16.1 “Odd” Personality Disorders

The cluster of “odd” personality disorders consists of the paranoid, schizoid, and schizotypal personality disorders. People with these disorders typically have odd or eccentric behaviors that are similar to but not as extensive as those seen in schizophrenia, including extreme suspiciousness, social withdrawal, and peculiar ways of thinking and perceiving things. Such behaviors often leave the person isolated. Some clinicians believe that these personality disorders are related to schizophrenia. In fact, schizotypal personality disorder is listed twice in DSM-5—as one of the schizophrenia spectrum disorders and as one of the personality disorders (Rosell et al., 2014; APA, 2013). Directly related or not, people with an odd cluster personality disorder often qualify for an additional diagnosis of schizophrenia or have close relatives with schizophrenia (Chemerinski & Siever, 2011).

Clinicians have learned much about the symptoms of the odd cluster personality disorders but have not been so successful in determining their causes or how to treat them. In fact, as you’ll soon see, people with these disorders rarely seek treatment.

Paranoid Personality Disorder

As you read earlier, people with paranoid personality disorder deeply distrust other people and are suspicious of their motives (APA, 2013). Because they believe that everyone intends them harm, they shun close relationships. Their trust in their own ideas and abilities can be excessive, though, as you can see in the case of Eduardo:

paranoid personality disorder A personality disorder marked by a pattern of distrust and suspiciousness of others.

For Eduardo, a researcher at a genetic engineering research company, this was the last straw. He had been severely chastised by his supervisor for disregarding company protocol and deviating from the research procedure on a major study. He knew where this was coming from. He had been “ratted out” by his jealous, conniving lab colleagues—petty and small-minded bureaucrats who were always plotting ways to get him in trouble. This time, Eduardo would not sit back quietly. He demanded a meeting with his supervisor and the three other researchers in the lab.

At the outset of the meeting, Eduardo insisted that he would not leave the room until he was told the name of the person who had ratted him out. He acknowledged that he had, in fact, altered the study’s research design in key ways—eliminating some of the rats that were to be included in the study, increasing the food intake for a number of the rats, and conducting certain blood analyses that he thought would be enlightening. He maintained that these alterations were more than justified. The lab study, as previously designed, was a dull waste of time. In contrast, his revisions would open the door to new insights and, potentially, enormous medical gains.

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Eduardo quickly shifted the focus of the meeting onto his lab colleagues. He stated that the other scientists were intimidated by his visionary ideas, and he accused them of trying to get him out of the way so they could continue to work in an unproductive, low-pressure atmosphere. He said that their desire to get rid of him was always apparent to him, revealed by their coldness toward him each and every day and their outright nastiness whenever he tried to correct them or offer constructive criticism. Now on a roll, Eduardo further accused them of always talking loudly to one another as they ate lunch at their desks, for the sole purpose of preventing him from completing the work tasks that he would bring to his desk. Nor did it escape his attention that they were always laughing at him, talking about him behind his back, and, on more than one occasion, trying to copy or destroy his notes.

The other researchers were aghast as Eduardo laid out his suspicions. They knew he didn’t like them, but they had not, until now, recognized the depth of his fury or the number of his imagined slights. One of them, Xavier, spoke up. First, they had no idea that he was unilaterally changing the research protocol, so of course there was no way that they could have reported his actions to the super visor. Second, and more generally, it was he, not they, who was always behaving in an unfriendly and back-stabbing manner. Was it not true that he had stopped speaking to all three of them two months ago and that he regularly tried to antagonize them—giving them dirty looks, slamming doors, and brushing hard into them whenever he passed them? In response, Eduardo grunted and laughed—a self-righteous laugh. His only response was to ask them how else they expected him to behave, given their ill will toward him.

Next, Eduardo’s supervisor, Lisa, spoke up. She said that in her objective opinion, none of Eduardo’s accusations were true. First, none of his colleagues had informed on him, because he had conducted his modified protocols after they had gone home. She had reviewed videos from the lab cameras as a matter of routine and had noticed him feeding rats that were supposed to be hungry later. While acknowledging that his research ideas were interesting, she pointed out that his unilateral changes in procedure were throwing off the validity of the study. Lisa reminded him that any deviation would have had to be approved by her and that she would not be able to give that approval without submitting a written request to their financial backers.

“Zero Degrees of Empathy” With the term “Skinhead” tattooed on the back of his head, this man awaits trial in Germany for committing neo-Nazi crimes against foreigners and liberals. Clinicians sometimes confront extreme racism and intolerance in their practices, particularly among clients with paranoid, antisocial, and certain other personality disorders. Famous developmental psychologist Simon Baron-Cohen proposes in his book Zero Degrees of Empathy that the common element in all such behaviors is a total lack of empathy.

Second, she said that in her observations of everyday lab interactions, it was Xavier’s account that rang true, not Eduardo’s. She even added a few points of her own—that Eduardo never smiled, always looked tense, regularly picked fights, and seemed to delight in criticizing others. She also noted that she had received many complaints from people outside the lab about Eduardo’s cold and aloof manner. Finally, she angrily pointed out that several fully competent assistants had quit over the past year because of his eruptions over slight errors and infractions. Eduardo’s response to Lisa was what she expected by this point, but no less offensive. He accused her of covering up for his treacherous co-workers and of being in the pocket of a compromised medical field with a financial stake in maintaining the status quo.

Later, in the privacy of her office, Lisa told Eduardo that she had no choice but to let him go. She said that his behavior in the meeting showed once and for all that he could not be trusted, no matter how gifted he was, and that his continued presence on the project would jeopardize its integrity. Eduardo was furious, but not really surprised. His past two jobs has also ended badly. As he was packing up his private belongings back in the lab, he made a point of sarcastically congratulating his co-worker Xavier “for successfully orchestrating my termination and for your victory on behalf of the forces of scientific mediocrity.”

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Ever on guard and cautious and seeing threats everywhere, people like Eduardo continually expect to be the targets of some trickery (see Figure 16-2). They find “hidden” meanings, which are usually belittling or threatening, in everything. In a study that required people to role-play, participants with paranoia were more likely than control participants to read hostile intentions into the actions of others (Turkat et al., 1990). In addition, they more often chose anger as the appropriate role-play response.

Figure 16.2: figure 16-2
Whom do you distrust?
Although distrust and suspiciousness are the hallmarks of paranoid personality disorder, even people without this disorder are surprisingly untrusting. In various surveys, the majority of respondents said they distrust Internet information, members of Congress, lawyers, journalists, social network ads, and television newscasters. (Information from: YouGov, 2014; Harris Interactive, 2013, 2006; Press TV, 2013; Mancx, 2012).

Quick to challenge the loyalty or trustworthiness of acquaintances, people with paranoid personality disorder remain cold and distant. A woman might avoid confiding in anyone, for example, for fear of being hurt; or a husband might, without any justification, persist in questioning his wife’s faithfulness. Although inaccurate and inappropriate, their suspicions are not usually delusional; the ideas are not so bizarre or so firmly held as to clearly remove the individuals from reality (Millon, 2011).

People with this disorder are critical of weakness and fault in others, particularly at work (McGurk et al., 2013). They are unable to recognize their own mistakes, though, and are extremely sensitive to criticism. They often blame others for the things that go wrong in their lives, and they repeatedly bear grudges (Rotter, 2011). As many as 4.4 percent of adults in the United States experience this disorder, which is apparently more common in men than in women (APA, 2013; Sansone & Sansone, 2011).

How Do Theorists Explain Paranoid Personality Disorder?The theories that have been proposed to explain paranoid personality disorder, like those about most other personality disorders, have received little systematic research (Triebwasser et al., 2013). Psychodynamic theories, the oldest of these explanations, trace the pattern to early interactions with demanding parents, particularly distant, rigid fathers and overcontrolling, rejecting mothers (Caligor & Clarkin, 2010; Williams, 2010). (You will see that psychodynamic explanations for almost all the personality disorders begin the same way—with repeated mistreatment during childhood and lack of love.) According to one psychodynamic view, some people come to view their environment as hostile as a result of their parents’ persistently unreasonable demands. They must always be on the alert because they cannot trust others, and they are likely to develop feelings of extreme anger. They also project these feelings onto others and, as a result, feel increasingly persecuted (Koenigsberg et al., 2001). Similarly, some cognitive theorists suggest that people with paranoid personality disorder generally hold broad maladaptive assumptions, such as “People are evil” and “People will attack you if given the chance” (Beck & Weishaar, 2014; Weishaar & Beck, 2006; Beck et al., 2004).

Biological theorists propose that paranoid personality disorder has genetic causes (APA, 2013; Bernstein & Useda, 2007). An early study that looked at self-reports of suspiciousness in 3,810 Australian twin pairs found that if one twin was excessively suspicious, the other had an increased likelihood of also being suspicious (Kendler et al., 1987). Once again, however, it is important to note that such similarities between twins might also be the result of common environmental experiences.

Treatments for Paranoid Personality DisorderPeople with paranoid personality disorder do not typically see themselves as needing help, and few come to treatment willingly (Millon, 2011). Furthermore, many who are in treatment view the role of patient as inferior and distrust and rebel against their therapists (Kellett & Hardy, 2013; Bender, 2005). Thus it is not surprising that therapy for this disorder, as for most other personality disorders, has limited effect and moves very slowly (Piper & Joyce, 2001).

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Object relations therapists—the psychodynamic therapists who give center stage to relationships—try to see past the patient’s anger and work on what they view as his or her deep wish for a satisfying relationship (Caligor & Clarkin, 2010; Salvatore et al., 2005). Self-therapists—the psychodynamic clinicians who focus on the need for a healthy and unified self—try to help clients reestablish self-cohesion (a unified personality), which they believe has been lost in the person’s continuing negative focus on others (Vermote et al., 2010; Silverstein, 2007). Cognitive and behavioral techniques have also been used to treat people with paranoid personality disorder, and are often combined into an integrated cognitive-behavioral approach. On the behavioral side, therapists help clients to master anxiety-reduction techniques and to improve their skills at solving interpersonal problems. On the cognitive side, therapists guide the clients to develop more realistic interpretations of other people’s words and actions and to become more aware of other people’s points of view (Kellett & Hardy, 2013; Leahy, Beck, & Beck, 2005). Antipsychotic drug therapy seems to be of limited help (Birkeland, 2013; Silk & Jibson, 2010).

Schizoid Personality Disorder

People with schizoid personality disorder persistently avoid and are removed from social relationships and demonstrate little in the way of emotion (APA, 2013). Like people with paranoid personality disorder, they do not have close ties with other people. The reason they avoid social contact, however, has nothing to do with paranoid feelings of distrust or suspicion; it is because they genuinely prefer to be alone. Take Eli:

schizoid personality disorder A personality disorder characterized by persistent avoidance of social relationships and little expression of emotion.

Eli, a student at the local technical institute, had been engaged in several different Internet certificate programs over the past few years, and was about to engage in yet another, when his mother, confused as to why he would not apply for a traditional degree at a “real” college, insisted he seek therapy. A loner by nature, Eli preferred not to socialize in any traditional sense, having little to no desire to get to know much about the people in his immediate social context. The way Eli saw it, … “at least at my school you just go to class and go home.”

Routinely, he slept through much of his day and then spent his evenings, nights, and weekends at the school’s computer lab, “chatting” with others over the Internet while not in class. Notably, people that he chatted with often sought to meet Eli, but he always declined these invitations, stating that he didn’t really have any desire to learn more about them than what they shared over the computer in the chat rooms. He described a family life that was similar to that of his social surroundings; he was mostly oblivious of his younger brother and sister, two outgoing teens, despite the fact that they seemed to hold him in the highest regard, and he had recently alienated himself entirely from his father, who had left the family several years earlier….

A marked deficit in social interest was notable in Eli, as were frequent behavioral eccentricities…. At best, he had acquired a peripheral … role in social and family relationships…. Rather than venturing outward, he had increasingly removed himself from others and from sources of potential growth and gratification. Life was uneventful, with extended periods of solitude interspersed.

(Millon, 2011)

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People like Eli, often described as “loners,” make no effort to start or keep friendships, take little interest in having sexual relationships, and even seem indifferent to their families. They seek out jobs that require little or no contact with others. When necessary, they can form work relations to a degree, but they prefer to keep to themselves. Many live by themselves as well. Not surprisingly, their social skills tend to be weak. If they marry, their lack of interest in intimacy may create marital or family problems.

People with schizoid personality disorder focus mainly on themselves and are generally unaffected by praise or criticism. They rarely show any feelings, expressing neither joy nor anger. They seem to have no need for attention or acceptance; are typically viewed as cold, humorless, or dull; and generally succeed in being ignored. This disorder is present in 3.1 percent of the adult population (APA, 2013; Sansone & Sansone, 2011). Men are slightly more likely to experience it than are women, and men may also be more impaired by it.

A darker knight In this scene from the hugely popular 2008 movie The Dark Knight, Bruce Wayne confronts Batman, Wayne’s alter ego and only real friend. True to the vision of comic book artist and writer Frank Miller, this film and its sequel, The Dark Knight Rises, present the crime-fighter as a singularly driven loner incapable of forming or sustaining relationships. Some clinical observers have argued that in key ways the current Dark Knight version of Batman displays the features of schizoid personality disorder.

How Do Theorists Explain Schizoid Personality Disorder?Many psychodynamic theorists, particularly object relations theorists, propose that schizoid personality disorder has its roots in an unsatisfied need for human contact (Caligor & Clarkin, 2010; Kernberg & Caligor, 2005). The parents of people with this disorder, like those of people with paranoid personality disorder, are believed to have been unaccepting or even abusive of their children. Whereas people with paranoid symptoms react to such parenting chiefly with distrust, those with schizoid personality disorder are left unable to give or receive love. They cope by avoiding all relationships.

Cognitive theorists propose, not surprisingly, that people with schizoid personality disorder suffer from deficiencies in their thinking. Their thoughts tend to be vague, empty, and without much meaning, and they have trouble scanning the environment to arrive at accurate perceptions (Kramer & Meystre, 2010). Unable to pick up emotional cues from others, they simply cannot respond to emotions. As this theory might predict, children with schizoid personality disorder develop language and motor skills very slowly, whatever their level of intelligence (APA, 2013; Wolff, 2000, 1991).

Treatments for Schizoid Personality DisorderTheir social withdrawal prevents most people with schizoid personality disorder from entering therapy unless some other disorder, such as alcoholism, makes treatment necessary (Mittal et al., 2007). These clients are likely to remain emotionally distant from the therapist, seem not to care about their treatment, and make limited progress at best (Colli et al., 2014; Millon, 2011).

Cognitive-behavioral therapists have sometimes been able to help people with this disorder experience more positive emotions and more satisfying social interactions (Beck & Weishaar, 2011; Weishaar & Beck, 2006; Beck et al., 2004). On the cognitive end, their techniques include presenting clients with lists of emotions to think about or having them write down and remember pleasurable experiences. On the behavioral end, therapists have sometimes had success teaching social skills to such clients, using role-playing, exposure techniques, and homework assignments as tools. Group therapy is apparently useful when it offers a safe setting for social contact, although people with schizoid personality disorder may resist pressure to take part (Piper & Joyce, 2001). As with paranoid personality disorder, drug therapy seems to offer limited help (Silk & Jibson, 2010; Koenigsberg et al., 2002).

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Schizotypal Personality Disorder

People with schizotypal personality disorder display a range of interpersonal problems marked by extreme discomfort in close relationships, very odd patterns of thinking and perceiving, and behavioral eccentricities (APA, 2013). Anxious around others, they seek isolation and have few close friends. Some feel intensely lonely. The disorder is more severe than the paranoid and schizoid personality disorders, as we see in the case of 41-year-old Kevin:

schizotypal personality disorder A personality disorder characterized by extreme discomfort in close relationships, very odd patterns of thinking and perceiving, and behavioral eccentricities.

Kevin was a night security guard at a warehouse, where he had worked since his high school graduation more than 20 years ago. His parents, both successful professionals, had been worried for many years, as Kevin seemed entirely disconnected from himself and his surroundings and had never taken initiative to make any changes, even toward a shift supervisory position. They therefore made the referral for therapy, and Kevin simply acquiesced. He explained that he liked his work, as it was a place where he could be by himself in a quiet atmosphere, away from anyone else. He described where he worked as “an empty warehouse; they don’t use it no more but they don’t want no one in there. It’s nice; ‘homey.’”

Throughout the … interview, Kevin remained aloof, never once looking at the counselor, usually answering questions with either one-word responses or short phrases, and usually waiting to respond until a second question was asked or the first question was repeated. He described, in … short, bizarre answers, a life devoid of almost any human interconnectedness, almost his only tangible contact being his brother, whom he saw only during major holidays. Living alone, he could only remember one significant relationship, and that was with a girl in high school. Very simply, he stated, “We graduated, and then I didn’t see her anymore.” He expressed no apparent loneliness, however, and appeared entirely emotionless regarding any aspect of his life….

Kevin … often seemed to experience a separation between his mind and his physical body. There was a strange sense of nonbeing or nonexistence, as if his floating conscious awareness carried with it a depersonalized or identityless human form. Behaviorally, his tendency was to be drab, sluggish, and inexpressive. He … appeared bland, indifferent, unmotivated, and insensitive to the external world…. Most people considered him to be [a] strange person … who faded into the background, self-absorbed … and lost to the outside world…. Bizarre “telepathic” powers enabled him to communicate with mythical or distant others…. Kevin also occasionally decompensated when faced with too much, rather than too little, stimulation…. He would simply fade out, becoming blank, losing conscious awareness, and turning off the pressures of the outer world.

(Millon, 2011)

BETWEEN THE LINES

A Common Belief

People who think that they have extrasensory abilities are not necessarily suffering from schizotypal personality disorder. In fact, 73 percent of Americans believe in some form of the paranormal or occult—ESP, astrology, ghosts, communicating with the dead, or psychics.

(Gallup Poll, 2005).

As with Kevin, the thoughts and behaviors of people with schizotypal personality disorder can be noticeably disturbed. These symptoms may include ideas of reference—beliefs that unrelated events pertain to them in some important way—and bodily illusions, such as sensing an external “force” or presence. A number of people with this disorder see themselves as having special extrasensory abilities, and some believe that they have magical control over others. Examples of schizotypal eccentricities include repeatedly arranging cans to align their labels, organizing closets extensively, or wearing an odd assortment of clothing. The emotions of these individuals may be inappropriate, flat, or humorless.

People with schizotypal personality disorder often have great difficulty keeping their attention focused. Correspondingly, their conversation is typically digressive and vague, even sprinkled with loose associations (Millon, 2011). Like Kevin, they tend to drift aimlessly and lead an idle, unproductive life (Hengartner et al., 2014). They are likely to choose undemanding jobs in which they can work below their capacity and are not required to interact with other people. Surveys suggest that 3.9 percent of adults—slightly more males than females—display schizotypal personality disorder (Rosell et al., 2014; Sansone & Sansone, 2011).

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When personality disorders explode In this video, Seung-Hui Cho, a student at Virginia Tech, described the slights he experienced throughout his life. After mailing the video to NBC News, he proceeded, on April 16, 2007, to kill 32 people, including himself, and to wound 25 others in a massive campus shooting. Most clinical observers agree that he displayed a combination of features from the antisocial, borderline, paranoid, schizoid, schizotypal, and narcissistic personality disorders, including boundless fury and hatred, extreme social withdrawal, persistent distrust, strange thinking, intimidating behavior and arrogance, and disregard for others.

How Do Theorists Explain Schizotypal Personality Disorder?Because the symptoms of schizotypal personality disorder so often resemble those of schizophrenia, researchers have hypothesized that similar factors may be at work in both disorders. A wide range of studies have supported such expectations (Hazlett et al., 2014; Rosell et al., 2014; Thompson et al., 2014). Investigators have found that schizotypal symptoms, like schizophrenic patterns, are often linked to family conflicts and to psychological disorders in parents. They have also learned that defects in attention and short-term memory may contribute to schizotypal personality disorder, just as they apparently do to schizophrenia. For example, research participants with either disorder perform poorly on backward masking, a laboratory test of attention that requires a person to identify a visual stimulus immediately after a previous stimulus has flashed on and off the screen. People with these disorders have a hard time shutting out the first stimulus in order to focus on the second. Finally, researchers have linked schizotypal personality disorder to some of the same biological factors found in schizophrenia, such as high activity of the neurotransmitter dopamine, enlarged brain ventricles, smaller temporal lobes, and loss of gray matter (Ettinger et al., 2014). As you read in Chapter 14, there are indications that these biological factors may have a genetic base.

Although these findings do suggest a close relationship between schizotypal personality disorder and schizophrenia, the personality disorder also has been linked to disorders of mood (Lentz, Robinson, & Bolton, 2010). More than half of people with schizotypal personality disorder also suffer from major depressive disorder at some point in their lives (APA, 2013). Moreover, relatives of people with depression have a higher than usual rate of schizotypal personality disorder, and vice versa. Thus, at the very least, this personality disorder is not tied exclusively to schizophrenia.

Treatments for Schizotypal Personality DisorderTherapy is as difficult in cases of schizotypal personality disorder as it is in cases of paranoid and schizoid personality disorders. Most therapists agree on the need to help these clients “reconnect” with the world and recognize the limits of their thinking and their powers. The therapists may thus try to set clear limits—for example, by requiring punctuality—and work on helping the clients recognize where their views end and those of the therapist begin. Other therapy goals are to increase positive social contacts, ease loneliness, reduce overstimulation, and help the individuals become more aware of their personal feelings (Colli et al., 2014; Sperry, 2003; Piper & Joyce, 2001).

Cognitive-behavioral therapists further combine cognitive and behavioral techniques to help people with schizotypal personality disorder function more effectively. Using cognitive interventions, they try to teach clients to evaluate their unusual thoughts or perceptions objectively and to ignore the inappropriate ones (Beck & Weishaar, 2011; Weishaar & Beck, 2006; Beck et al., 2004). Therapists may keep track of clients’ odd or magical predictions, for example, and later point out their inaccuracy. When clients are speaking and begin to digress, the therapists might ask them to sum up what they are trying to say. In addition, specific behavioral methods, such as speech lessons, social skills training, and tips on appropriate dress and manners, have sometimes helped clients learn to blend in better with and be more comfortable around others (Farmer & Nelson-Gray, 2005).

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Antipsychotic drugs have been given to people with schizotypal personality disorder, again because of the disorder’s similarity to schizophrenia. In low doses the drugs appear to have helped some people, usually by reducing certain of their thought problems (Rosenbluth & Sinyor, 2012; Silk & Jibson, 2010).