Subject code: PSY536

Subject Name: Psychopathology

Academic Task: Assignment 3
Date of submission: 27th April 2022
Submitted By: Anu Abraham
Registration Number: 12103723
Roll No: RU2105A31
Section: U2105
Submitted to: Dr.Jahangeer Majeed
 Topic: Personality Disorder

INTRODUCTION
A person’s broadly characteristic traits, coping styles, and ways of interacting in the social
environment emerge during childhood and normally crystallize into established patterns by
the end of adolescence or early adulthood. These patterns constitute the individual’s
personality—the set of unique traits and behaviors that characterize the individual. Today
there is reasonably broad agreement among personality researchers that about five basic
personality trait dimensions can be used to characterize normal personality. This five-factor
model of personality traits includes the following five trait dimensions: neuroticism,
extraversion/ introversion, openness to experience, agreeableness/antagonism, and
conscientiousness(Goldberg, 1990; John & Naumann,2008; McCrae & Costa, 2008).

Clinical Features of PersonalityDisorders

For most of us, our adult personality is attuned to the demands of society. In other words,
we readily comply with most societal expectations. In contrast, there are certain people who,
althoughthey do not necessarily display obvious symptoms of most of the disorders
discussed in this book, nevertheless have certain traits that are so inflexible and maladaptive
that they are unable to perform adequately at least some of the varied roles expected of
them by their society, in which case we may say that they have a personality disorder
(formerly known as a character disorder). Two of the general features that characterize most
personality disorders are chronic interpersonal difficulties and problems with
one’s identity or sense of self (Livesley, 2001).

According to general DSM-5 criteria for diagnosing a personality disorder, the person’s
enduring pattern of behavior must be pervasive and inflexible, as well as stable and of long
duration. It must also cause either clinically significant distress or impairment in functioning
and be manifested in at least two of the following areas: cognition, affectivity, interpersonal
functioning, or impulse control. From a clinical standpoint, people with personality
disorders often cause at least as much difficulty in the lives of others as they do in their own
lives. Other people tend to find the behavior of individuals with personality disorders
confusing, exasperating, unpredictable, and, to varying degrees, unacceptable. Whatever the
particular trait patterns affected individualshave developed (obstinacy, covert hostility,
suspiciousness, or fear of rejection, for example), these patterns color their reactions to each
new situation and lead to a repetition of the same maladaptive behaviors because they do not
learn from previous mistakes or troubles. For example, a dependent person may wear
out a relationship with someone such as a spouse by incessant and extraordinary demands
such as never being left alone. After that partner leaves, the person may go almost
immediately into another equally dependent relationship without choosing the
new partner carefully.

Personality disorders typically do not stem from debilitating reactions to stress in the recent
past, as do posttraumatic stress disorder (PTSD) or many cases of major depression. Rather,
these disorders stem largely from the gradual development of inflexible and distorted
personality and behavioral patterns that result in persistently maladaptive ways of
perceiving, thinking about, and relating to the world. In many cases, major stressful
life events early in life help set the stage for the development of these inflexible and
distorted personality patterns.

The category of personality disorders is broad, encompassing behavioral problems that

differ greatly in form and severity. In the milder cases we find people who generally
function adequately but who would be described by their relatives, friends, or associates as
troublesome, eccentric, or hard to get to know. Like Bob, they may have difficulties
developing close relationships with others or getting along with those with whom they do
have close relationships. One severe form of personality disorder (antisocial personality
disorder) results in extreme and often unethical “acting out” against society. Many such
individuals are incarcerated in prisons, although some are able to manipulate others and
keep from getting caught.

DSM-5 CATEGORIES
The DSM-5 personality disorders are grouped into three clusters. These were derived on the
basis of what were originally thought to be important similarities of features among the
disorders within a given cluster.
1. Cluster A: Includes paranoid, schizoid, and schizotypal personality disorders. People
with these disorders often seem odd or eccentric, with unusual behavior ranging from
distrust and suspiciousness to social detachment.
2. Cluster B: Includes histrionic, narcissistic, antisocial, and borderline personality
disorders. Individuals with these disorders share a tendency to be dramatic,
emotional, and erratic.
3. Cluster C: Includes avoidant, dependent, and obsessive compulsive personality
disorders. In contrast to the other two clusters, people with these disorders often
show anxiety and fearfulness.

Personality disorders first appeared in the DSM in 1980 (in DSM-III). Although the use of
clusters has continued since then, research has raised many questions about their valid-
ity. As will be discussed later in this chapter (see “Unresolved Issues”), there are substantial
limitations to the category and cluster designations. Indeed, several proposals carefully
considered by the DSM-5 task force were to remove four personality disorders entirely and
abandon the cluster organization. One of the primary issues is that there are simply too
many overlapping features across both categories and clusters (Krueger & Eaton, 2010;
Sheets & Craighead, 2007; Widiger & Mullins-Sweatt, 2005). Nevertheless, because much
of the research literature to date has used these clusters as an organizing rubric in one way
or another, we still mention them here.

Since their entry into the DSM in 1980, the personality disorders have been coded on a
separate axis, Axis II. This was because they were regarded as different enough from the
standard psychiatric syndromes (which were coded on Axis I) to warrant separate
classification. However, in DSM-5, the multiaxial system was abandoned. Personality
disorders are now included with the rest of the disorders we discuss in this textbook.
Personality disorders are often associated with (or comorbid with) anxiety disorders One
summary of evidence estimated that about three-quarters of people diagnosed with a
personality disorder also have another disorder as well
(Dolan-Sewell et al., 2001).
Personality Disorder Characteristics Gender ratio
Cluster A
• Paranoid Suspiciousness and mistrust males > females
of others; tendency to see self
as blameless; on guard for
perceived attacks by others
• Schizoid Impaired social relationships; males > females
inability and lack of desire to
form attachments to others
• Schizotypal Peculiar thought patterns; males > females
oddities of perception and
speech that interfere with
communication and social
interaction
Cluster B
• Histrionic Self-dramatization; over males = females
concern with attractiveness;
tendency to irritability and
temper outbursts if attention
seeking is frustrated
• Narcissistic Grandiosity; preoccupation males > females
with receiving attention;
self-promoting; lack of
empathy
• Antisocial Lack of moral or ethical males > females
development; inability to
follow approved models of
behavior; deceitfulness;
shameless manipulation of
others; history of conduct
problems as a child
• Borderline Impulsiveness; inappropriate females = males
anger; drastic mood shifts;
chronic feelings of boredom;
attempts at self-mutilation or
suicide
Cluster C
• Avoidant Hypersensitivity to rejection males = females
or social derogation; shyness;
insecurity in social
interaction and initiating
relationships
• Dependent Difficulty in separating in males = females
 relationships; discomfort at
being
alone; subordination of needs
in order to keep others
involved in
a relationship; indecisiveness
• Obsessive- Excessive concern with males > females (by 2:1)
Compulsive order, rules, and trivial
details; perfectionistic; lack
of expressiveness and
warmth; difficulty in
relaxing and having fun

Difficulties Doing Research on Personality Disorders

A special caution is in order regarding the diagnosis of personality disorders because more
misdiagnoses probably occur here than in any other category of disorder. There are a
number of reasons for this. One problem is that diagnostic criteria for personality disorders
are not as sharply defined as they are for most other diagnostic categories, so they are often
not very precise or easy to follow in practice. For example, it may be difficult to diagnose
reliably whether someone meets a given criterion for dependent personality disorder such as
“goes to excessive lengths to obtain nurturance and support from others” or “has difficulty
making everyday decisions without an excessive amount of advice and reassurance from
others.” Because the criteria for personality disorders are defined by inferred traits or
consistent patterns of behavior rather than by more objective behavioral standards (such as
having a panic attack or a prolonged and persistent depressed mood), the clinician must
exercise more judgment in making the diagnosis than is the case for many other disorders.

With the development of semistructured interviews and self-report inventories for the
diagnosis of personality disorders, certain aspects of diagnostic reliability increased
substantially. However, because the agreement between the diagnoses made on the basis of
different structured interviews or self-report inventories is often rather low, there are still
substantial problems with the reliability and validity of these diagnoses (Clark & Harrison,
2001; Livesley, 2003; Trull & Durrett, 2005). This means, for example, that three different
researchers using three different assessment instruments may identify groups of individuals
with substantially different characteristics as having a particular diagnosis such as
borderline or narcissistic personality disorder. Of course, this virtually ensures that few
obtained research results will be replicated by other researchers even though the groups
studied by the different researchers have the same diagnosticlabel (Clark & Harrison, 2001)

General Sociocultural Causal Factors for Personality Disorders

The sociocultural factors that contribute to personality disorders are not well understood. As
with other forms of psychopathol- ogy, the incidence and particular features of personality
disorders vary somewhat with time and place, although not as much as one might guess
(Allik, 2005; Rigozzi et al., 2009). Indeed, there is less variance across cultures than within
cultures. This may be related to findings that all cultures (both Western andnon-Western,
including Africa and Asia) share the same five basic personality traits discussed earlier, and
their patterns of covariation also seem universal.
Some researchers believe that certain personality disorders have increased in American
society in recent years (e.g., Paris, 2001). If this claim is true, we can expect to find the
increase related to changes in our culture’s general priorities and activities. Is our emphasis
on impulse gratification, instant solutions, and pain-free benefits leading more people to
develop the self-centered lifestyles that we see in more extreme forms of the
personality disorders? For example, there is some evidence thatnarcissistic personality
disorder is more common in Western cultures, where personal ambition and success are
encouraged and reinforced (e.g., Widiger & Bornstein, 2001). There is also some evidence
that histrionic personality might be expected to be (and is) less common in Asian cultures,
where sexual seductiveness and drawing attention to oneself are frowned on; by contrast, it
may be higher in Hispanic cultures, where such tendencies are common and well tolerated
(Bornstein, 1999). Within the United States, rates of BPD are higher in Hispanic Americans
than in African Americans and Caucasians, but rates of schizotypal personality disorder are
higher in African Americans than in Caucasians (Chavira et al., 2003).

It has also been suggested that known increases over the 60 years since World War II in
emotional dysregulation (depression, self-injurious behavior, and suicide) and impulsive
behaviors (substance abuse and criminal behavior) may be related to increases in the
prevalence of borderline and ASPDs over the same time period. This could stem from
increased breakdown of the family and other traditional social structures (Paris, 2001, 2007)
and may vary across cultures depending on whether similar breakdowns have occurred.

Treatments and Outcomesfor Personality Disorders

Personality disorders are generally very difficult to treat, in part because they are, by
definition, relatively enduring, pervasive, and inflexible patterns of behavior and inner
experience. Moreover, many different goals of treatment can be formulated, and some are
more difficult to achieve than others. Goals might include reducing subjective distress,
changing specific dysfunctional behaviors, and changing whole patterns of behavior or the
entire structure of the personality.
In many cases, people with personality disorders enter treatment only at someone else’s
insistence, and they often do not believe that they need to change. Moreover, those from the
odd/eccentric
Cluster A and the erratic/dramatic Cluster B have general difficulties in forming and
maintaining good relationships, including with a therapist. For those from the
erratic/dramatic
Cluster B, the pattern of acting out typical in their other relationships is carried into the
therapy situation, and instead of dealing with their problems at the verbal level they may
become angry at their therapist and loudly disrupt the sessions. Non- completion of
treatment is a particular problem in the treatment of personality disorders; a recent review of
the research reported that an average of 37 percent of personality disorder patients
drop out of therapy prematurely (McMurran et al., 2010).

In addition, people who have a personality disorder in addition to another disorder (such as
depression or an eating disorder) do not, on average, do as well in treatment for their other
disorder as do patients without comorbid personality disorders (Crits-Christoph & Barber,
2002, 2007; Pilkonis, 2001). This is partly because people with personality disorders have
rigid, ingrained personality traits that often lead to poor therapeutic relationships and
additionally make them resist doing the things that would help improve their other
conditions.

Treating Borderline Personality Disorder

Of all personality disorders, most clinical and research attention has been paid to the
treatment of BPD. This is due to the severity of this disorder and the high risk of suicide that
is associated with it. Treatment often involves both psychological and biological treatment
approaches, with medications being used as an adjunct to psychological treatment, which is
considered essential.
Biological Treatments The use of medications is controversial with this disorder because it
is so frequently associated with suicidal behavior. Today, antidepressant medications (most
often from the SSRI category) are considered most safe and useful for treating rapid mood
shifts, anger, and anxiety (Lieb et al 2004), as well as for impulsivity symptoms including
impulsive aggression such as self-mutilation (Koenigsberg et al., 2002,2007; Markovitz,
2004; Silk & Feurino, 2012). In addition, low doses of antipsychotic medication have
modest effects that are broad based; that is, patients show some improvement in depression,
anxiety, suicidality, impulsive aggression, rejection sensitivity, and especially transient
psychotic symptoms and cognitive and perceptual distortions (Koenigsberg et al., 2007;
Markovitz, 2001, 2004; Silk & Feurino, 2012). Finally, mood-stabilizing medications such
as carbazemine may be useful in reducing irritability, suicidality, affective instability
and impulsive aggressive behavior (Koenigsberg et al., 2007; Lieb et al., 2004). However,
the consensus to date is that drugs are only mildly beneficial for BPD (Paris, 2009).

Psychosocial Treatments : Clinical trials suggest that several types of psychotherapy may
be effective for BPD. As discussed below, however, these treatments share two common
weaknesses. These are their relative complexity and long duration, both of which makes
them difficult to disseminate to the broader population (Paris, 2009).
Dialectical behavior therapy , developed by Marsha Linehan, is a unique kind of cognitive
and behavioral therapy specifically adapted for BPD (Linehan, 1993; Linehan & Dexter-
Mazza, 2008; Lynch & Cuper, 2012; Robins 2001). Linehan believes that patients’ inability
to tolerate strong states of negative affect is central to this disorder. One of the primary goals
of treatment is to encourage patients to accept this negative affect without engaging in self-
destructive or other maladaptive behaviors. Accordingly, Linehan has developed a
problem-focused treatment based on a clear hierarchy of goals, which prioritizes decreasing
suicidal and self-harming behavior and increasing coping skills. The therapy combines
individual and group components as well as phone coaching. In the group setting, patients
learn interpersonal effectiveness, emotion regulation, and distress tolerance skills. The
individual therapist, in turn, uses therapy sessions and phone coaching to help the patient
identify and change problematic behavior patterns and apply newly learned skills effectively

Treating Other Personality Disorders

Treatment of Cluster A and other Cluster B personality disorders is not, so far, as promising
as some of the recent advances that have been made in the treatment of BPD. In schizotypal
personality disorder, low doses of antipsychotic drugs (including the newer, atypical
antipsychotics; e.g., Keshavan et al., 2004; Koenigsberg 2007; Raine, 2006) may result in
modest improvements. Antidepressants from the SSRI category may also be useful. How-
ever, no treatment has yet produced anything approaching a cure for most people with this
disorder (Koenigsberg et al., 2002, 2007; Markovitz, 2001, 2004; Silk & Ferino, 2012).
Other than uncontrolled studies or single cases, no systematic, controlled studies of treating
people with either medication or psychotherapy yet exist for paranoid, schizoid, narcissistic,
or histrionic disorder (Becket al., 2003; Crits-Christoph & Barber, 2007). One reason for
this is that these people (because of the nature of their personality pathology) rarely seek
treatment.
Although not extensively studied, treatment of some Cluster C disorders, such as dependent
and avoidant personality disorder, appears somewhat more promising. Winston and
colleagues (1994) found significant improvement in patients with Cluster C disorders using
a form of short-term psychotherapy that is active and confrontational (see also Pretzer &
Beck,1996). Several studies using cognitive-behavioral treatment with avoidant personality
disorder have also reported significant gains (see Crits-Christoph & Barber, 2007), and a
recent meta-analysis concluded both cognitive-behavioral and psychodynamic therapies
resulted in significant and lasting treatment gains (Simon, 2009). Another study in the
Netherlands concluded that short-term inpatient treatment for Cluster C personality
disorders is even more effective than long-term inpatient or outpatient therapy (Bartak et al.,
2011). Antidepressants from the MAOI and SSRI categories may also sometimes help in the
treatment of avoidant personality disorder, just as they do in closely related social phobia
(Koenigsberg 2007; Markovitz, 2001)