood and are relatively stable over time. Let’s look at the types of personality disorders and then take a closer look at one that sometimes lands people in jail: antisocial personality disorder.

Types of Personality Disorders

The DSM–5 lists 10 specific personality disorders (see TABLE 15.3). They fall into three clusters: (a) odd/eccentric, (b) dramatic/erratic, and (c) anxious/inhibited. The strange high school student, for example, could have schizotypal personality disorder (odd/eccentric cluster); the drama queen could have histrionic personality disorder (dramatic/erratic cluster); the neat freak could have obsessive-compulsive personality disorder (anxious/inhibited cluster). In fact, browsing through the list may awaken other high school memories. Don’t rush to judgment, however. Most of those kids are probably quite healthy and fall far short of qualifying for a diagnosis; after all, high school can be a rocky time for everyone, which is why personality disorders are not diagnosed in children or adolescents. The DSM–5 even notes that early personality problems often do not persist into adulthood. Still, the array of personality disorders suggests that there are multiple ways an individual’s gift of a unique personality could become a problem.

Ever browse a copy of Architectural Digest and wonder who would live in one of those perfect homes? A person with obsessive-compulsive personality disorder might fit right in. This personality disorder (characterized by excessive perfectionism) should not be mistaken, by the way, for obsessive-compulsive disorder—the anxiety disorder in which the person suffers from repeated unwanted thoughts or actions.

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Personality disorders have been a bit controversial for several reasons. First, critics question whether having a problematic personality is really a disorder. Given that approximately 15% of the U.S. population has a personality disorder according to the DSM–5, perhaps it might be better just to admit that a lot of people are difficult and leave it at that. Another question is whether personality problems correspond to “disorders” in that there are distinct types or whether such problems might be better understood as extreme values on trait dimensions such as the Big Five traits discussed in the Personality chapter (Trull & Durrett, 2005). In DSM–IV, personality disorders appeared as a separate type of disorder from all of the other disorders described above (specifically, those major disorders were all in a category called Axis I and personality disorders were in Axis II). However, in DSM–5 personality disorders have earned equal footing as full-fledged disorders. One of the most well studied of all the personality disorders is antisocial personality disorder.

Cluster	Personality Disorder	Characteristics
A. Odd/ Eccentric	Paranoid	Distrust in others, suspicion that people have sinister motives. Apt to challenge the loyalties of friends and read hostile intentions into others’ actions. Prone to anger and aggressive outbursts but otherwise emotionally cold. Often jealous, guarded, secretive, overly serious.
	Schizoid	Extreme introversion and withdrawal from relationships. Prefers to be alone, little interest in others. Humorless, distant, often absorbed with own thoughts and feelings, a daydreamer. Fearful of closeness, with poor social skills, often seen as a “loner.”
	Schizotypal	Peculiar or eccentric manners of speaking or dressing. Strange beliefs. “Magical thinking” such as belief in ESP or telepathy. Difficulty forming relationships. May react oddly in conversation, not respond, or talk to self. Speech elaborate or difficult to follow. (Possibly a mild form of schizophrenia.)
B. Dramatic/ Erratic	Antisocial	Impoverished moral sense or “conscience.” History of deception, crime, legal problems, impulsive and aggressive or violent behavior. Little emotional empathy or remorse for hurting others. Manipulative, careless, callous. At high risk for substance abuse and alcoholism.
	Borderline	Unstable moods and intense, stormy personal relationships. Frequent mood changes and anger, unpredictable impulses. Self-mutilation or suicidal threats or gestures to get attention or manipulate others. Self-image fluctuation and a tendency to see others as “all good” or “all bad.”
	Histrionic	Constant attention seeking. Grandiose language, provocative dress, exaggerated illnesses, all to gain attention. Believes that everyone loves them. Emotional, lively, overly dramatic, enthusiastic, and excessively flirtatious. Shallow and labile emotions. “Onstage.”
	Narcissistic	Inflated sense of self-importance, absorbed by fantasies of self and success. Exaggerates own achievement, assumes others will recognize they are superior. Good first impressions but poor longer-term relationships. Exploitative of others.
C. Anxious/ Inhibited	Avoidant	Socially anxious and uncomfortable unless they are confident of being liked. In contrast with schizoid person, yearns for social contact. Fears criticism and worries about being embarrassed in front of others. Avoids social situations due to fear of rejection.
	Dependent	Submissive, dependent, requiring excessive approval, reassurance, and advice. Clings to people and fears losing them. Lacking self-confidence. Uncomfortable when alone. May be devastated by end of close relationship or suicidal if breakup is threatened.
	Obsessive-compulsive	Conscientious, orderly, perfectionist. Excessive need to do everything “right.” Inflexibly high standards and caution can interfere with their productivity. Fear of errors can make them strict and controlling. Poor expression of emotions. (Not the same as obsessive-compulsive disorder.)
Source: From DSM–5 (American Psychiatric Association, 2013).

Table 15.3: Clusters of Personality Disorders

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Antisocial Personality Disorder

Henri Desiré Landru began using personal ads to attract a woman “interested in matrimony” in Paris in 1914, and he succeeded in seducing 10 of them. He bilked them of their savings, poisoned them, and cremated them in his stove, also disposing of a boy and two dogs along the way. He recorded his murders in a notebook and maintained a marriage and a mistress all the while. The gruesome actions of serial killers such as Landru leave us frightened and wondering; however, bullies, compulsive liars, and even drivers who regularly speed through a school zone share the same shocking blindness to human pain. The DSM–5 includes the category of antisocial personality disorder (APD) and defines it as a pervasive pattern of disregard for and violation of the rights of others that begins in childhood or early adolescence and continues into adulthood.

Henri Desiré Landru (1869–1922) was a serial killer who met widows through ads he placed in newspapers’ lonely hearts columns. After obtaining enough information to embezzle money from them, he murdered 10 women and the son of one of the women. He was executed for serial murder in 1922.

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Adults with an APD diagnosis typically have a history of conduct disorder before the age of 15. In adulthood, a diagnosis of APD is given to individuals who show three or more of a set of seven diagnostic signs: illegal behavior, deception, impulsivity, physical aggression, recklessness, irresponsibility, and a lack of remorse for wrongdoing. About 3.6% of the general population has APD, and the rate of occurrence in men is 3 times the rate in women (Grant et al., 2004).

What are some of the factors that contribute to APD?

The terms sociopath and psychopath describe people with APD who are especially coldhearted, manipulative, and ruthless—yet may be glib and charming (Cleckley, 1976; Hare, 1998). Although psychologists usually try to explain the development of abnormal behavior as a product of childhood experiences or difficult life circumstances, those who work with APD seem less forgiving, often noting the sheer dangerousness of people with this disorder. Many people with APD do commit crimes, and many are caught because of the frequency and flagrancy of their infractions. Among 22,790 prisoners in one study, 47% of the men and 21% of the women were diagnosed with APD (Fazel & Danesh, 2002). Statistics such as these support the notion of a “criminal personality.”

Both the early onset of conduct problems and the lack of success in treatment suggest that career criminality often has an internal cause (Lykken, 1995). Evidence of brain abnormalities in people with APD is also accumulating (Blair, Peschardt, & Mitchell, 2005). One line of investigation has looked at sensitivity to fear in psychopaths and individuals who show no such psychopathology. For example, criminal psychopaths who are shown negative emotional words such as hate or corpse exhibit less activity in the amygdala and hippocampus than do noncriminals (Kiehl et al., 2001). The two brain areas are involved in the process of fear conditioning (Patrick, Cuthbert, & Lang, 1994), so their relative inactivity in such studies suggests that psychopaths are less sensitive to fear than are other people. Violent psychopaths can target their aggression toward the self as well as others, often behaving in reckless ways that lead to violent ends. It might seem peaceful to go through life “without fear,” but perhaps fear is useful in keeping people from the extremes of antisocial behavior.

Personality disorders are enduring patterns of thinking, feeling, relating to others, or controlling impulses that cause distress or impaired functioning.
They include three clusters: odd/eccentric, dramatic/erratic, and anxious/inhibited.
Antisocial personality disorder is associated with a lack of moral emotions and behavior; people with antisocial personality disorder can be manipulative, dangerous, and reckless, often hurting others and sometimes hurting themselves.

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