13.6 SUMMING UP

Diagnosing Personality Disorders

• A personality disorder is characterized by maladaptive personality traits that begin by young adulthood and continue through adulthood; these traits are relatively inflexible, are expressed across a wide range of situations, and lead to distress or impaired functioning. A personality disorder affects three areas of functioning: affect, behavior (including social behavior), and cognition.
• In DSM-5, personality disorders are grouped into three clusters: Cluster A, characterized by odd or eccentric behaviors related to features of schizophrenia; Cluster B, characterized by dramatic and erratic behaviors and problems with emotional regulation; and Cluster C, characterized by anxious or fearful behaviors.
• The category of personality disorders in DSM-5 has been criticized on numerous grounds.
• The neuropsychosocial approach explains how personality disorders develop by highlighting the interactions among three sorts of factors:
  
  • Neurological factors primarily involve the effects of genes on temperament.
  • Psychological factors include temperament, operant conditioning, and dysfunctional beliefs.
  • Social factors include insecure attachment that can result from childhood abuse or neglect.
• Treatments for personality disorders include medications for comorbid symptoms, CBT or psychodynamic therapy, and family education and therapy, as well as couples, interpersonal, and group therapy.

Odd/Eccentric Personality Disorders

• The essential feature of paranoid personality disorder is a persistent and pervasive mistrust and suspiciousness, which is accompanied by a bias to interpret other people’s motives as hostile. Although paranoid personality disorder and paranoid schizophrenia both involve suspicious beliefs, people with the personality disorder have some capacity to evaluate whether their suspicions are based on reality.
• Schizoid personality disorder is characterized by a restricted range of emotions in social interactions and few—if any—close relationships; people with this disorder have poor social skills. They report rarely experiencing strong emotions, and they prefer to be—and function best when—isolated from others.
• Schizotypal personality disorder is characterized by eccentric thoughts, perceptions, and behaviors, as well as by having very few close relationships. This personality disorder has three groups of symptoms: cognitive-perceptual, interpersonal, and disorganized. Schizotypal personality disorder is viewed as a milder form of schizophrenia.
• Paranoid, schizoid, and schizotypal personality disorders are on the spectrum of schizophrenia-related disorders, and close relatives of people with any of these odd/eccentric personality disorders are more likely to have schizophrenia. Schizotypal personality disorder involves neurological abnormalities that are less severe than those associated with schizophrenia.
• People with odd/eccentric personality disorders are reluctant participants in treatment. Treatment may address fundamental issues, such as isolation and suspiciousness. Treatment for schizotypal personality disorder may include antipsychotic medication (although at lower doses than used for psychotic disorders), and CBT.

Dramatic/Erratic Personality Disorders

• The hallmark of antisocial personality disorder is a persistent disregard for the rights of others, which may lead these people to violate rules or laws or to act aggressively.
• The diagnostic criteria for antisocial personality disorder overlap with aspects of psychopathy. However, psychopathy is defined by a more restrictive set of criteria, which focus on emotional and interpersonal characteristics, such as a lack of empathy and antisocial behaviors.
• Psychopathy and antisocial personality disorder arise from feedback loops among various factors, including genes, lack of empathy, classical and operant conditioning, abuse or neglect or inconsistent discipline in childhood, parents’ criminal behavior, and attachment style. Treatment for psychopathy has generally not been successful; treatment for antisocial personality disorder focuses on modifying specific behaviors and has some degree of success, at least temporarily, in motivated people.
• Borderline personality disorder is characterized by volatile emotions, an unstable self-image, and impulsive behavior in relationships. People with this disorder have problems with emotional regulation and may engage in self-harming behaviors or try to commit suicide.
• Factors that contribute to borderline personality disorder include the genetic and neurological underpinnings of emotional dysregulation, a relatively low threshold for emotional responsiveness, an easily changeable sense of self, cognitive distortions, and a history of abuse, neglect, or feeling invalidated by others. Treatment for borderline personality may include medication, DBT, CBT, intensive psychodynamic therapy, and IPT.
• The hallmark of histrionic personality disorder is attention seeking, usually through exaggerated emotional displays. Symptoms may also include a sense of boredom or emptiness and a low tolerance for frustration.
• Narcissistic personality disorder is characterized by a grandiose sense of self-importance and a constant desire for praise and admiration. People with this disorder may also feel a sense of entitlement, behave arrogantly, and have difficulty understanding other people’s points of view.

Fearful/Anxious Personality Disorders

• The hallmark of avoidant personality disorder is social inhibition, which usually stems from feeling inadequate and being overly sensitive to negative evaluation. Although similar to social phobia, the criteria for avoidant personality disorder are more pervasive and involve a more general reluctance to take risks. CBT methods that are used to treat social phobia can also be effective with avoidant personality disorder.
• Dependent personality disorder is characterized by submissive and clingy behaviors, based on fear of separation; these behaviors are intended to elicit attention and reassurance, and place responsibility for making decisions on other people. People with dependent personality disorder are chronically plagued by self-doubt and consistently underestimate their abilities; in fact, they may not know how to function independently.
• Obsessive-compulsive personality disorder is characterized by preoccupations with perfectionism, orderliness, and self-control and by low levels of flexibility and efficiency. These rigid personality traits may lead these people to have difficulty prioritizing and making decisions, and they are often intolerant of emotional or “illogical” behavior in others.