PERSONALITY DISORDERS

According to the DSM-4, personality disorders are patterns of experiences and

behaviors that are drastically different from the norm. An individual exhibits
deviant patterns of behavior in at least two of the areas of thinking, mood, personal
relations and impulse control. The way they cope with life’s problems and relate to
each other may be considered troublesome, strange or tiresome to others; but the
people themselves may not feel a great deal of anxiety or distress except when they
encounter special crises.

There are ten personality disorders which are grouped into three major classes or
clusters.

CLUSTER A- identifies odd or eccentric personality disorders.

1. Paranoid personality disorder: it is characterized by persistent feelings of

distrust and suspicion against others. Such a person may experience constant
but unjustified suspicions that others are planning to deceive them.
2. Schizoid personality disorder: these individuals prefer solitary activities
and seem emotionally detached and uninterested in relationships with others.
3. Schizotypal personality disorder: it is also characterized by need for
isolation and includes magical or unconventional beliefs.
Ex. The individual might believe he/she has magical powers.

CLUSTER B- includes dramatic and emotional disorders.

1. Antisocial personality disorder: also known as psychopathic or sociopathic

personality, this disorder is characterized by an apparent disregard for rules
and laws and the feelings of others.
 Causes: some psychologists suggest a biological defect that makes
ordinary punishments and rewards ineffective in these children’s
upbringing. Others suggest it might be genetic- if a family member has had
the disorder (especially the parents) it increases the chance of the disorder. A
number of environmental factors in the childhood home, school, and
community may also contribute to the disorder. Some psychologists believe
that parents are to blame in two ways. First, when the parent is cold
and distant, the child imitates this behavior in his/her interactions with
others. Second, when the parent applies rewards and punishments
inconsistently, the child learns the tricks of escaping and avoiding
punishment but never learns an appropriate social role. Studies have
also shown that genetic factors are more important for adults with the
 disorder, while environmental factors are more important in antisocial
children.

 Symptoms: Such individuals show great skill in short term interactions,

with an uncanny knack for saying just the things other people want to
hear. They appear charming, confident, mature and sincere and manage
to get others’ help and trust. However their behavior is inconsistent with
their words. They do not follow through on promises or obligations, are
willing to deceive and defraud others and do not form close relations
with anyone. Other symptoms include:
 Persistent lying or stealing
 Tendency to violate the rights and boundaries of others
 Substance abuse
 Aggressive, often violent behavior; prone to getting involved in fights
 A persistent agitated or depressed feeling (dysphoria)
 Inability to tolerate boredom
 Lack of remorse, related to hurting others
 Impulsiveness
 A sense of extreme entitlement

 Treatment:

Psychotherapy: Psychotherapy for people with ASP should focuses on helping the individual
understand the nature and consequences of his disorder so he can be helped to control his
behavior.
Cognitive therapy: The cognitive therapy’s major goal is to help the patient understand how
he creates his own problems and how his distorted perceptions prevent him from seeing
himself the way others view him.
Medications : Several drugs, however, have been shown to reduce aggression, a common
problem for many antisocials. Medication may help alleviate other psychiatric disorders that
coexist with ASP, including major depression, anxiety disorder or attention-
deficit/hyperactivity disorder, thus producing a ripple effect that can reduce antisocial
behavior.
Addiction and Family Counseling: people with ASP who stop abusing drugs are less likely
to engage in antisocial or criminal behaviors and have fewer family conflicts and emotional
problems. Following a treatment program, patients should be encouraged to attend
meetings of Alcoholics Anonymous, Narcotics Anonymous or Cocaine Addicts Anonymous.
Antisocials with spouses and families may benefit from marriage and family counseling.
Bringing family members into the process may help antisocial patients realize the impact of
their disorder. Therapists who specialize in family counseling may help address the
antisocial person’s trouble maintaining an enduring attachment to his spouse or partner, his
inability to be an effective parent, problems with honesty and responsibility, and the anger
and hostility that can lead to domestic violence. Antisocials who were poorly parented may
need help learning appropriate parenting skills.
Prison : Incarceration may be the best way to control the most severe and persistent cases
of antisocial personality disorder. Keeping antisocial offenders behind bars during their most
active criminal periods reduces their behaviors’ social impact.

2. Borderline personality disorder: this is indicated by an unstable sense of

self, impulsivity, and a tendency towards strict ‘black and white’ thinking.
Such individuals are generally found to have unstable relationships and engage
in self destructive behavior such as self mutilation, reckless spending or binge
eating.

3. Histrionic personality disorder: this disorder is characterized by extreme

emotionality and a constant attention-seeking behavior. These individuals are
lively, dramatic, enthusiastic, and flirtatious. They may be inappropriately
sexually provocative, express strong emotions with an impressionistic style, and
be easily influenced by others. People with this disorder are usually able to
function at a high level and can be successful socially and professionally. They
usually have good social skills, but tend to use these skills to manipulate other
people and become the center of attention. Furthermore, histrionic personality
disorder may affect a person's social or romantic relationships or their ability to
cope with losses or failures. They often fail to see their own personal situation
realistically, instead tending to dramatize and exaggerate their difficulties.
They usually blame others for failures or disappointments. They may go
through frequent job changes, as they become easily bored and have trouble
dealing with frustration. Because they tend to crave novelty and excitement,
they may place themselves in risky situations. All of these factors may lead to
greater risk of developing depression.

 Causes:

NEUROCHEMICAL/PHYSIOLOGICAL CAUSES. The tendency towards an excessively

emotional reaction, common among patients with HPD, may be attributed to a
malfunction in a group of neurotransmitters called catecholamines. (Norepinephrine
belongs to this group of neurotransmitters.)

DEVELOPMENTAL CAUSES. Most psychoanalysts agree that a traumatic childhood

contributes towards the development of HPD. Some theorists suggest that the more
severe forms of HPD derive from disapproval in the early mother-child relationship.
Individuals with HPD also differ in the severity of the maladaptive defense
mechanisms they use. Patients with more severe cases of HPD may utilize the defense
mechanisms of repression, denial, and dissociation.

BIOSOCIAL LEARNING CAUSES. Biosocial learning models of HPD suggest that

individuals may acquire HPD from inconsistent interpersonal reinforcement offered by
parents. Proponents of biosocial learning models indicate that individuals with HPD
have learned to get what they want from others by drawing attention to themselves.

SOCIOCULTURAL CAUSES. Studies of specific cultures with high rates of HPD suggest
social and cultural causes of HPD. For example, some researchers would expect to
find this disorder more often among cultures that tend to value uninhibited displays
of emotion.

PERSONAL VARIABLES. Researchers have found some connections between the age of
individuals with HPD and the behavior displayed by these individuals. For example,
research suggests that seductiveness may be employed more often by a young adult
than by an older one. To impress others, older adults with HPD may shift their
strategy from sexual seductiveness to a paternal or maternal seductiveness.

 Symptoms: The symptoms include:

 Constant seeking of reassurance or approval.
 Excessive dramatics with exaggerated displays of emotions.
 Excessive sensitivity to criticism or disapproval.
 Inappropriately seductive appearance or behavior.
 Excessive concern with physical appearance.
 A need to be the center of attention (self-centeredness).
 Low tolerance for frustration or delayed gratification.
 Rapidly shifting emotional states that may appear shallow to others.
 Opinions are easily influenced by other people, but difficult to back up with
details.
 Tendency to believe that relationships are more intimate than they actually
are.
 Making rash decisions.
 Threatening or attempting suicide to get attention.
 Refusal to speak when confronted.
  Treatment:

Psychodynamic therapy: it is believed to assist patients to become aware of their

own feelings and decrease their emotional reactivity. Therapists work with thematic
dream material related to intimacy and recall. Individuals with HPD may have difficulty
recalling because of their tendency to repress material.

Cognitive-behavioral therapy: Cognitive therapy is a treatment directed at

reducing the dysfunctional thoughts of individuals with HPD. It teaches individuals
with HPD to identify automatic thoughts, to work on impulsive behavior, and to develop
better problem-solving skills. Behavioral therapists use response cost to decrease the
excessively dramatic behaviors of these individuals. Response cost is a behavioral
technique that involves removing a stimulus from an individual's environment so that
the response that directly precedes the removal is weakened. Behavioral therapy for
HPD includes techniques such as modeling and behavioral rehearsal.

Group therapy: is suggested to assist individuals with HPD to work on interpersonal

relationships. Psychodrama techniques or group role play can assist individuals with
HPD to practice problems at work and to learn to decrease the display of excessively
dramatic behaviors.

Family therapy: Family therapy can support family members to meet their own
needs without supporting the histrionic behavior of the individual with HPD who uses
dramatic crises to keep the family closely connected. Family therapists employ
behavioral contracts to support assertive behaviors rather than temper tantrums.

Medications: Pharmacotherapy is not a treatment of choice for individuals with HPD

unless HPD occurs with another disorder. For example, if HPD occurs with depression,
antidepressants may be prescribed. Medication needs to be monitored for abuse.

Alternative therapies: Meditation has been used to assist extroverted patients

with HPD to relax and to focus on their own inner feelings. Some therapists employ
hypnosis to assist individuals with HPD to relax when they experience a fast heart rate
or palpitations during an expression of excessively dramatic, emotional, and excitable
behavior.

4. Narcissistic personality disorder: it is defined by the DSM-4 as "a pervasive

pattern of grandiosity, need for admiration, and a lack of empathy." The
narcissist is described as turning inward for gratification rather than depending
on others and as being excessively preoccupied with issues of personal
adequacy, power and prestige. Narcissistic personality disorder is closely linked
to self-centeredness.

 Causes: the following factors could be possible causes for this disorder.

 An oversensitive temperament at birth

 Overindulgence and overvaluation by parents

 Valued by parents as a means to regulate their own self-esteem

 Excessive admiration that is never balanced with realistic feedback

 Unpredictable or unreliable caregiving from parents

 Severe emotional abuse in childhood

 Being praised for perceived exceptional looks or talents by adults

 "Excessive praise for good behaviors or excessive criticism for poor
behaviors in childhood"

 Symptoms: an individual with this disorder generally shows one or more

of the following symptoms.

 has a grandiose sense of self-importance

 is preoccupied with fantasies of unlimited success, power, brilliance,

beauty, or ideal love

 believes that he or she is "special" and unique

 requires excessive admiration

 has a sense of entitlement

 is interpersonally exploitative

 lacks empathy
  is often envious of others or believes others are envious of him or her
 shows arrogant, haughty behaviors or attitudes

CLUSTER C- includes fearful and anxious personality disorders.

1. Avoidant personality disorder: characterized by a pervasive pattern of

social inhibition, feelings of inadequacy, extreme sensitivity to negative
evaluation and avoidance of social interaction. People with avoidant
personality disorder often consider themselves to be socially inept or
personally unappealing, and avoid social interaction for fear of being ridiculed,
humiliated, rejected or disliked. They typically present themselves as loners
and report feeling a sense of alienation from society. Avoidant personality
disorder is usually first noticed in early adulthood, and is associated with
perceived or actual rejection by parents or peers during childhood. Whether
the feeling of rejection is due to the extreme interpersonal monitoring
attributed to people with the disorder is still disputed.

 Causes: The cause of avoidant personality disorder is not clearly defined,

and may be influenced by a combination of social, genetic, and
psychological factors. The disorder may be related to temperamental
factors that are inherited. Specifically, various anxiety disorders in
childhood and adolescence have been associated with a temperament
characterized by behavioral inhibition, including features of being shy,
fearful, and withdrawn in new situations.

Many people diagnosed with avoidant personality disorder have had

painful early experiences of chronic parental and or societal criticism or
rejection. The need to bond with the rejecting parents makes the
avoidant person hungry for relationships but their longing gradually
develops into a defensive shell of self-protection against repeated
criticisms.

 Symptoms: People with avoidant personality disorder are preoccupied

with their own shortcomings and form relationships with others only if
they believe they will not be rejected. Loss and rejection are so painful
that these individuals will choose to be lonely rather than risk trying to
connect with others.

 Hypersensitivity to criticism or rejection

  Self-imposed social isolation
 Extreme shyness in social situations, though feels a strong desire for close
relationships
 Avoids interpersonal relationships

 Avoids physical contact because it has been associated with an unpleasant or

painful stimulus.

 Feelings of inadequacy
 Severe low self-esteem

 Self loathing
 Mistrust of others

 Extreme shyness/timidity
 Emotional distancing related to intimacy

 Highly self-conscious
 Self-critical about their problems relating to others

 Loss of self-identity
 Problems in occupational functioning

 Lonely self-perception
 Feeling inferior to others

 Chronic substance abuse/dependence

 Investment in fixed fantasies

 Treatment:

Psychodynamically oriented therapies: These approaches are usually

supportive; the therapist empathizes with the patient's strong sense of shame and
inadequacy in order to create a relationship of trust.

Cognitive-behavioral therapy: This approach assumes that faulty thinking

patterns underlie the personality disorder, and therefore focuses on changing distorted
cognitive patterns by examining the validity of the assumptions behind them.

Group therapy: Group therapy may provide patients with avoidant personality
disorder with social experiences that expose them to feedback from others in a safe,
controlled environment. An empathetic environment in the group setting can help each
member overcome his or her social anxieties. Social skills training can also be
incorporated into group therapy to enhance social awareness and feedback.

Family and marital therapy: Family or couple therapy can be helpful for a patient
who wants to break out of a family pattern that reinforces the avoidant behavior. The
focus of marital therapy would include attempting to break the cycle of rejection,
criticism or ridicule that typically characterizes most avoidant marriages.

Medications: The use of monoamine oxidase inhibitors (MAOIs) has proven useful in
helping patients with avoidant personality disorder to control symptoms of social
unease and experience initial success.

2. Dependant personality disorder: formerly known as asthenic personality

disorder, it is characterized by a pervasive psychological dependence on other
people. According to the DSM-4, it a "pervasive and excessive need to be taken
care of that leads to submissive and clinging behavior and fears of separation,
beginning by early adulthood and present in a variety of contexts.

 Causes: It is commonly thought that the development of dependence in

these individuals is a result of over-involvement and intrusive behavior by
their primary caretakers. Caretakers may foster dependence in the child
to meet their own dependency needs, and may reward extreme loyalty
but reject attempts the child makes towards independence. Families of
those with dependent personality disorder are often do not express their
emotions and are controlling; they demonstrate poorly defined relational
roles within the family unit. Individuals with dependent personality
disorder often have been socially humiliated by others in their
developmental years. They may carry significant doubts about their
abilities to perform tasks, take on new responsibilities, and generally
function independently of others. This reinforces their suspicions that
they are incapable of living autonomously. In response to these feelings,
they portray a helplessness that elicits caregiving behavior from some
people in their lives.

 Symptoms: a person suffering from dependant personality disorder

generally displays the following symptoms:
  difficulty in making everyday decisions without an excessive amount of advice
and reassurance from others

 Need for others to assume responsibility for most major areas of their life
 difficulty in expressing disagreement with others because of fear of loss of
support or approval (this does not include realistic fears of retribution)
 difficulty in initiating projects or doing things on his or her own (because of a
lack of self-confidence in judgment or abilities rather than a lack of motivation
or energy)

 going to excessive lengths to obtain nurturance and support from others, to the
point of volunteering to do things that are unpleasant

 Feeling uncomfortable or helpless when alone because of exaggerated fears of

being unable to care for himself or herself

 Urgently seeking another relationship as a source of care and support when a

close relationship ends

 Unrealistically preoccupied with fears of being left to take care of themselves.

 Treatment: The focus of treatment is adaptation, i.e., how individuals

respond to the environment. Treatment interventions teach more
adaptive methods of managing distress, improving interpersonal
effectiveness, and building skills for affective regulation. For individuals
with DPD, the goal of treatment is not independence but autonomy.
Autonomy has been defined as the capacity for independence and the
ability to develop intimate relationships. The long-range goal is to
increase DPD individuals' sense of independence and ability to function.
Clients with DPD must build strength rather than foster neediness.

Psychodynamically oriented therapies: A long-term approach to psychodynamic

treatment can be successful, but may lead to heightened dependencies and difficult
separation in the therapeutic relationship over time. The preferred approach is a time-
limited treatment plan consisting of a predetermined number of sessions. This has been
proved to facilitate the exploration process of dependency issues more effectively than
long-term therapy in most patients.

Cognitive-behavioral therapy: Cognitive-behavioral approaches attempt to increase the

affected person's ability to act independently of others, improve their self-esteem, and
enhance the quality of their interpersonal relationships. Often, patients will play an active
role in setting goals. Methods often used in cognitive-behavioral therapy(CBT) include
assertiveness and social skills training to help reduce reliance on others, including the
therapist.

Interpersonal therapy: Treatment using an interpersonal approach can be useful because

the individual is usually receptive to treatment and seeks help with interpersonal
relationships. The therapist would help the patient explore their long-standing patterns of
interacting with others, and understand how these have contributed to dependency issues.
The goal is to show the patient the high price they pay for this dependency, and to help
them develop healthier alternatives. Assertiveness training and learning to identify feelings
is often used to improve interpersonal behavior.

Group therapy: When a person is highly motivated to see growth, a more interactive
therapeutic group can be successful in helping him/her to explore passive-dependent
behavior. If the individual is socially reluctant or impaired in his/her assertiveness,
decision-making, or negotiation, a supportive decision-making group would be more
appropriate. Time-limited assertiveness-training groups with clearly defined goals have
been proven to be effective.

Family and marital therapy: Individuals with dependent personality disorder are usually
brought to therapy by their parents. They are often young adults who are struggling with
neurotic or psychotic symptoms. The goal of family therapy is often to untangle the
enmeshed family relationships, which usually elicits considerable resistance by most family
members unless all are in therapy. Marital therapy can be productive in helping couples
reduce the anxiety of both partners who seek and meet dependency needs that arise in the
relationship.

Medications: Individuals with dependent personality disorder can experience anxiety and
depressive disorders as well. In these cases, it may occasionally prove useful to use
antidepressants or anti-anxiety agents. Unless the anxiety or depression is considered
worthy of a primary diagnosis, medications are generally not recommended for treatment
of the dependency issues or the anxiety or depressive responses. Persons with dependent
personality disorder may become overly dependent on any medication used.

3. Obsessive compulsive personality disorder: people with OCPD tend to

stress perfectionism above all else, and feel anxious when they perceive that
things are not "right." Sigmund Freud was the first person to characterize what
is now known as obsessive-compulsive or anankastic personality disorder as the
anal-retentive character. This fixation fit into his theory of psychosexual
development.

People with OCPD may try to rid themselves of excess energy when anxious or
excited by twitching or doing unpredictable things. They may hoard money for
future use, keep their home perfectly organized, or be anxious about
delegating tasks for fear that they won't be completed correctly. There are few
moral 'grey' areas for a person with fully developed OCPD; actions and beliefs
are either completely right, or absolutely wrong. As might be expected,
interpersonal relationships are difficult because of the excessive demands
placed on friends, romantic partners and children. Persons with OCPD often
have a negative outlook on life (pessimism).

 Causes: There are four primary areas that cause anxiety for OCPD
personalities: time, relationship, uncleanliness, and money.

 Symptoms:

 Preoccupation with details, rules, lists, order, organization, or schedules to the

extent that the major point of the activity is lost
 Showing perfectionism that interferes with task completion (e.g., is unable to
complete a project because his or her own overly strict standards are not met)
 Excessive devotion to work and productivity to the exclusion of leisure
activities and friendships (not accounted for by obvious economic necessity)
 Being overconscientious, scrupulous, and inflexible about matters of morality,
ethics, or values (not accounted for by cultural or religious identification)
 Inability to discard worn-out or worthless objects even when they have no
sentimental value
 Reluctance to delegate tasks or to work with others unless they submit to
exactly his or her way of doing things
 Adopting a miserly spending style toward both self and others; money is viewed
as something to be hoarded for future catastrophes

 Shows rigidity and stubbornness

 Treatment: Treatment for OCPD normally involves psychotherapy and

self help. Anti-anxiety medication will reduce the feeling of fear and
SSRIs can replace the chronic frustration with a sense of well-being, as
well as reducing stubbornness and negative rumination. A mild
tranquilizer can reduce alcohol dependence, if present. ADD medication
can improve task completion by improving mental focus, which will
provide visible success and improve outlook for recovery. Caffeine
sensitivity may be an exacerbating factor.

Psychotherapy

 Behavior therapy — Talking with a psychotherapist about ways to

change compulsions into healthier, productive actions.
 Psychotherapy — Talking with a trained counsellor or
psychotherapist who understands the condition.
 Psychopharmacology - A psychiatrist can prescribe medications
which may make self-management and participation in other
therapies possible and/or more productive