LO 10 Differentiate between antisocial and borderline personality disorders.

Before reading this chapter, you probably knew something about depression, bipolar disorder, and schizophrenia. But you may have been less familiar with a somewhat common group of disorders relating to personality. Approximately 1 in 10 adults in the United States has a personality disorder (Lenzenweger, Lane, Loranger, & Kessler, 2007). People with personality disorders exhibit “an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment” (American Psychiatric Association, 2013, p. 645). Specifically, someone with a personality disorder behaves in a way that deviates substantially in the following areas: (1) cognition, including perceptions of self, others, and events; (2) emotional responses; (3) interpersonal functioning; and (4) impulse control. In order to be diagnosed with a personality disorder, one must struggle in at least two of these four categories. In addition, these problems must be resistant to change and have far-reaching consequences for interpersonal relationships.

Like personality traits in general, the core qualities of people with personality disorders (as well as the problems that result) are fairly stable over a lifetime and across situations. When diagnosing this type of disorder, the clinician must focus on troublesome personality traits—and be very careful not to confuse them with problems resulting from developmental changes, culture, drug use, or medical conditions.

The DSM–5 includes 10 personality disorder types (Table 12.9). Here, we direct the spotlight onto those that have received the greatest amount of research attention: antisocial personality disorder and borderline personality disorder.

Many films, including The Girl with the Dragon Tattoo and The Silence of the Lambs, feature characters who behave in ways most people find incomprehensible. The qualities of these characters often parallel a diagnosis of antisocial personality disorder.

People with antisocial personality disorder may seek personal gratification even when it means violating ethical standards and breaking laws. They sometimes lie or con others, and exhibit aggressive, impulsive, or irritable behaviors. These individuals have difficulty feeling empathy, and may not show concern for others or feel remorse upon hurting them. Other common behavior patterns include carelessness in sexual relationships, and the use of intimidation to control others (American Psychiatric Association, 2013). Around 1% of American adults are diagnosed with antisocial personality disorder, which is more common in men than women (Lenzenweger et al., 2007).

How does antisocial personality disorder develop? There is some evidence for family risk factors, but it is unclear how much of this risk is transmitted through genes, and how much results from learning. Heredity does appear to play a role, as first-degree biological relatives of people with antisocial personality disorder are more likely to have the disorder than those in the general population (American Psychiatric Association, 2013). However, no single gene has been implicated in the development of antisocial behavior patterns. Like most mental health problems, antisocial personality disorder seems to result from a complex interaction of genes and environment (Ferguson, 2010).

You may be wondering what is unique about the brain of a person with antisocial personality disorder. Some studies point to irregularities in the frontal lobes, a region of the brain that is crucial for executive functioning. For example, reduced tissue volume in the prefrontal cortex (11% less than expected) is apparent in some men with antisocial personality disorder. This deficit might be linked to reduced morality, and problems in decision making, planning, and learning in relation to fear, all potentially associated with antisocial behavior. The fact that the prefrontal cortex plays a role in controlling arousal may explain why people with this disorder tend to seek out stimulation, including aggressive and antisocial activities (Raine, Lencz, Bihrle, LaCasse, & Colletti, 2000).

Borderline personality disorder is distinguished by an incomplete sense of self and feelings of emptiness. People with this disorder tend to be emotionally unstable and extremely needy. They may exhibit intense anger, have difficulty controlling their temper, and get into physical fights. They can be impulsive when it comes to sexual activity, substance abuse, and spending money, and may threaten or attempt suicide on a recurring basis. Developing intimacy may also be a struggle, and relationships tend to be unstable, tainted with feelings of mistrust and fear of abandonment. Those with borderline personality disorder may see the world in terms of black and white, rather than different shades of gray. This tendency to perceive extremes may lead a person to become overinvolved or totally withdrawn in relationships (American Psychiatric Association, 2013).

According to the DSM–5, individuals with borderline personality disorder experience emotions that are unstable, intense, and inappropriate for the situation at hand. They may feel extreme anxiety and insecurity, concern about being rejected one moment, worried about being too dependent the next. Depressed moods are common, along with feelings of hopelessness, pessimism, and shame. The person may act without thinking and frequently change plans.

Seventy-five percent of people diagnosed with borderline personality disorder are female, and research suggests that some traits associated with this disorder have a genetic component (American Psychiatric Association, 2013). There is also evidence that childhood trauma sets the stage for the development of this condition. A biosocial developmental model has been proposed, indicating an early vulnerability that includes impulsive behavior and increased “emotional sensitivity.” If the environment is right, this susceptibility can lead to problems with emotions, behaviors, and cognitive processes (Crowell, Beauchaine, & Linehan, 2009).

As you now know, personality disorders stem from well-established personality characteristics. People suffering from these disorders have traits that are relatively easy to characterize. This is not the case for people with dissociative disorders, whose personal identities may be very difficult to pin down.

LO 11 Identify differences among dissociative disorders.

Dissociative disorders are disturbances in normal psychological functioning that can include problems with memory, identity, consciousness, perception, and motor control. The main feature of these disorders is dissociation, or a disturbance in the normally unified experience of psychological functions involved in memory, consciousness, perception, or identity (Spiegel et al., 2011). Dissociation may lead to difficulty recalling personal information (for example, where I live, who I am), or the feeling of being detached from one’s body.

In North America and Europe, the prevalence of dissociative disorders imposes a high financial burden (Brand, Classen, McNary, & Zaveri, 2009), in part because of lengthy treatment times. Dissociative disorders generally do not resolve with a simple drug prescription or a couple of therapy sessions. Here, we focus our discussion on two dissociative disorders: dissociative amnesia and dissociative identity disorder.

DISSOCIATIVE AMNESIA People suffering from dissociative amnesia have difficulty remembering important personal information. Often the lost memories center on traumatic or stressful events. In some cases the amnesia is localized, or fixed around a certain event; other times it may span a lifetime. Those with dissociative amnesia typically report a great deal of distress or impairment in relationships, work, and other important areas of life, and put a lot of effort into managing the mundane details of daily existence (Staniloiu & Markowitsch, 2012).

A person with dissociative amnesia who wanders in a confused and unexpected manner may also be experiencing dissociative fugue (fyüg; Spiegel et al., 2011). Consider this example from a case study: A 62-year-old woman was found in a city many miles from home. She had no understanding of her whereabouts or activities since leaving home. After a medical evaluation, physicians determined there was no neurological or physical explanation for her memory loss. Over time, she was able to recall some events from the “preceding weeks,” including an argument with her husband that left her in despair (Rajah, Kumar, Somasundaram, & Kumar, 2009). As often occurs with dissociative amnesia, this woman’s memory loss seemed to be associated with distressing events.

DISSOCIATIVE IDENTITY DISORDER Perhaps the most commonly known dissociative disorder is dissociative identity disorder (often referred to as multiple personality disorder), which is characterized by the presence of two or more distinct personalities. Dissociative identity disorder is considered the most complicated and persistent of the dissociative disorders (Sar, 2011). One of its key features is a lack of connection among behavior, awareness, memory, and cognition. There is often a reported gap in remembering day-to-day events and personal information. One may feel significant distress in relationships, work, and other areas. And this experience cannot be related to substance use or medical issues.

Clinicians must be mindful of cross-cultural and religious differences in relation to dissociative states. For example, some characteristics associated with dissociative identity disorder seem to occur in Brazilian mediums, and it is important to distinguish between a culturally accepted religious practice and disordered behavior (Moreira-Almeida, Neto, & Cardeña, 2008). Some studies suggest that dissociative identity disorder impacts females more than males, but findings are inconsistent. Societal factors, specifically childhood abuse and trauma, appear to play a significant role (Sar, 2011).

WHAT CAUSES DISSOCIATIVE DISORDERS? A great deal of controversy surrounds the apparent increase in diagnoses of dissociative identity disorder in the United States. One possible explanation is that clinicians are reinforcing the development of these dissociations. In other words, by suggesting the possibility of alternate personalities or using hypnosis to “recover” lost memories, the clinician “cues” the individual to believe an alternate personality is responsible for behaviors (Lynn, Lilienfeld, Merckelbach, Giesbrecht, & van der Kloet, 2012). These disorders are difficult to substantiate when they are based on self-reports. We should also note that they are often linked to childhood abuse and neglect, war, and terrorism not only in the United States, but also around the globe (American Psychiatric Association, 2013). Thus, education about and the prevention of early-life stress, as it relates to childhood abuse and neglect, is of significant importance (Sar, 2011).

Question 1

1. contact with reality.

2. manic episodes.

3. developmental processes.

4. the self and interpersonal relationships.

Question 2

Question 3

Question 4