Chapter 6
Personality Disorders
Kenneth N. Levy and Benjamin N. Johnson
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Personality disorders (PDs) are a heterogeneous group
of mental disorders that arise when an individual’s
personality is considered impaired and maladaptive.
As will be discussed in greater detail, PDs are highly
prevalent in the general population (up to 18%) and
much higher in patient populations (up to 75%).
In addition to being prevalent, PDs are often under­
appreciated sources of social cost, family burden,
and morbidity and mortality (Hueston, Mainous, &
Schilling, 1996).
This chapter first defines personality and PDs,
differentiating them from related constructs, such as
temperament. It outlines current classification and
diagnostic frameworks for PDs, grounded in a his-
torical perspective. It then provides data as well as
implications of the high prevalence and comorbidity
of PDs with other conditions, followed by an over-
view of assessment techniques, with their respective
advantages and disadvantages. Next, it summarizes
recent meta-analytic data regarding the efficacy of
treatments for PDs. Finally, the chapter concludes
by providing a look back at major accomplishments
in the field of PD research and treatment and a look
forward toward the progress the field likely will
make in the next decade.
DEFINITIONS AND VARIANTS
What Is Personality?
Personality is a commonly used term that is often
ill-defined even in the context of mental health
(Livesley, 2001). Most conceptions understand per-
sonality as an umbrella concept that encompasses
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the dynamic organization of psychological function-
ing of enduring and consistent patterns of thoughts,
feelings, and behaviors that can be flexibly experi-
enced and expressed in a variety of circumstances
(e.g., Allport, 1961; Mischel & Shoda, 1995). Thus,
personality is a coherent self-system that is relatively
consistent but also flexible and responsive to cir-
cumstances; in essence, personality is who you are.
As such, personality represents a complex interac-
tion of temperament, internalized experiences, and
evolved behavioral patterns that come to be shaped
by our interpretation of these attributes and the con-
sequences of our life choices.
The concept of personality can be distinguished
from related terms, such as temperament and
­character. Traditionally, temperament has been
conceptualized as those aspects of personality that
are constitutional or biological in origin and related
to the general reactivity of the individual. At a
basic level, temperament can be thought of as an
individual’s “characteristic nature.” These inborn
differences show themselves from the beginning
of life. Temperament has a number of different
conceptions; however, most of these conceptions
emphasize the general reactivity of the individual,
such as susceptibility and reactivity to emotional
stimulation, the strength and speed of response, and
the quality and intensity of mood. Other aspects of
temperament include activity level, tendency toward
smiling and laughing, fearfulness, distress to limita-
tions, soothability, and vocal activity.
A body of research has suggested that tempera-
ment may not be as heritable or stable as initially
173
 Levy and Johnson
thought. For example, genetic studies suggest that
temperamental variables are only 50%–60% herita-
ble (Heath, Cloninger, & Martin, 1994), with some
estimates as low as 20% heritability for certain tem-
peramental variables (Saudino, 2005). This suggests
that environmental influence may play a large role
in temperamental development. Furthermore, find-
ings from longitudinal sibling research have shown
that temperamental variables in early adolescence
only explain 20%–60% of the variance in the same
variables 2 to 3 years later, suggesting considerable
fluctuation in temperament over time (Ganiban
et al., 2008).
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Character is more complicated to understand
than temperament. Initial descriptions of character
tended to be synonymous with personality, with the
terms used somewhat interchangeably, particularly
in the psychoanalytic literature. Freud, for example
wrote about character types in a manner similar
to how we now discuss personality disorders.
Freud viewed personality formation as the process
whereby an individual develops stable and enduring
patterns of thinking, feeling, and behaving. These
patterns were in large part the result of adaptations
both to internal presses (e.g., drives in Freud’s termi-
nology; temperament by 21st century terminology)
as well as the external demands placed by others and
society at large. Character formation resulted from
the resolution of these conflicts or the compromise
between these competing interests.
What Is a Personality Disorder?
Most definitions of personality disorders stress the
chronic, long-standing nature of characteristics and
patterns of responding to distress that often are lim-
ited in variability and rigidly applied regardless of
appropriateness to context (Blatt et al., 1997). For
example, in the Diagnostic and Statistical Manual of
Mental Disorders, Fifth Edition (DSM–5; American
Psychiatric Association, 2013) PDs are described
as a pattern of inner experience and behavior that
deviates from cultural norms. These patterns of
perceiving, relating to, and thinking about the envi-
ronment and oneself are pervasive, inflexible, and
stable over time and result in distress or impairment
in functioning (American Psychiatric Association,
2000). People with PDs tend to find themselves in
174
vicious cycles in which they enact the very experi-
ences trying to be avoided, and these patterns come
to define that individual’s experience. The ways the
individual thinks, feels, acts, and relates to others
directly restricts the capacity to work, pursue goals,
and enjoy intimate relationships.
Most models of personality disorders conceptual-
ize these pathologies as primarily disorders of self
and relatedness. The criteria specified for each of
the personality disorders in Section II of the DSM–5
(American Psychiatric Association, 2013) centrally
describe problems with sense of identity or inter-
personal problems. For example, impoverished
interpersonal relationships are a cardinal feature of
both schizoid and avoidant personality disorders;
such individuals prefer to be alone and often seek
solitude. Central to both dependent and borderline
PD are difficulties with aloneness as well as preoc-
cupation with fears of abandonment and the disso-
lution of close relationships (e.g., Gunderson, 1996;
Zanarini et al., 2007). Histrionic and narcissistic
individuals often need to be the center of attention
and have difficulty not being admired by others.
An alternative model to diagnosing PDs included
in DSM–5 (American Psychiatric Association, 2013)
places self and relatedness as the core aspects of the
definition of a PD, with symptoms organized along
each of these two domains. The alternate criteria
for borderline personality disorder (BPD) evaluate
problems in self-functioning—particularly identity
diffusion and feelings of emptiness—and inter-
personal functioning. These problems of self and
relatedness are not separate but rather are highly
interdependent and have a cyclical relationship
with one another. For example, chronic feelings of
emptiness and uncertainty about oneself may lead
individuals with BPD to look to their relationships
to define who they are. Given the affective lability
associated with this disorder, how such individu-
als see themselves in relation to others may then be
highly dependent on the affective context—“I feel
good because the person I love is good to me,” and
conversely “I feel bad because this person is bad to
me.” Furthermore, with a sense of self so centrally
tethered to others, when there is a threat to a signifi-
cant relationship ending, one comes to feel that the
self is also threatened—“If I am not her boyfriend

then who am I?” This may lead to intense fears of
abandonment as well as desperate and impulsive
attempts to pull the person back.
A Brief History of Personality
Disorders
Because modern PDs such as borderline and narcis-
sistic PD only first appeared in the DSM system with
the advent of the Diagnostic and Statistical Manual
of Mental Disorders, Third Edition (DSM–III; Ameri-
can Psychiatric Association, 1980), they often are
thought of as being of recent vintage. The concept
of PD, however, is evident in the writings of classi-
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cal times (Morey, 1997). The best-known classical
account is of the legend of Narcissus, the subject of
the Greek myth from which the term narcissism is
derived, originally sung as Homeric hymns in the
seventh or eighth century b.c. (Hamilton, 1942)
and popularized in Ovid’s Metamorphoses (8/1958).
­Narcissus showed a lack of empathy and consid-
eration toward those who cared about him and
evidenced a grandiose sense of self in falling in love
with his own reflection in a pool of water.
Modern conceptions of PDs begin with Pinel’s
concept of manie sans delire (“madness with-
out ­delirium,” or confusion of the mind; Pinel,
1801/1962). Before Pinel’s publication, psychopa-
thology was usually tied to psychoses. By contrast,
Pinel described patients who lacked impulse con-
trol, often raged when frustrated, and who were
prone to outbursts of violence but who were not
subject to delusions. About that time, Benjamin
Rush made similar observations in the United States.
These writers were among the first to note that psy-
chological disorders could occur even when ability
to reason was intact and without a loss of contact
with reality.
By the late 19th century and early 20th century,
Kraepelin (1904), Bleuler (1924), and Kretschmer
(1926) described personality types, such as asthenic,
autistic, schizoid, and cyclothymic (or cycloid); how-
ever, these writers conceptualized them as premorbid
personalities to schizophrenic and manic-depressive
disorders—thus, they were more similar to tempera-
ments than PDs and were strongly tied to psychosis.
Freud (1906–1908/1959), for example, wrote
about character types, describing the “anal-character”
Personality Disorders
as frugal, orderly, parsimonious, and obstinate,
as well as obsessional, not unlike 21st-century
obsessive-compulsive personality disorder (OCPD).
Abraham (1921, 1924/1994), using Freud’s psycho-
sexual states as referent points, described the “oral
character,” the precursor to the modern conceptual-
ization of dependent personality disorder (DPD), as
desiring excessive levels of nurturance, acting child
like, and expecting to be rescued, protected, fed, and
supported by others.
Personality Disorders in the DSM
Personality disorders have been included in every
edition of the DSM, but their conceptualization has
changed dramatically over time. The first edition
of the Diagnostic and Statistical Manual of Mental
Disorders (American Psychiatric Association, 1952)
was a glossary describing 108 diagnostic categories
based on Adolf Meyer’s developmental psychobio-
logic views, many of which were described as reac-
tions to environmental conditions that could result
in emotional problems. This first DSM distinguished
among four personality pattern disturbances
­(inadequate, paranoid, cyclothmic, and schizoid),
three personality trait disturbances (emotionally
unstable, passive-aggressive, and compulsive), and
two sociopathic personality disturbances” (antiso-
cial and dissocial).
The Diagnostic and Statistical Manual of Mental
Disorders, Second Edition (DSM–II; American Psy-
chiatric Association, 1968) specified 182 different
disorders and distinguished between neurotic and
psychotic disorders. Except for the description of
neuroses, which were strongly influenced by psy-
chodynamic thought, DSM–II did not provide a
theoretical framework for understanding nonorganic
mental disorders but instead were based on the best
clinical judgment of a committee of experts and its
consultants (Widiger et al., 1991).
The DSM–III (American Psychiatric Association,
1980) provided a detailed lexicon or taxonomy that
established common definitions of mental disorders
that now enabled investigators and clinicians to
have greater consistency (reliability) in their diag-
noses. In attempts “to resolve various diagnostic
issues, the developers relied, as much as possible,
on research evidence relevant to various kinds of
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 Levy and Johnson
diagnostic validity” (American Psychiatric Associa-
tion, 1980, p. 3).
The DSM–III used primarily descriptive symp-
tom criteria to create a multiaxial diagnostic clas-
sification system, separating personality disorders
(Axis II) from “clinical syndromes” (Axis I). The
classificatory system was polythetic (Millon, 1991),
meaning that not all symptoms or diagnostic crite-
ria for a given disorder were necessary for making
a diagnosis. Thus, the classificatory system created
prototypic descriptions of particular disorders based
on a cluster of symptoms, and these became the
concrete signs of particular discrete categories.
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Although PDs appeared in every DSM since its
inception, it was only in the Diagnostic and Sta-
tistical Manual of Mental Disorders, Fourth Edition
(DSM–IV; American Psychiatric Association, 1994)
that a general definition of a personality disorder
was introduced. This definition, which carried over
into DSM–5 (American Psychiatric Association,
2013), stresses the core features of a PD as being
pathological, persistent, and pervasive. Additionally,
a PD should be noticeable by young adulthood and
include behavior that is markedly inconsistent with
what would be expected in one’s culture.
The current edition of the manual is the DSM–5
(American Psychiatric Association, 2013). DSM–5
sought to place many disorders along a spectrum
(e.g., autism spectrum disorder) or among disorders
that are similar, not only in phenomenology but
also in genetic and neural substrates. For instance,
posttraumatic stress disorder (PTSD) and obsessive-
compulsive disorder (OCD) were moved out of the
superordinate anxiety disorder category and placed
alongside more similar disorders like acute stress
disorder and trichotillomania, respectively. Fur-
thermore, DSM–5 eliminated the division between
disorders of childhood and disorders of adulthood,
attempting to incorporate a developmental perspec-
tive into the consideration of each individual cri-
terion set. In so doing, however, DSM–5 may have
blurred the conceptual boundaries between distinct
longitudinally stable disorders and disorders that
may be earlier or later manifestations of other simi-
lar disorders.
Currently, a number of systems are used to clas-
sify PDs. These include the International Statistical
176
Classification of Diseases and Related Health Problems,
10th Revision (ICD–10; World Health Organization
[WHO], 1992), the DSM–5 (American Psychiatric
Association, 2013), the Psychodynamic Diagnostic
Manual (PDM; Psychodynamic Task Force, 2006),
and classification systems developed by Millon
(1977) and Westen and Shedler (1999b; see Table
6.1). Worldwide, the ICD–10 and the DSM–5 are the
two main systems used and will serve as the focus
for discussing classification, although we will focus
mainly on the DSM system.
The ICD–10 contains nine PDs: paranoid, schiz-
oid, dissocial, emotionally unstable (borderline type
and impulsive type), histrionic, anankastic, anxious
(avoidant), and dependent. There is also an “other
specific personality disorders” category that includes
eccentric, immature, narcissistic, passive-aggressive,
and psychoneurotic PDs as well as categories for
“personality disorder, not otherwise specified” and
“mixed and other personality disorders.”
Section III of DSM–5 (American Psychiatric
Association, 2013) utilizes two main criteria to diag-
nose PDs: (a) severity is determined by clinically
significant impairment in identity and relationship
functioning, and (b) type is determined by a profile
of pathological personality traits. To assess severity of
functioning difficulties, DSM–5 Section III provides
the Level of Personality Functioning Scale (LPFS),
which assessors may use as a rubric to rate impair-
ment (on a 0–4 scale) across four domains: identity,
self-direction, empathy, and intimacy. These four
areas of personality functioning capture much of the
distress and impairment experienced by individuals
with PDs. For determining pathological personal-
ity traits (the second main criterion in this alternate
model), DSM–5 lays out five personality disorder
trait domains composed of 25 individual facets. The
domains, negative affectivity (vs. emotional stability),
detachment (vs. extraversion), antagonism (vs. agree-
ableness), disinhibition (vs. conscientiousness), and
psychoticism (vs. lucidity), resemble the five domains
of the Five-Factor Model (FFM; Costa & McCrae,
1992) but are framed in a way to capture pathologi-
cal personality features more precisely. In making
specific PD diagnoses, assessors must compare infor-
mation obtained on both functioning and personality
traits against criteria for the PD of interest.
 Personality Disorders

TABLE 6.1

Comparison of the DSM–5 with the ICD–10, PDM, Millon, and Westen and Shedler Personality Disorder
Classification Systems

DSM–5 ICD–10 PDM Millon Westen and Shedler

Cluster Aa
Paranoid Paranoid Paranoid Paranoid Paranoid
Schizoid Schizoid Schizoid Schizoid Schizoid
Schizotypal Schizotypal
Cluster B
Histrionic Histrionic Hysterical Histrionic Histrionic
Antisocial Dissocial Psychopathic Antisocial Antisocial-psychopathic
Borderline Emotionally Borderline Dysphoric: emotionally dysregulated
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unstable—borderline
type
Emotionally
unstable—impulsive
type
Narcissistic Narcissistic Narcissistic Narcissistic
Cluster C
Obsessive-compulsive Anankastic Obsessive-compulsive Compulsive Obsessional
Avoidant Anxious Phobic Avoidant Dysphoric: avoidant
Dependent Dependent Dependent Dysphoric: dependent-masochistic
Sadistic and Sadistic
Sadomasochistic
Masochistic Masochistic Dysphoric: dependent-masochistic
Depressive Melancholic
Somatizing
Anxious
Dissociative
Negativistic Dysphoric: hostile-externalizing
Hypomanic
Dysphoric: high-functioning neurotic
Other specified Other specified Mixed/other
personality disorder personality disorders;
mixed personality
disorder
Unspecified personality Personality disorder,
disorder unspecified

Note. ICD–10 = International Statistical Classification of Diseases and Related Health Problems, 10th Revision; PDM =
Psychodynamic Diagnostic Manual; DSM–5 = Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Millon’s
classification system drawn from Millon (1977). Westen and Shedler’s classification system drawn from Westen and
Shedler (1999).
a Cluster terminology and categorization utilized only by DSM–5.

As mentioned above, the DSM–IV and DSM–5
highlight the core components of a PD as being
pathological, persistent, and pervasive. Building on
this general definition, DSM–5 describes 10 specific
personality disorders: paranoid, schizoid, schizo-
typal, antisocial, borderline, histrionic, narcissistic,
avoidant, dependent, and obsessive-compulsive,
which are grouped into three clusters, A, B, and C,
based on description similarities. Cluster A is for
odd and eccentric disorders and includes paranoid,
schizoid, and schizotypal PDs. Cluster B is for dra-
matic, emotional, and erratic disorders and includes

177
 Levy and Johnson

antisocial, borderline, histrionic, and narcissistic
PDs. Cluster C is for anxious or fearful disorders
and includes avoidant, dependent, and OCPDs. The
DSM–5 also includes categories for “other specified
personality disorder” and “unspecified personal-
ity disorder” as well as “personality change due to
another medical condition.”
Cluster A: Odd-Eccentric
Personality Disorders
Paranoid personality disorder. According to
the Diagnostic and Statistical Manual of Mental
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■■ Is unwilling to forgive others even for minor
wrongs
■■ Persistently suspects that friends or colleagues
will be disloyal or untrustworthy
■■ Persistently suspects that his or her romantic
partner is being unfaithful
■■ Hesitates to be candid with others for fear that
they will use information against him or her in a
malicious or sabotaging way
Schizoid personality disorder. The term schizoid
was coined by Bleuler (1929) to describe individu-
als who tended to turn inwardly and away from the

Disorders, Fourth Edition, Text Revision (DSM–IV–

external world, be indifferent to relationships or
TR; American Psychiatric Association, 2000), para-
pleasure, show muted emotional expressiveness,
noid personality disorder (PPD) is characterized
be comfortably dull, and have vague undeveloped
by a consistent pattern of distrust of the motives of
interests. Originally, two distinct subtypes of the
other people. Furthermore, people with this disor-
schizoid personality were identified: the anaes-
der assume that people intentionally will exploit,
thetic or insensitive type, characterized as indif-
harm, or deceive them, and they often feel deeply
ferent, uninterested, unfeeling, unemotional, and
injured by another person. They frequently are
dull, and the hyperaesthetic or overly sensitive
reluctant to become close to others out of fear that
type (Kretschmer, 1925). The hyperaesthetic type
any personal information they reveal about them-
is the forerunner of the DSM avoidant personality
selves will later be used to hurt them. An individual
disorder.
with this disorder is also severely sensitive to criti-
DSM–5 (American Psychiatric Association,
cism and therefore is likely to often feel attacked,
2013) notes that those with schizoid personality
threatened, or criticized by others. He or she might
disorder (SPD) are characteristically detached from
read hidden meanings or malevolent intentions
and uninterested in social relationships. People
into innocent remarks, mistakes, or compliments.
with SPD may choose careers or hobbies that allow
It is also difficult for a person with PPD to forgive
them to avoid contact with other people, and they
others for perceived insults or injuries. Prolonged
typically are uninterested in developing intimate
hostility, aggression, reactions of anger to perceived
or sexual relationships. In addition, those with
insults, and jealousy without adequate justification
SPD have a flatness of affect that leads others to
are also common. Although PPD is often thought
experience them as cold and aloof. Not only do
of as a schizophrenia spectrum disorder (Kraepelin,
they derive little pleasure from sensory or inter-
1921; Siever & Davis, 1991), it may have a stronger
personal experiences, they usually are unmoved by
familial relationship with delusional disorder than
the disapproval of others. They might claim that
with schizophrenia (Kendler, Masterson, & Davis,
they do not experience strong emotions, whether
1985).
positive or negative. Furthermore, people with SPD
To receive a diagnosis, individuals must meet
may fail to respond to social cues, such as a smile,
four or more of the following criteria:
leading others to perceive them as self-absorbed,
■■ Is suspicious, without evidence, of being used, socially inept, or conceited. Within the FFM, SPD
manipulated, or harmed by others is thought to reflect extremely low scores on the
■■ Views, without evidence, what others say or do extraversion facets of sociability and warmth (Trull,
as intentionally threatening or harmful 1992).
■■ Readily views and reacts quickly to benign events To receive a diagnosis, individuals must meet
or remarks as attacking his or her character four or more of the following criteria:

178

■■ Has little or no interest in close relationships
■■ Has little or no interest in sexual activity with
others
■■ Has little or no interest in activities or hobbies
■■ Has very few, if any, close relationships
■■ Prefers activities that do not involve interaction
with others
■■ Shows little, if any, reactivity to others’ praise or
criticism
■■ Shows little, if any, affect or emotion
Schizotypal personality disorder. The diagnosis
of schizotypal personality disorder (STPD) has its
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roots in research with two distinct sets of popula-
tions (clinical and familial) and therefore may rep-
resent an especially heterogeneous category. From
clinical populations, researchers variously described
patients whose symptomatology resembled that of
patients with schizophrenia, yet lacked the sever-
ity and frank psychosis of schizophrenia. On the
other hand, research from nonclinical populations
in Danish adoption studies has found subthreshold
schizophrenic symptoms in nonpsychotic relatives
of schizophrenia patients (e.g., Kety et al., 1968).
Familial samples may differ from clinically selected
samples by presenting with more negative symptoms
(e.g., social isolation and impaired functioning),
whereas clinical samples are better characterized by
positive, psychotic-like symptoms (e.g., eccentric-
ity, ideas of reference, and socially inappropriate
behavior).
According to DSM–5, STPD is characterized by a
pattern of marked interpersonal deficits, discomfort
with close relationships, behavioral eccentricities,
and distortions in perception and thinking. The
DSM notes that individuals with STPD will often
seek treatment for anxiety, depression, or other
affective dysphoria. Although people with this dis-
order may experience transient psychotic episodes,
they must be distinguished from those with non-PD
psychotic disorders that feature more persistent
delusions and hallucinations. Ideas of reference
are a common feature of STPD, as are odd beliefs
such as magical thinking, extreme superstition, or
a preoccupation with paranormal phenomena. In
addition, people with STPD might have percep-
tual distortions, such as bodily illusions or sensory
Personality Disorders
alterations, and many have odd thought and speech
patterns. For example, their speech might be exces-
sively vague, abstract, or loose, yet still maintain
basic coherence. They often appear uncomfort-
able and act peculiar in social situations, and their
affective expression is frequently constricted or
inappropriate.
To receive a diagnosis, individuals must meet
five or more of the following criteria:
■■ Exhibits ideas that seemingly insignificant events
or occurrences have special meaning or value
■■ Holds beliefs in the occult, magic, or the super-
natural that are not shared by other members of
his or her cultural background
■■ Appears to think or speak in nondescript,
­superficial, abstract, or stereotyped ways
■■ Experiences unusual perceptions or bodily
sensations
■■ Shows affect that is inconsistent or unusual given
the context
■■ Exhibits behavior that is inconsistent or unusual
given the context
■■ Exhibits paranoia or distrust of others
■■ Avoids social situations for fear of being hurt,
harmed, or manipulated by others
■■ Has very few, if any, close relationships
Cluster B: Dramatic-Erratic
Personality Disorders
Borderline personality disorder. Affective labil-
ity, as seen in BPD, has been identified in individu-
als since the works of the ancient Greek physician
Aretaeus. It was not until the early 20th century,
however, that this syndrome was given the name
borderline (A. Stern, 1938) to describe patients who
were considered borderline psychotic, that is, at the
border between psychosis and neurosis, or from a
psychoanalytic perspective on the border of analyz-
ability and nonanalyzability.
Other names frequently used to describe these
patients that indicate the relationship between
schizophrenia and borderline pathology included:
ambulatory and latent schizophrenia, schizo-
phrenic character, abortive schizophrenia, pseudo-
psychopathic schizophrenia, psychotic character,
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 Levy and Johnson
subclinical schizophrenia, occult schizophrenic,
pseudo-neurotic schizophrenia, and borderland
(Frosch, 1964). Additionally, for many, the hall-
mark of these patients became their difficultness to
treat (Waldinger & Gunderson, 1984).
To receive a DSM diagnosis of BPD, individuals
must meet five or more of the following criteria:
■■ Vacillates between valuing and devaluing close
others and consistently experiences relationships
characterized by instability
■■ Exhibits instability or frequent shifts in self-
image, sense of identity, and goals
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■■ Experiences quick and sudden shifts in mood,
especially that appear to exceed what is expected
given the context
■■ Experiences or displays intense and inappropri-
ate anger
■■ Experiences persistent feelings of emptiness
■■ Experiences paranoia or dissociation when
acutely stressed
■■ Is impulsive in more than one domain
■■ Exhibits suicidal or self-harming behavior,
thoughts, or threats on more than one occasion
■■ Expresses significant fears of abandonment and
exhibits behaviors intended to reduce the possi-
bility of being abandoned
Antisocial personality disorder. Traits and behav-
iors corresponding to antisocial personality disor-
der (ASPD) have been described using such terms
as sociopath, psychopath, deviant, amoral, moral
insanity, and dyssocial. The term antisocial personal-
ity disorder was introduced with the publication of
DSM–III (American Psychiatric Association, 1980)
and represented an attempt to operationalize the
much-maligned term of psychopathy. The ­criteria
were derived from empirical research based on
Robins’s (1966) seminal work.
As defined by DSM–5, ASPD is a pervasive pat-
tern of irresponsible behavior and disregard for the
rights of others that begins in childhood or early
adolescence. People with this disorder repeatedly
engage in unlawful or reckless behavior. Frequently
victimizing others and blaming their victims for
their own fate, they typically lack remorse for
­having hurt or mistreated another person. “They
had it coming” is a common rationalization for
180
victimized others. Alternatively, a person with this
disorder might minimize the negative consequences
of their actions, or blame others for being weak or
foolish. Those with ASPD are prone to impulsive-
ness, irritability, and aggressiveness that often leads
to physical fights or assault, and they have a reckless
disregard for the safety of themselves or others. In
addition, they might repeatedly fail to honor work
or financial obligations, or they may display other
evidence of consistent and extreme irresponsibility.
Manipulativeness, deceitfulness, and dishonesty are
central features of this disorder, often making col-
lateral sources of information necessary for accurate
diagnosis.
To receive a diagnosis, individuals must present
with evidence of conduct disorder before age
15 years, as well as three or more of the following
criteria as adults:
■■ Is impulsive in more than one domain
■■ Shows lack of respect for laws or social customs
by repeatedly engaging in illegal activity
■■ Exhibits irresponsibility by repeated absentee-
ism or by failing to honor debts, loans, or other
obligations
■■ Is aggressive or irritable to the point of repeat-
edly engaging in physical fights
■■ Manipulates others, lies, or is frequently deceitful
■■ Shows little, if any, consideration of the safety of
him- or herself or others
■■ Shows little, if any, remorse or empathy for oth-
ers he or she may have endangered, injured,
slighted, or taken advantage of
Histrionic personality disorder. Histrionic
personality disorder (HPD) has its early roots in
Hippocrates’ writings more than 2,000 years ago
on “hysteria” in women, thought to be caused by
a “wandering womb” (Veith, 1977). According to
ancient Greek medicine, the uterus would detach
from its proper place and wander throughout the
body, affecting the brain and causing excessive
emotionality.
Hysteria was first officially linked to the term his-
trionic personality in DSM–II (American Psychiatric
Association, 1968), which listed hysterical person-
ality disorder and mentioned HPD parentheti-
cally thereafter. By DSM–III (American Psychiatric

Association, 1980), however, hysterical personality
disorder had been replaced completely by HPD.
The core components of HPD include excessive
emotionality, attention-seeking behavior, egocen-
tricity, flirtatiousness, seductiveness, and denial of
anger. Other characteristics of HPD are extreme
gregariousness, manipulativeness, low frustra-
tion tolerance, suggestibility, and somatization. In
addition, according to DSM–IV–TR (American Psy-
chiatric Association, 2000), histrionic individuals
consistently use their physical appearance to draw
attention to themselves, spending excessive time,
attention, and money on clothes and grooming.
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To receive a diagnosis, individuals must meet
five or more of the following criteria:
■■ Experiences distress if he or she is not the center
of attention
■■ Engages with others in a sexually inappropriate
or exaggerated way
■■ Uses his or her physical appearance in a showy
or attention-seeking way
■■ Speaks in a vague, dramatic, or superficial manner
■■ Exhibits exaggerated emotions or carries him- or
herself in a theatrical or dramatic way
■■ Shows quickly changing or shallow emotions
■■ Is easily swayed by others’ opinions or
suggestions
■■ Feels that he or she is closer to others than they
feel to him or her
Narcissistic personality disorder. According to
DSM–5 (American Psychiatric Association, 2013),
the central features of narcissistic personality disor-
der (NPD) are pervasive grandiosity, a constant need
for admiration, and a lack of empathy for others. An
individual with NPD has a sense of self-importance
and an attitude of arrogance that might manifest in
boastfulness, pretentiousness, or disdain. An overes-
timation of one’s own abilities and a devaluation of
others are characteristic of this disorder. Also com-
mon is a preoccupation with fantasies about one’s
own brilliance, beauty, or expected success.
People suffering from NPD usually require con-
stant attention and admiration and may become
furious with others who do not shower them with
compliments or accolades. People with this dis-
order commonly are concerned with their own
Personality Disorders
performance and how others evaluate them. They
typically have fragile self-esteem, so their self-­
importance might alternate with feelings of unwor-
thiness. They frequently either experience feelings
of envy of other people or imagine that others are
envious of them.
The sense of entitlement that is central to NPD
often precludes the recognition of others’ abilities,
needs, feelings, or concerns. Individuals with this
disorder might discuss their own problems or con-
cerns in lengthy detail, yet react with insensitivity or
impatience to the problems of others. Inappropriate
and hurtful remarks frequently are uttered by people
with NPD, although they typically are oblivious to
how these remarks affect others. They might also
unconsciously exploit others and believe that the
needs and feelings of other people are signs of weak-
ness. To others these individuals appear cold, disin-
terested, disdainful, snobbish, or patronizing.
To receive a diagnosis, individuals must meet
five or more of the following criteria:
■■ Considers his or her own importance to be much
greater than others
■■ Considers only high-status or unique people to
be able to understand him or her or to be worth
affiliating with
■■ Frequently fantasizes about being highly suc-
cessful, wealthy, powerful, or having the perfect
romantic relationship
■■ Exhibits frequent envy of others or frequently
considers others to be envious of him or her
■■ Seeks or demands excessive respect or deference
■■ Expects specialized treatment or unwavering
compliance from others
■■ Takes advantage of others for personal gain
■■ Is unable or unwilling to show empathy or con-
cern for others
■■ Exhibits arrogance in his or her behaviors or
attitudes
Cluster C: Anxious-Fearful
Personality Disorders
Avoidant personality disorder. Avoidant person-
ality disorder (AVPD) was a new category added
to the DSM–III (American Psychiatric Association,
1980) based on an evolutionary social-learning
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 Levy and Johnson
theory of PDs (Millon, 1981). According to DSM–5,
people with AVPD are characterized by pervasive
social inhibition and discomfort in social situations,
feelings of inadequacy and low self-esteem, and
hypersensitivity to criticism or rejection. Although
they long for close relationships, they avoid activi-
ties that involve interpersonal contact and have
difficulty joining group activities. People with this
disorder assume that other people will be critical
and disapproving. They act with restraint in social
situations and have difficulty sharing intimate
feelings for fear of criticism, disapproval, shame,
or ridicule. They have a strong need for certainty
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and security that severely restricts their ability
to become close to others, and they typically are
not able to establish new friendships or intimate
relationships without the assurance of uncritical
acceptance.
People with AVPD frequently feel socially incom-
petent, personally unappealing, or inferior to oth-
ers. Therefore, they are reluctant to engage in new
activities and they tend to be shy, inhibited, and
quiet to avoid attracting attention to themselves.
In addition, they are hypervigilant about detecting
subtle cues that suggest the slightest criticism or
rejection. Because they expect others to disapprove
of them, they quickly detect any indication of such
disapproval and typically feel extremely hurt.
To receive a diagnosis, individuals must meet
four or more of the following criteria:
■■ Avoids new activities or ventures for fear of
embarrassment
■■ Fears negative evaluation in occupational set-
tings, which leads to frequent avoidance of occu-
pational activities that involve others
■■ Fears negative evaluation in social arenas, which
leads to frequent avoidance of social interactions
with others
■■ Considers him- or herself to be incapable, unat-
tractive, or of less value than others
■■ Hesitates to form relationships with others unless
he or she is certain of being well-liked
■■ Is shy, restrained, or quiet in interactions with
strangers due to feelings of inadequacy
■■ Is often unwilling to be open or candid in rela-
tionships for fear of being negatively evaluated
182
Dependent personality disorder. The history
of DPD begins with descriptions of oral depen-
dency by Abraham and Freud. The DSM (American
Psychiatric Association, 1952) mentioned what
was called “passive-dependent personality,” which
was virtually synonymous with DSM–5 (American
Psychiatric Association, 2013) DPD.
According to the DSM–5, the central character-
istic of DPD is a pervasive need to be taken care of
that begins by early adulthood. People with this dis-
order have an exaggerated fear that they are incapa-
ble of doing things or taking care of themselves on
their own, and they therefore rely on other people
(usually one person) to help them. They rely heav-
ily on advice and reassurance from others in making
decisions. Because of their lack of self-confidence,
it is difficult for people with DPD to begin tasks on
their own without being assured that someone is
supervising them. They may appear to others to be
incompetent because they believe that they are inept
and they present themselves as such.
DSM–5 notes that because of their dependency
on others, people with DPD often fail to learn basic
independent living skills, and frequently find them-
selves in abusive or otherwise unbalanced relation-
ships. It is not unusual for people with DPD to feel
unrealistically fearful of being abandoned. They
are typically passive and unwilling to disagree or
become appropriately angry with the person on
whom they depend. They will go to great lengths to
secure or maintain the support of another person.
People with DPD usually feel highly uncomfort-
able being alone because of an exaggerated fear of
helplessness or the inability to care for themselves.
The end of an intimate relationship often will be fol-
lowed by urgent efforts to replace the person with
another source of closeness and support.
To receive a diagnosis, individuals must meet
four or more of the following criteria:
■■ Requires considerable input or advice from oth-
ers before being able to make everyday decisions
■■ Is reliant on others for managing finances, living
arrangements, and other major areas of responsibility
■■ Is often unable to begin projects or activities due
to a fear of the consequences of his or her own
incapacity or ignorance

■■ Willingly engages in unpleasant tasks or duties
to gain support and encouragement from
others
■■ Avoids arguments or disagreements with others
for fear of losing their assistance or care
■■ If a close relationship ends, he or she tries
desperately to form a new source of care and
assistance
■■ Is distressed when alone due to feelings of help-
lessness or an inability to take care of him- or
herself
■■ Exhibits excessive fear of being able to man-
age his or her own affairs or care for him- or
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herself.
Obsessive-compulsive personality disorder. The
modern concept of OCPD has its roots in Freud’s
description of the anal personality as one who
is excessively orderly, obstinate, and parsimoni-
ous (Freud, 1906–1908/1959). Synonymous with
anankastic personality disorder in the ICD–10, the
DSM–5 (American Psychiatric Association, 2013)
describes OCPD as a pervasive pattern of perfec-
tionism, orderliness, and inflexibility that begins by
early adulthood. People with OCPD have an exces-
sive need for control that interferes with their ability
to maintain interpersonal relationships or employ-
ment. They are typically preoccupied with rules,
lists, schedules, or other minor details (Abraham,
1921). Their rigidity, inflexibility, and stubbornness
often prevent them from accepting any new ideas or
alternative ways of doing things, creating difficulty
in both work and personal relationships.
In addition, the DSM notes that individuals with
OCPD often sacrifice personal relationships in favor
of work and become obsessively devoted to pro-
ductivity. They hold both themselves and others to
unrealistic standards of morality, ethics, or values.
They are also reluctant to delegate tasks to others
because they insist that everything be done their
own way. Their excessive attention to trivial details,
however, often interferes with their ability to com-
plete a task (Horney, 1950).
Individuals with OCPD usually have difficulty
expressing emotion (Horney, 1950) and are subject
to dichotomous thinking, magnification, catastro-
phizing, and displays of anger, frustration, and
Personality Disorders
irritability. The DSM further notes that individu-
als with OCPD might be reluctant to throw away
worthless and unsentimental objects for fear that
they might be needed at a later date. Furthermore,
people with this disorder might hoard money and
tightly control spending, believing that money
should be saved for a future catastrophe.
To receive a diagnosis, individuals must meet
four or more of the following criteria:
■■ Values details, organization, and rules over the
main point of activities
■■ Is so devoted to ensuring tasks are done properly
or correctly that they are often not completed
■■ Avoids working with others or delegating tasks
without being sure that his or her own way of
doing things will be followed
■■ Strongly prefers occupational activities over lei-
sure activities or friendships
■■ Maintains more rigid views of ethics and moral-
ity than other members of his or her cultural
background
■■ Exhibits excessive stubbornness and inflexibility
■■ Avoids spending money on activities or goods
that are not considered absolutely necessary
■■ Hoards useless or broken items even if they have
no sentimental value
The Psychodynamic Diagnostic Manual
In response to growing dissatisfaction with the DSM
approach within the psychodynamic community,
a task force was created by the major psychoana-
lytic organizations to develop a diagnostic manual,
the PDM (Psychodynamic Task Force, 2006), that
articulated disorders that were more consistent with
psychodynamic theory and addressed concerns of
psychodynamic clinicians (e.g., integrating descrip-
tions of inferred internal psychological processes,
such as defense and external manifestations of dis-
orders; Psychodynamic Task Force, 2006). Included
in the PDM is an axis describing personality pat-
terns and disorders (Axis P). This conceptualization
is based on an integration of the theoretical and
clinical work of Kernberg and Westen and Shedler
as well as the empirical research on PDs broadly.
Similar to the DSM, the PDM differentiates PD as a
different class from personality proper, symptom
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 Levy and Johnson
disorders, psychosis, and the effects of brain trauma,
chronic stress, and substances. The PDM points out
that one can have an obsessive personality without
necessarily having an obsessive personality disorder.
Also based on Kernberg (1984), the PDM makes
distinctions in the level of personality organiza-
tion in terms of the severity of the PD with distinc-
tions between healthy personalities (the absence
of personality disorder), neurotic-level PDs, and
­borderline-level PD, and unlike manuals from the
DSM system, the PDM discusses the implications for
level of the severity dimension for psychotherapy.
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Dimensional Models
Both the DSM–5 (American Psychiatric Association,
2013) Section II criteria and the ICD–10 (WHO,
1992) classification systems use categorical diagnostic
taxonomies that present PDs as representing distinct
clinical syndromes with specific cutoff points for
reaching threshold for a specific PD. Although the use
of categories implies discontinuity—that is, one either
has or does not have the disorder—many researchers
have argued that PDs can be better conceptualized
along a continuum or dimension from normality
to pathology. Two current systems exist by which
dimensional assessment of PDs are possible: the FFM
(Costa & McCrae, 1992) and ICD–11 (proposed to be
released in 2017) dimensional frameworks.
The FFM is one of the most widely studied
alternatives to the DSM categorical approach with
regard to the assessment of personality disorders.
In the FFM, PDs typically are assumed to repre-
sent extreme or maladaptive variants of normal
personality traits. The five higher order traits and
various lower order facets have been related to DSM
PD categories in a number of studies. Given this
research on the Five-Factor Model, some authors
have suggested that a personality trait approach is
sufficient to encapsulate personality disorder con-
structs. Indeed, a considerable corpus of studies
has posited and supported the use of the FFM as an
alternative to categorical diagnoses for PDs (Trull &
Durrett, 2005). For example, the DSM–5 Section III
alternative model to the assessment and diagnosis
of PDs utilizes a trait-based approach, reflecting a
shift toward dimensional PD assessment adopted by
many in the field.
184
The ICD–11, in contrast to the dimensional
models discussed previously that are based on
dimensional ratings of traits and personality con-
structs, has adopted a dimensional model based on
the notion of severity of dysfunction ­(Gunderson,
Links, & Reich, 1991; Tyrer, 1999; Tyrer &
­Johnson, 1996). This model is consistent with the
approach taken by the DSM–5 workgroup’s con-
ceptualization of severity of functional impairment
particularly around self and other functioning
(American Psychiatric Association, 2013; Tyrer,
2013). This approach is consistent with other clini-
cal writers such as Kernberg (Kernberg & Caligor,
2005) who have stressed severity as an important
diagnostic indicator.
The ICD–11 dimensional scale ranges from 0
to 4, with 0 indicating no personality disorder; 1
some personality difficulty as indicated by being
subthreshold for one or more PDs; 2 indicating the
presence of a simple personality disorders, that is,
meeting criteria for one or more disorders within
the same cluster; 3 as a complex or diffuse PD, as
indicated by meeting criteria for one or more PDs
across more than one cluster; and 4, a severe PD as
indicated by meeting criteria for severe disruption to
both the individual and others.
Prototype Models
In contrast to classical categories used in the DSM
systems, some have proposed the use of prototypes.
Learning psychology has shown that humans tend
to use prototype models when storing or retrieving
information about categories (Rosch, 1983). In this
vein, Westen and Shedler (2007; Shedler & Westen,
2007) have proposed a prototype-based model of
PD assessment, the Shedler-Westen Assessment Pro-
cedure (SWAP), in which patients are rated against
detailed descriptions of personality pathology on a
scale assessing similarity and dissimilarity. These
authors provide initial data from 496 psychiatrists
and psychologists who report on their caseload
using individual descriptive items, such as “tends to
feel unhappy, depressed, or despondent” (Westen &
Shedler, 1999b).
Factor analysis of these data resulted in only
some factors resembling DSM diagnostic categories.
Other factors, such as what Westen and Shedler

labeled “dysphoric personality disorder,” accounted
for large portions of the variance in items, but they
were distinct from DSM nosology. Several advan-
tages of the SWAP prototype measure are that it is
empirically derived, reduces diagnostic overlap and
artifactual comorbidity resulting from orthogonal
rotation of factors in the factor analysis, and assesses
severity of personality pathology through dimen-
sional ratings.
INCIDENCE AND COMORBIDITY
Epidemiology
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Epidemiological data in the United States indicate
that PDs have a high overall lifetime prevalence
ranging between 5.9% and 21.5% in the community
(Crawford et al., 2005; Lenzenweger et al., 2007;
Trull et al., 2010) with most estimates between 9%
and 11%. International epidemiological studies find
similar rates ranging from 4.4% to 13.4%, depending
on whether PD not otherwise specified (PDNOS)
was included or not (Coid et al., 2006).
Using DSM–IV (American Psychiatric Associa-
tion, 1994) PD criteria, 9.1% of an epidemiological
sample from the National Comorbidity Survey Rep-
lication study met criteria for a personality disor-
der (Lenzenweger et al., 2007). In 2001 and 2002,
prevalence data of 7 of the 10 PDs assessed through
the National Epidemiological Survey on Alcohol
and Related Conditions (NESARC) suggested that
14.79% of adult Americans—or 30.8 million—had
at least one PD (B. F. Grant et al., 2004).
Among countries other than the United States,
PD prevalence rates tend to vary. In Norway, PDs
are prevalent at 13.4% (Torgersen, Kringlen, &
­Cramer, 2001), and in Germany, around 10%
(Maier et al., 1992). In Great Britain, the estimate is
lower, at 4.4% (Coid et al., 2006). If assessed based
on ICD–10 criteria, the general prevalence rate of
PDs is estimated to be 6.5% in Australia (Jackson &
Burgess, 2000; Maier et al., 1992). There are almost
no community data on PDs from countries other
than the United States, the United Kingdom, Ger-
many, Norway, and Australia.
In primary care settings, about a third of people
presenting to general practitioners had a personality
disorder (Casey & Tyrer, 1990). The vast majority
Personality Disorders
of patients were not presenting for PDs but pre-
sented as problematic medical patients (Emerson
et al., 1994). Patients with Cluster C PDs are the
most common PDs to be encountered in primary
care settings (Moran et al., 2000).
Rates of PDs are generally much higher in clini-
cal populations. Studies using structured diagnostic
assessments have found that 20%–40% of psychiat-
ric outpatients and about 50% of psychiatric inpa-
tients meet criteria for a PD (de Girolamo & Reich,
1993; Dowson & Grounds, 1995; Moran, 1999).
Studies on the prevalence of specific PDs in the
general community have found rates for paranoid PD
ranging from 0.4% to 3.3%; schizoid, 0.5% to 0.9%;
schizotypal, 0.6% to 5.6%; histrionic, 1.3% to 3.0%;
narcissistic, 0% to 6.2%; antisocial 0.2% to 3.7%;
avoidant, 0% to 1.3%; dependent, 1.6% to 6.7%; and
obsessive-compulsive, 1.7% to 6.4% (Baron et al.,
1985; ­Coryell & Zimmerman, 1989; Drake & Vail-
lant, 1985). Wave 2 data from the NESARC study
has found rates of 5.9% for BPD (B. F. Grant et al.,
2008), 6.2% for NPD (Stinson et al., 2008), and 3.9%
for schizotypal PD (Pulay et al., 2009). The most
consistently studied PD in community studies has
been antisocial PD, which has a lifetime prevalence
of between 2% and 3% and is especially common in
those living in urban areas (Moran, 1999).
Research generally has shown that individu-
als diagnosed with PDs are likely to be single (e.g.,
Stinson et al., 2008). These studies also have found
that PDs are generally more common in younger
age-groups (particularly the 25–44 age-group).
Many PDs are distributed equally between men
and women in representative population samples,
although most studies have found increased rates in
men of NPD, STPD, and ASPD, and increased rates
in women of AVPD and DPD.
Comorbidity
At a community level, individuals with PD are more
likely to suffer from alcohol and drug problems.
In addition, they are more likely to experience
adverse life events, such as relationship difficulties,
housing problems, and long-term unemployment
(Moran, 1999).
Reasons for comorbidity include discrete dis-
orders sharing risk factors, overlap between risk
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 Levy and Johnson
factors, and that one disorder creates increased
risk for the other disorder. For example, substance
abuse and PDs may share temperamental aspects
of impulsivity and negative affect as a shared risk
factor (Szerman & Peris, 2015) and PTSD and PDs
may share traumatic experiences as a shared risk
factor. Additionally, substance abuse may impair
identity formation and lead to PDs such as ASPD
and BPD. Conversely, ASPD and BPD may impair a
person’s capacity to regulate him- or herself and lead
to the use of substances. Thus, rates and patterns
of comorbidity could represent the natural order or
nature of psychopathology—that is, these could rep-
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resent true or valid levels of comorbidity. Different
disorders may share a common etiology and be dif-
ferent phenotypic expressions of a common causal
factor or factors.
Some estimates suggest that 75% of patients
with a PD meet criteria for another mental dis-
order ­(Clarkin & Kendall, 1992; Dolan-Sewell,
Krueger, & Shea, 2001; Fyer et al., 1988). For
instance, most patients who meet criteria for a PD
also meet criteria for at least one other PD. In fact,
the average patient meeting criteria for a PD is
diagnosed with 2.8 to 4.6 PDs (Widiger & Frances,
1994) and it is common for patients to meet criteria
for as many as five or more DSM PDs. This level of
comorbidity has been considered a serious problem
within the following domains: (a) the validity of the
­concept of PDs, (b) the DSM system as a whole, and
(c) the interviews developed to assess PD and dis-
orders in general (see the Identification and Assess-
ment section).
Compounding the problem is that PDs are highly
comorbid with the more episodic syndromal dis-
orders, originally referred to as Axis I disorders in
DSM–III (American Psychiatric Association, 1980)
and DSM–IV (American Psychiatric Association,
1994). For instance, current mood disorders are
comorbid with PDs between 15% and 50% (B. F.
Grant et al., 2008; J. E. Grant, Mooney, & Kush-
ner, 2012; Pulay et al., 2009) and anxiety disorders
around 30%–60% (J. E. Grant et al., 2012; Lenzen-
weger et al., 2007; Newton-Howes et al., 2010), with
these estimates being even higher for lifetime comor-
bidity of these disorders. Furthermore, substance
abuse and impulse control disorders are commonly
186
comorbid with PDs (Zanarini, Frankenburg, Dubo,
et al., 1998). PDs are frequently comorbid with
paraphilias (Raymond et al., 1999), dissociative dis-
orders (Ono & Okonogi, 1988), and factious disor-
ders (Zubenko et al., 1987). In fact, although sexual
function disorders are relatively rare, around half
of individuals with a PD also display some form of
lifetime psychosexual dysfunction (Zimmerman &
Coreyell, 1989). Zanarini refers to the pattern of
comorbidity observed in PDs as “complex comorbid-
ity” because of the high number of comorbid diag-
noses and the co-occurrence of both internalizing
(e.g., depression) and externalizing disorders (e.g.,
substance use disorders).
Among Cluster A PDs, about two thirds of
patients with PPD meet criteria for another PD, most
frequently schizotypal, narcissistic, borderline, and
avoidant PDs (Bernstein, Useda, & Siever, 1993).
SPD is consistently comorbid with schizotypal and
avoidant PDs (Bernstein et al., 1993). STPD appears
highly comorbid with other PDs, especially Cluster
B PDs (Pulay et al., 2009), and it is often comorbid
with dysthymia and anxiety disorders (Alnæs &
Torgersen, 1988).
In Cluster B, ASPD is frequently comorbid
with borderline (Becker et al., 2000), narcissistic
­(Oldham et al., 1992), histrionic (Lilienfeld et al.,
1986), and schizotypal PDs (Marinangeli et al.,
2000). Research has demonstrated that ASPD has
a particularly strong association with substance
use disorders (Kessler et al., 1997). HPD is consis-
tently comorbid with borderline and narcissistic
PDs (Becker et al., 2000; Marinangeli et al., 2000;
Oldham et al., 1992). Some studies have also found
HPD to co-occur substantially with antisocial
­(Lilienfeld et al., 1986; Marinangeli et al., 2000;
Oldham et al., 1992) and dependent (Oldham et al.,
1992) PDs and with psychoactive substance use
(Oldham et al., 1995). NPD is often comorbid with
borderline, schizotypal, and obsessive-compulsive
PDs (Stinson et al., 2008; Zimmerman, Roths-
child, & Chelminski, 2005). Some evidence suggests
that antisocial and histrionic PDs also may be highly
comorbid with NPD (Oldham et al., 1992; Zimmer-
man et al., 2005). Epidemiological data suggests
that alcohol use disorders are significantly comorbid
in NPD, although these and other substance use

problems are relatively less frequent compared to
those diagnosed in other PDs (Stinson et al., 2008;
Trull et al., 2010). The comorbidity of BPD is espe-
cially complex, as BPD has been conceptualized as
both an internalizing and an externalizing disorder
(Blatt & Levy, 2003; Levy & Blatt, 1999), contribut-
ing to rates of more than 80% comorbidity with at
least one current non-PD disorder and an average of
3.2 comorbid non-PD disorders per patient (Lenzen-
weger et al., 2007).
The comorbidity of Cluster C PDs is often less
clear. Although AVPD has been conceptualized as
linked to SPD and has been found to be comorbid
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with SPD (Oldham et al., 1992), multidimensional
scaling has found AVPD can be discriminated from
SPD but not DPD (Widiger et al., 1987). AVPD is
often comorbid with DPD (Oldham et al., 1992) as
well as with mood, anxiety, and eating disorders
(Oldham et al., 1995) and especially social phobia
(Alnæs & Torgersen, 1988). DPD is substantially
comorbid with mood, anxiety, and non-PD psy-
chotic disorders (Oldham et al., 1995) and border-
line and avoidant PDs (Marinangeli et al., 2000;
Oldham et al., 1992). DPD is also frequently comor-
bid with PPD (Marinangeli et al., 2000) and OCPD
(Oldham et al., 1992). The results of studies on
OCPD comorbidity are inconsistent. Although some
evidence suggests OCPD co-occurs significantly
with several other PDs, including borderline, nar-
cissistic, histrionic, paranoid, and schizotypal PDs
(Marinangeli et al., 2000), other data find significant
comorbidity with DPD among the PDs (Oldham
et al., 1992). Investigations of the relationship
between OCPD and OCD also have yielded mixed
results, with some researchers finding significant
co-occurrence (AuBuchon & Malatesta, 1994; Baer
et al., 1992; Skodol et al., 1995), and others failing
to find a strong relationship between these disorders
(Black et al., 1993; Joffe, Swinson, & Regan, 1988).
On the whole, the literature on OCD and OCPD
suggests that the majority of patients with OCD do
not meet criteria for OCPD (Pfohl & Blum, 1991).
Furthermore, for those with OCD with concurrent
PD diagnosis, OCPD occurs no more frequently
than any other PD. Previous authors have concluded
that information is insufficient to support a mean-
ingful relationship between OCD and OCPD.
Personality Disorders
The bulk of the evidence indicates that PDs,
while frequently comorbid with non-PDs, appear
to be a distinct, independent problem that provide
important information to the clinician in terms of
the impact on course and treatment (Fournier et al.,
2008; Grilo et al., 2010; Zanarini et al., 2004). With
regard to PTSD, researchers have found high rates
of childhood abuse in BPD populations (Ogata et al.,
1990), and some have argued that trauma may be
a potential trigger of posttraumatic BPD symptoms
(Soloff, Lynch, & Kelly, 2002). Although it is accu-
rate that many BPD patients have suffered traumatic
physical or sexual abuse, not all have. In fact, data
suggest that 30%–70% have not. Thus, the idea
that BPD is really a complex PTSD can only explain
between 30%-70% of BPD cases, whereas the diag-
nosis of BPD can explain all cases, including those
with complex traumas.
In addition to mental disorders, PDs often pres-
ent with comorbidity among medical and physi-
cal conditions as well. For example, data from the
NESARC suggest that a diagnosis of BPD may be
related to a number of physical health conditions,
such as hypertension, cardiovascular disease, and
gastrointestinal diseases (El-Gabalawy et al., 2010).
This study further found that comorbid medical
conditions may in fact increase the risk of suicide
attempts in BPD, highlighting that paying attention
to comorbidity is vital. In sum, PDs are both highly
prevalent and highly comorbid with a range of psy-
chiatric and medical disorders.
Effects of PD Comorbidity on
Other Disorders
Although it has been common to view a comorbid
PD as being a variant of the disorder it is comor-
bid with, the evidence suggests the opposite. For
instance, when comorbid, PDs negatively affect the
course of other disorders and the outcome of oth-
erwise efficacious treatments. Bipolar patients with
comorbid PDs are less employed, use more medica-
tions, have increased rates of alcohol and substance
use disorders, show poorer treatment response, and
have significantly worse interepisode functioning
than bipolar patients not afflicted with PDs (­ Bieling,
Green, & MacQueen, 2007). Interestingly, the
reverse is not true: a comorbid bipolar disorder
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 Levy and Johnson
does not affect the course or outcome of treatment
for PD patients (Gunderson et al., 2006). Similarly,
a number of studies have found that improvements
in BPD often were followed by improvements
in depression but that improvements in depres-
sion were not followed by improvements in BPD
(Gunderson et al., 2004; D. N. Klein & Schwartz,
2002; Links et al., 1995). BPD also adversely affects
treatment for substance abusers, but substance
abuse (highly comorbid with BPD) does not appear
to alter the course of treatment for BPD (Lee et al.,
2010). Finally, a number of studies have shown that
the efficacy of treatment of PTSD is significantly
Copyright American Psychological Association. Not for further distribution.
reduced when the patient has comorbid BPD (Cloi-
tre & Koenen, 2001; Feeny, Zoellner, & Foa, 2002).
IDENTIFICATION AND DIAGNOSIS
Identification and Assessment
Most psychologists in clinical practice rely on
unstructured clinical interviews for diagnosing
patients presenting for treatment (Zimmerman,
2003). Unstructured clinical interviews, however,
can be idiosyncratic and unreliable and are vulner-
able to a number of biases, such as failure to con-
sider all of the necessary diagnostic criteria (and
failure to consider additional symptoms and diag-
noses beyond the chief complaints once a disorder
has been identified). A number of studies comparing
clinical diagnoses made by unstructured interviews
with diagnoses made using structured and semis-
tructured interviews have shown poor correspon-
dence between the two and have indicated that
unstructured clinical interviews miss many diagno-
ses (e.g., Barbato & Hafner, 1998; Ramirez Basco
et al., 2000).
This problem appears to be particularly pro-
nounced for PDs. For example, in university-based
outpatient clinics, when clinicians were left to their
own judgments based on unstructured clinical
interviews, they diagnosed BPD in 0.4% of almost
500 patients seen compared with 14.4% by struc-
tured interview (Zimmerman & Mattia, 1999).
This means that 97% of those patients diagnosed
by structured interviews with BPD were missed by
unstructured clinical interviews. The research evi-
dence is clear that without a formal assessment most
188
cases of PDs will be missed (Levy, 2013; Magnavita
et al., 2010). This may be especially true of NPD and
ASPD in which manifestations of pathology can be
relatively nuanced, distress is denied and external-
ized, self-monitoring is high, and the criteria for
these disorders have both high face validity and a
negative connotation.
Beyond the unstructured clinical interview,
clinicians and researchers can draw from an array
of sources when assessing PDs. These sources
include self-report paper-and-pencil or computer-
administered inventories, clinician rating scales and
checklists, structured and semistructured clinical
interviews, projective techniques, and data from
informants. Many of these instruments assess PDs
based on the prevailing taxonomy in DSM–IV–TR
(American Psychiatric Association, 2000) and
DSM–5 (American Psychiatric Association, 2013),
which articulates the 10 PDs described earlier. A
number of instruments exist, however, that are based
on other conceptualizations of PDs and pathology.
Semistructured Interviews
Semistructured interviews provide specific, care-
fully selected questions for each diagnostic criterion
to be assessed, with the purpose of increasing the
consistency between interviewers through the use
of systematic, replicable, and objective methods.
Semistructured interviews are meant to be semis-
tructured rather than fully structured because they
include many open-ended and indirect questions,
allow for interviewers to follow up, seek elabora-
tion, and obtain clarification of the information pro-
vided as well as observation of the patient’s manner
of responding and relating to the interviewer. Thus,
to conduct a semistructured interview, the inter-
viewer needs to have training and experience to uti-
lize the clinical judgment required to know when to
follow up and how to rate the criteria.
A number of semistructured and structured inter-
views are available for the full range of DSM PDs.
These include the Structured Interview for DSM Per-
sonality Disorders—Revised (SIDP–R; Pfohl, Blum, &
Zimmerman, 1997), Structured Clinical Interview for
DSM–IV Personality Disorders (SCID–II; First et al.,
1995), International Personality Disorders Examina-
tion (IPDE; Loranger, 1999), Personality Disorder

Interview—IV (PDI–IV; ­Widiger & Corbett, 1995),
and the Diagnostic Interview for Personality Disor-
ders (DIPD–IV; Zanarini et al., 1987, 2000). They
differ from each other in their wording of questions,
inclusion of follow-up, suggestions for inquiry, and
organization. For instance, the SCID–II is orga-
nized by disorder, whereas the IPDE is organized by
domains of functioning (e.g., work, relationships,
self, affect). Although these interviews have varying
levels of psychometric data, evidence suggests that
they are promising measures with good reliability and
initial validity data. No data suggest that one struc-
tured interview is more valid than another.
Copyright American Psychological Association. Not for further distribution.
A number of semistructured and structured
interviews also assess for specific DSM PDs. These
include the Revised Diagnostic Interview for Border-
lines (DIB–R; Zanarini et al., 1989) and Borderline
Personality Disorder Severity Index (BPDSI; Arntz
et al., 2003), the Diagnostic Interview for Narcissism
(Gunderson, Ronningstam, & Bodkin, 1990), and the
Hare Psychopathy Checklist—Revised (Hare, 1991).
In addition, ASPD can be assessed using the National
Institute of Mental Health Diagnostic Interview
Schedule, Antisocial Section (Robins et al., 1981).
A number of semistructured interviews utilize
other conceptions of PDs. These include (a) the
Structured Interview for the Five-Factor Model of
Personality (Trull & Widiger, 1997), which assesses
the five domains of the FFM and is the only semis-
tructured interview that assesses general personal-
ity; (b) the Personality Assessment Schedule (PAS;
Tyrer, 1988), which assess 24 traits (e.g., aggres-
sion, impulsivity, conscientiousness) and generates
dimensional ratings of five personality styles (nor-
mal, passive-dependent, sociopathic, anankastic,
and schizoid; and (c) the Structured Interview of
Personality Organization (STIPO; Clarkin et al.,
2004), which allows for dimensional assessment of
identity, defenses, and reality testing based on Kern-
berg’s (1981) structural interview. This interview
is conceptually concordant with DSM–5 (American
Psychiatric Association, 2013) Section III conceptu-
alization of PDs.
Clinician Rating Scales
A number of clinician rating scales are available,
such as the Personality Assessment Form (PAF;
Personality Disorders
Shea, Glass, Pilkonis, Watkins, & Docherty, 1987),
the SWAP (Westen & Shedler, 1999a), and scales
for the PDM. The PAF presents a brief paragraph
that describes important features of each PD, and
the individual’s similarity to the description is rated
by an evaluator using a six-point scale. The SWAP
is a 200-item Q-set of personality-descriptive state-
ments designed to quantify clinical judgment based
on the rater’s knowledge of clinical data about the
patient. Clinicians are directed to arrange the 200
items (presented on separate index cards) into eight
categories with a fixed distribution ranging from
those that are not descriptive of the patient to those
that are highly descriptive of the patient. SWAP
ratings have been shown to be reliable and have
concordance with independently carried out semis-
tructured interviews. The SWAP has demonstrated a
reduction in comorbidity with other PDs, especially
Cluster B PDs. This reduction is important because
a lack of discreteness of PDs has been a frequent cri-
tique of their construct validity.
Self-Report Instruments
Of the number of self-report instruments used to
assess for PDs, the most widely used are the Millon
Clinical Multiaxial Inventory (MCMI–III; Millon,
Millon, & Davis, 1994), the Personality Diagnos-
tic Questionnaire—Fourth Edition (PDQ–4; Hyler
et al., 1992), the Personality Assessment Inventory
(PAI; Morey, 1991), and the Dimensional Assess-
ment of Personality Pathology—Basic Questionnaire
(Schroeder, Wormworth, & Livesley, 1992). Other
PD measures include the Schedule of Nonadaptive
and Adaptive Personality (SNAP; Clark, 1993), the
OMNI Personality Inventory (OMNI; Loranger,
2001), the Personality Inventory Questionnaire
(PIQ–II; Widiger, 1987), the Wisconsin Personality
Disorder Inventory (WIPSI–IV; M. H. Klein et al.,
1993), and the Minnesota Multiphasic Personality
Inventory 2—Personality Disorder Scales (MMPI
2–PD; Morey, Waugh, & Blashfield, 1985).
A number of self-report scales assess specific
PDs. The most commonly used include the Psy-
chopathic Personality Inventory (PPI; Lilienfled &
Windows, 2005), Pathological Narcissism Inven-
tory (PNI; Pincus et al., 2009) and Narcissistic Per-
sonality Inventory (NPI; Raskin & Hall, 1979) for
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 Levy and Johnson
narcissism, and the Borderline Symptom Index (BSI;
Bohus et al., 2007), Borderline Personality Inven-
tory (BPI, Leichsenring,1999), and the Inventory of
Personality Organization (IPO; Clarkin, Foelsch, &
Kernberg, 1995).
Because self-report measures tend to result in
higher diagnostic base rates than interviews and
there is poor concordance between them and inter-
view measures, they are not recommended for diag-
nosis (McDermut & Zimmerman, 2005). A number
of researchers, however, have used and recommend
a two-stage or stepped procedure for identifying
people with PDs. Self-report measures are adminis-
Copyright American Psychological Association. Not for further distribution.
tered as an alert to the probability of a PD, and then
a ­semistructured interview is administered to those
who scored positive for a PD to verify its presence
and type.
A number of screening instruments have been
developed to assess for PDs broadly and specifi-
cally. The most commonly used measures include
the Standardized Assessment of Personality
Disorders–Abbreviated Scale (SAPAS; Moran et al.,
2003), Iowa Personality Disorder Screen (IPDS;
Langbehn et al., 1999), Inventory of Interpersonal
Problems–Personality Disorders-25 (IIP-PD-25; B.
L. Stern et al., 2000), and International Personality
Disorders Examination–Screening Questionnaire;
IPDE-SQ; Loranger, 1999).
The IPDE-SQ screens for the 10 DSM–IV (Ameri-
can Psychiatric Association, 1994) personality
disorders: paranoid, schizoid, schizotypal, antiso-
cial, borderline, histrionic, narcissistic, avoidant,
dependent, and obsessive-compulsive. The IPDE-SQ
PD scales are scored based on the sum of endorsed
items. According to the scoring system, the endorse-
ment of three or more items is suggestive of the
presence of that disorder. As noted previously,
previous research (Lenzenweger et al., 1997) has
shown that the screener is highly sensitive to iden-
tify those with PD diagnoses.
Use of informant information is important when
assessing PDs. Sole reliance on an individual’s per-
sonal report, which is the most common practice
both clinically and in research (Klonsky & O ­ ltmanns,
2002), can prove problematic. Although research
shows that agreement between self- and peer-
reported personality traits in normal samples can be
190
good to excellent (McCrae & John, 1998), within
clinical samples, findings between patient-reported
data from interviews and measures with informants’
report tend to range from poor to adequate (Klon-
sky & Oltmanns, 2002). Informants can be aware
of and have a better sense of behaviors, traits, and
symptoms that the patient may be defensive about or
consciously motivated to withhold from assessors.
Informants are more willing to report on negative
aspects of the patient, such as arrogance, dishonesty,
suspiciousness, hostility, and dependence (Bernstein,
Ahluvalia, Pogge, & Handelsman, 1997).
Depending on the age, life situation, suspected
diagnoses, and reason for referral of an individual,
informants can include friends, spouses, parents,
children, colleagues, law enforcement or parole offi-
cers and court records or judges, and previous and
current treaters. For example, when a patient comes
into treatment because of an ultimatum from their
spouse or significant other, it is important to gather
information from that person. Likewise, if a patient
comes in for treatment because their boss has made
it a condition of employment, it would be important
to gather information from the boss. It is particu-
larly important to meet with and gather data from
informants when ASPD might be present. Addition-
ally, it is important to gather informant information
for any patient presenting to treatment with legal
difficulties or through a court mandate.
The recommendation to utilize data from self-
report, interviews, and observation as well as from
informants simultaneously in making a diagnosis
is in accordance with the “longitudinal, expert,
all-data (LEAD) standard” (Pilkonis et al., 1991),
which recommends that optimal diagnostic practice
requires the consideration of all available data to
derive a “best estimate” diagnosis or set of diagno-
ses. This method has been shown to be more valid
and reliable than diagnostic interviews alone (Pil-
konis et al., 1991) and to result in fewer comorbid
diagnoses (Levy et al., 1998).
Differential Diagnosis
Another consideration in PD assessment is differ-
ential diagnosis, which consists of choosing from
among two or more similar diagnostic criteria the
diagnosis that best fits the presenting features.

The differential diagnosis for PDs commonly includes
mood disorders, such as bipolar, major depression,
and dysthymia; anxiety disorders; PTSD; and sub-
stance abuse disorders (SUDs). PDs frequently are
comorbid with all these disorders, which complicates
the diagnostic and clinical decision-making process.
For example, it is often unclear whether symptoms of
depression or anxiety reflect a comorbid diagnosis or
are primarily an expression of personality pathology.
Even when not comorbid with other disorders,
PDs can present in ways that resemble other disor-
ders, particularly Cluster A disorders with psychotic
spectrum disorders, Cluster B disorders with mood
Copyright American Psychological Association. Not for further distribution.
disorders, and Cluster C disorders with anxiety
disorders. These similarities in presentation make
it important for practicing clinicians to be able to
determine differential diagnoses or to determine
whether a disorder is comorbid. Studies have shown
that it takes between 6 and 10 years after first psy-
chiatric contact for those with BPD to be diagnosed
properly (Meyerson, 2009; Zanarini, Frankenburg,
Dubo, et al., 1998). During this gap, patients usually
receive inadequate treatment.
Differential diagnosis of PDs may be categorized
into three types: (a) differential from the effects of
substances; (b) differential from similar disorders,
including more episodic syndromal disorders (e.g.,
major depression, bipolar II, generalized anxiety
disorder, panic disorder, formerly called Axis I)
and other personality disorders (formerly Axis II);
and (c) differentiating clinical levels of personality
pathology from subclinical or healthy personality
functioning.
Unipolar depression. One of the most com-
mon differential diagnoses of PDs is with various
mood disorders, such as major depressive disorder
(MDD), depressive disorder NOS, and persistent
depressive disorder (formerly called dysthymia).
Those with PDs, particularly BPD and NPD, often
experience depression, and the patient’s phenome-
nological experience is often that they are depressed.
In fact, research shows that BPD patients typically
score as high or higher on measures of depression as
those with MDD (Levy et al., 2007).
Making this differential requires an extensive
evaluation of the symptoms and quality of the
Personality Disorders
depression experienced. In BPD, the depression is
often experienced as chronic dysphoria and empti-
ness (Zanarini, Frankenburg, DeLuca, et al., 1998).
In NPD, the depression tends to occur more spo-
radically and after failures of one sort or another or
when individuals are in a vulnerable state (Caligor,
Levy, & Yeomans, 2015). In addition, those with
BPD and NPD often report chronic suicidality and
periodic self-injury and suicidal attempts, typically
after interpersonal discord. Without careful assess-
ment, the suicidality, suicide attempts, and self-
injury can easily but mistakenly be interpreted as
part of a depression rather than a response to inter-
personal discord.
In contrast to MDD in which the depressed mood
is episodic, in BPD the depressed mood is often
chronic and tends to vacillate with anger and irri-
tability (as opposed to normal mood or expansive
mood in bipolar disorder). Also, in contrast to those
with MDD, borderline patients often show more
mood reactivity than is typical of those in a depres-
sive episode. It is not unusual for a suicidal and
otherwise seemingly depressed patient with BPD to
quickly become quite relieved, cavalier, and even
social with the other patients upon admission to an
inpatient hospital unit. BPD patients often do not
present with the neurovegetative signs that are fre-
quently typical of those with major depression and
are more likely to report atypical symptoms (e.g.,
increased appetitive and excessive sleeping). Symp-
toms related to poor appetite are not accompanied by
weight loss, belaying the report of decreased appetite.
Probably the most important issue for differenti-
ating BPD from MDD concerns identity disturbance.
People with MDD alone do not suffer from identity
disturbance, whereas identity disturbance is typi-
cally present in BPD. Given the chronic nature of
the BPD patient’s depressed mood, it often can be
difficult to differentiate BPD from dysthymia (now
called persistent depressive disorder in DSM–5 [Amer-
ican Psychiatric Association, 2013]). Once again,
mood reactivity, lack of neurovegetative signs,
chronic irritability, suicidality, and parasuicidality
are characteristic of BPD.
Bipolar disorders. Another common and chal-
lenging differential diagnosis for those with PDs,
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 Levy and Johnson
particularly those with BPD, NPD, and ASPD, is
with bipolar disorder, particularly bipolar II. The
comorbidity between PDs and bipolar I and II tends
to be around 28%–48% (e.g., George et al., 2003;
Kay et al., 1999).
A large amount of data now suggests that those
with BPD are often misdiagnosed with bipolar dis-
order. Even when bipolar disorder is present, it is
important to determine whether a PD is present
because evidence suggests that a comorbid PD diag-
nosis negatively affects the course and outcome for
bipolar disorder, whereas comorbid bipolar disor-
der does not affect the course and outcome for PDs
Copyright American Psychological Association. Not for further distribution.
(e.g., Bieling et al., 2007; Gunderson et al., 2006;
Kay et al., 2002).
At a practical level, probably the most impor-
tant point of confusion in differentiating PDs from
bipolar disorder concerns affective instability or
emotional lability. Because affective instability is a
core symptom of bipolar disorder, when it occurs in
PDs, it is often mistaken as an indicator of bipolar
disorder. Research shows, however, that affective
instability in BPD is qualitatively different than
what is proposed in the criteria for bipolar disor-
der. Affective instability in bipolar disorder occurs
spontaneously and evolves over a period of days
and weeks and tends to be longstanding (American
Psychiatric Association, 2013). Additionally, the
mood swings seen in bipolar disorder are typically
between depression and elation, expansiveness, and
grandiosity. On the other hand, in BPD and other
PDs, the affective instability is reactive (i.e., envi-
ronmentally driven), usually occurs in response
to interpersonal events or internal thought pro-
cesses, and tends to be of short duration and display
frequent vacillations. These vacillations are not
between depression and elation or grandiosity, but
rather are between depression and anger, hostility,
and irritability (Reisch et al., 2008). BPD patients
report significantly more frequent and intense affec-
tive shifts than those with bipolar disorder (Reisch
et al., 2001). Interestingly, the affective instability
in BPD patients, compared with bipolar patients,
tends to be more intense and frequent and to shift
between depression and anxiety on the one hand
and euthymia and anger on the other (Henry et al.,
2001; Reisch et al., 2001).
192
Similar confusions arise when differentiating
impulsivity and irritability in BPD and bipolar dis-
order. Impulsivity and irritability in BPD is chronic,
whereas in bipolar disorders, these characteristics
must represent a distinct occurrence and occur as
part of a manic or hypomanic episode to be counted
toward those disorders.
Trauma disorders. Distinguishing between PDs
and PTSD can be clear-cut when the PTSD is an
acute symptomatic reaction to a discrete traumatic
event accompanied by psychophysiological cor-
relates. With regard to acute traumas, chronic
impulsivity, irritability, and identity disturbance will
distinguish BPD and PTSD. This is especially easy to
determine when the symptoms of BPD predate the
traumatic event. The premorbid functioning in those
with PTSD is usually good.
It is much more difficult, however, to disentangle
these disorders in the context of the enduring effects
that early and chronic trauma can have on personal-
ity development. A number of clinical researchers
and theorists have suggested that BPD can be
reconceptualized as a form of complex PTSD
(e.g., Herman, 1993; Hodges, 2003; Kroll, 1993).
Studies show that 30%–70% of BPD patients
have broadly experienced traumatic events (e.g.,
Zanarini & Frankenburg, 1997); conversely,
30%–70% of those with BPD do not. Additionally,
studies of consecutive admissions find that between
30% and 45% of BPD have a history of abuse, which
often is not significantly different than other mental
disorders (e.g., Chapman et al., 2004).
In a study of women with PTSD who experienced
early childhood abuse, a comorbid BPD diagnosis
did not affect traditional symptoms of PTSD, such
as the frequency and severity of intrusions, avoid-
ance, and arousal (Heffernan & Cloitre, 2000). A
comorbid BPD diagnosis, however, did result in
elevations in the newly proposed DSM–5 (Ameri-
can Psychiatric Association, 2013) symptoms of
PTSD that historically were thought to be part of the
BPD symptom picture: anger, anxiety, dissociation,
and interpersonal problems (Heffernan & Cloitre,
2000). These findings suggest that BPD and tradi-
tional PTSD can be distinguished by their symp-
tom picture and can cast doubts on the concept of

complex PTSD as a substitute for BPD. Thus, anger
and interpersonal problems as well as anxiety and
dissociation would suggest the possible comorbidity
of BPD and the need for assessment in the context of
trauma and PTSD.
Anxiety disorders. Other important differential
diagnoses include anxiety disorders, particularly
generalized anxiety disorder (GAD) and panic disor-
der. Those with PDs, particularly BPD, often report
diffuse anxiety that may at times resemble GAD.
The PD patient, however, tends to vacillate between
feeling anxious over a range of situations and being
Copyright American Psychological Association. Not for further distribution.
remarkably unconcerned and cavalier about situa-
tions in which anxiety would be appropriate.
Additionally, whereas in GAD the anxieties often
are discordant to the situation (e.g., the student with
high grades who worries excessively about his or her
grades), the worry in PDs tends to be about current
crises that have arisen and dissipates once the crises
are resolved. For example, a supervisee reports that
she believes a patient may have GAD because of the
patient’s excessive worry about whether or not her
disability benefits will be renewed. The patient is
concerned because she has been talking in therapy
about her off-the-books job, and she is afraid that
the review agency will discover she is working. The
anxiety interferes with her sleep and eating and
also is making her irritable. Once her benefits are
renewed, however, her anxiety quickly resolves,
which is indicative more of a PD (or even healthy
functioning) than GAD.
Substance use disorders. It is often the case that
PD patients who abuse substances do so as a func-
tion of their PD. Sometimes, however, problems
associated with substance abuse can create many of
the symptoms of a PD. That is, patients who abuse
substances can behave in ways consistent with PDs
as a function of substance use. For example, it is
not unusual for those with SUDs to act in antiso-
cial ways, such as lying or stealing to obtain drugs
or alcohol. Such a person while on drugs or in the
pursuit of drugs may show a callous, remorseless
attitude. The patient may not have engaged in these
behaviors or shown such an attitude either before
the development of the SUD or after becoming
sober, suggesting the absence of antisocial PD.
Personality Disorders
In a retrospective chart review study of 137
inpatient borderline patients, more than two thirds
met DSM–III (American Psychiatric Association,
1980) criteria for substance use disorders (Dulit
et al., 1990). Interestingly, when substance use was
not used as a criterion for BPD, 35% of patients no
longer met DSM–III criteria for BPD. This subgroup
was marked by lower severity of symptoms and
less chronicity of course. Thus, a subgroup of PD
patients may appear to have PDs because of behav-
iors associated with comorbid substance use, and
these patients likely would lose the PD diagnosis
after achieving abstinence.
It is relatively easy to rule out a PD for patients
whose PD behavior begins after substance use, par-
ticularly when in adulthood or whose PD behavior
quickly remits after refraining from substance use.
It is much more difficult to make this determination
when substance use begins early or when the patient
is in the throes of substance use. In these cases, it is
useful to rely on the hallmark indicators of PDs that
are independent of the consequences of substance
abuse, such as identity disturbance in BPD.
TREATMENT
PDs are considered a major treatment challenge.
Historically, PDs have been thought to be difficult to
treat, with patients frequently not adhering to treat-
ment recommendations, using services chaotically,
and repeatedly dropping out of treatment. Many
clinicians are intimidated by the prospect of treating
BPD patients and are pessimistic about the outcome
of treatment (Lewis & Appleby, 1988; Lequesne &
Hersh, 2004; McDonald-Scott et al., 1992). Thera-
pists treating patients with BPD have displayed high
levels of burnout and have been known to be prone
to enactments and even engagement in iatrogenic
behaviors (Linehan et al., 2000).
In recent years, however, a number of random-
ized controlled trials (RCTs) have found PDs can be
treated successfully. Beginning with Linehan et al.’s
(1991) seminal RCT of dialectical behavior therapy
(DBT), a range of treatments—deriving from both
the cognitive–behavioral (CBT) and psychodynamic
(PDT) traditions—have shown efficacy in RCTs and
now are available for clinician use. In addition to
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 Levy and Johnson
DBT, efficacious treatments include schema-focused
therapy (SFT) and systems training for emotional
predictability and problem solving (STEPPS) from a
CBT perspective and mentalization-based treatment
(MBT), dynamic deconstructive psychotherapy
(DDP), and transference-focused psychotherapy
(TFP) from a psychodynamic perspective. Several
other treatments appear promising, such as Meares’s
Interpersonal Treatment (Stevenson et al., 1992),
Ryle’s Cognitive Analytic Therapy (CAT; Ryle,
Poynton, & Brockman, 1990), and Beck’s CBT
(Beck, Freeman, & Davis, 2004), and have received
support through RCT designs. All treatments with
Copyright American Psychological Association. Not for further distribution.
demonstrated efficacy or effectiveness share some
commonalities: they tend to be long-term, inte-
grative, structured, and modified from standard
treatments.
Meta-Analyses of Treatment for PDs
Several meta-analyses of psychotherapy for PDs
provide encouraging findings (Budge et al., 2013;
Leichsenring & Leibing, 2003; Perry et al., 1999).
One meta-analysis (Perry et al., 1999) identified 15
studies, including six RCTs, and found pre–post
effect sizes ranging from 1.1 to 1.3. A second meta-
analysis (Leichsenring & Leibing, 2003) examined
the efficacy of both PDT (14 studies) and CBT
(11 studies) in the treatment of patients with PDs;
11 of the studies were RCTs. The authors reported
pre- to posttreatment effect sizes using the longest
term follow-up data reported in the studies. For
psychodynamic psychotherapy (mean length of
treatment was 37 weeks), the mean follow-up period
was 1.5 years after treatment end and the pre- to
posttreatment effect size was 1.46, indicating that
psychodynamic treatment benefits endure over time.
For CBT (mean length of treatment was 16 weeks),
the mean follow-up period was 13 weeks, and the
pretreatment to posttreatment effect size was 1.0.
The authors concluded that both PDT and CBT
demonstrated effectiveness for patients with PDs,
but that current evidence for long-term effective-
ness is stronger for psychodynamic psychotherapy.
The most recent and comprehensive meta-analysis
on PDs (Budge et al., 2013) analyzed 30 studies
that compared an active psychotherapeutic treat-
ment with treatment as usual, finding that active
194
psychotherapeutic treatments were more efficient
than treatment-as-usual comparisons, with medium
effect size (d = .40). In addition, the effectiveness
of PDT for individuals with PDs is supported by
two more recent meta-analytic studies for short-
term PDT (Town, Abbass, & Hardy, 2011) and for
the treatment of depression with comorbid PDs
(Abbass et al., 2011).
Findings from these meta-analyses suggest that
psychodynamic and CBT-based treatments for PDs
are far more effective than no treatment, are mod-
estly more effective than treatments as usual, and
appear to be equally effective for PDs. Additionally,
longer term treatments might yield better outcomes.
At the same time, findings from these meta-
analyses of PDs are difficult to interpret because of
the mixing of different disorders both within studies
included in meta-analyses and within and between
meta-analyses. These different PDs vary quite a bit
in terms of severity. Further complicating the inter-
pretation are the different controls used across stud-
ies and within meta-analyses. Research on specific
PDs would be more informative particularly when
the control group is better accounted for.
Pharmacotherapy
A systematic review of 40 RCTs for the PDs (most
of which focused on BPD) found some limited
effect of psychotropic medication for specific PD
symptoms, such as the mood stabilizer lithium for
aggression in ASPD and monoamine oxidase inhibi-
tors for social anxiety in AVPD (Triebwasser &
Siever, 2007). A 2010 review of 21 pharmacological
treatment studies of BPD and STPD suggested that
antipsychotics were moderately effective for cogni-
tive or perceptual symptoms as well as for reducing
anger (Ingenhoven et al., 2010). Antidepressants
had a small effect on anxiety symptoms, but they
were not effective for depression among these
patients or for treating core PD symptomatology.
Further systematic review evidence suggests anti-
psychotic medication may be especially helpful in
reducing psychotic features of both BPD and STPD,
and lithium may be effective for aggressive features
among PDs such as ASPD (Hori, 1998). Another
recent review posited that antipsychotics may help
reduce psychotic features and behavioral symptoms

among the PDs (Öyekçin & Yıldız, 2012). This
review suggested that (a) psychotherapy for BPD
might be enhanced with concurrent pharmacologi-
cal treatment when mood, cognitive, or behavioral
symptoms are severe; (b) AVPD may be treated with
the serotonin–norepinephrine reuptake inhibitor
venlafaxine or with selective serotonin reuptake
inhibitors (SSRIs); and (c) STPD may respond to
antipsychotics; but (d) ASPD is not responsive to
medication, contradicting earlier findings of the effi-
cacy of lithium in this disorder (Hori, 1998).
For BPD specifically, a systematic review
and meta-analysis of 27 RCTs conducted by the
Copyright American Psychological Association. Not for further distribution.
Cochrane Collaboration determined that mood sta-
bilizers, such as lamotrigine, showed some efficacy
in treating both core and accessory features of the
disorder (Lieb et al., 2010). The second-generation
antipsychotic aripiprazole also showed some effect
in reducing BPD symptoms. Antidepressant medi-
cations (e.g., SSRIs) were not found to be effective
as a BPD treatment option. These findings partially
confirmed an earlier review (Nosé et al., 2006)
that found that mood stabilizers reduced affective
instability and anger in BPD, and antipsychotics
were effective in reducing impulsivity and aggres-
sion as well as improving interpersonal functioning.
As the authors of these studies point out, however,
pharmacotherapy for the PDs tends to have only
limited effect and to focus on specific core or sec-
ondary symptoms of specific disorders, rather than
on global change, and, if used, should be considered
adjunctive treatment to psychotherapy, which is the
gold standard of care for PDs.
Self-Help Resources
A number of self-help resources are available for
people with PDs, particularly BPD. These resources
include (a) books written by professionals and/or
patients or family members geared toward patients,
families, and professionals; (b) Internet resource
centers that provide information through text,
videos, and additional links; and (c) self-help and
family organizations that in addition to website and
written information provide lectures, education, and
trainings and support to people with PDs and their
families. Many of these resources provide mecha-
nisms for referrals, provide advocacy, and bring
Personality Disorders
current research findings to individuals and families
suffering from PDs.
In the United States the main self-help and
family organizations include the BPD Resource
Center (http://www.bpdresourcecenter.org), Treat-
ment and Research Advancements for Borderline
Personality Disorder (http://www.tara4bpd.org),
National Education Alliance for BPD (NEA-BPD;
http://www.borderlinepersonalitydisorder.com),
and RethinkBPD. Other online resources include
http://www.BPDCentral.com, http://www.
borderlinepersonalitydisorder.com, http://www.
bpdworld.org, http://www.nimh.nih.gov/health/
topics/borderline-personality-disorder/index.shtml,
and http://www.bpdfamily.com. The BPD Resource
Center contains a number of videos with prominent
BPD researchers and clinicians as well as patients
discussing aspects of the disorder, the experience of
BPD, and the kind of changes that can occur with
treatment. In addition to producing a documen-
tary called Back from the Edge that weaves together
patient accounts, family commentary, and expert
advice, they also have provided local lectures
and outreach and, importantly, a referral service.
RethinkBPD has provided lectures and developed a
documentary called The Fight Within Us.
The two largest and most far-reaching orga-
nizations are TARA and NEA-BPD. These orga-
nizations not only provide current research
information to patients and families but also
provide educational trainings and support groups
to families. NEA-BPD has sponsored family edu-
cation workshops throughout the United States
as well as a periodic call-in series to speak with
experts in the field. Additionally, these two orga-
nizations have carried out research relevant to
families as well as the outcome of their family edu-
cation programs. Using retrospective self-reports,
TARA examined the outcome for 74 graduates
of its family education program. They found sig-
nificant decreases in a number of problem areas,
such as violent arguments, financial bailouts,
suicide threats, and hospitalizations, as well as
significant improvements in family relationships
(Porr, 2010). In two published studies (Hoff-
man, Fruzzetti, & Buteau, 2007; Hoffman et al.,
2005), NEA-BPD examined the outcome of its
195
 Levy and Johnson
Family–Connections program, a 12-week program,
for 55 and 45 family members, respectively. Across
the two studies, they found significant decreases
in grief, burden, and depression and significant
increases in mastery. These studies examined only
treatment completers, however, and none of these
studies employed control groups, making the
results difficult to interpret. One RCT examined
12 weeks of psychoeducation for patients with
BPD (Zanarini & Frankenburg, 2008). Although
psychoeducation resulted in significant decreases
in impulsivity and storminess in relationships,
there was no effect on psychosocial functioning.
Copyright American Psychological Association. Not for further distribution.
Self-help books for BPD include Stop Walking on
Eggshells, I Hate You, Don’t Leave Me: Understanding
Borderline Personality Disorder, Self-Help for Manag-
ing the Symptoms of Borderline Personality Disorder,
The Borderline Personality Disorder Survival Guide,
Borderline Personality Disorder Demystified, and Get
Me Out of Here: My Recovery From Borderline Person-
ality Disorder.
Books geared toward families with a member
who has been diagnosed with a personality disor-
der include Understanding and Treating Borderline
Personality Disorder: A Guide for Professionals and
Families, Overcoming Borderline Personality Disorder:
A Family Guide for Healing and Change, Remnants of
a Life on Paper, Loving Someone With Borderline Per-
sonality Disorder, and The Essential Family Guide to
Borderline Personality Disorder. As evident from this
review, although BPD has received much attention
in the domain of self-help and psychoeducation,
such resources for other PDs are lacking.
MAJOR ACCOMPLISHMENTS
A key achievement in the field of PD research has
been the establishment of diagnostic cutoffs and
consensual diagnostic criteria for PDs. The reliabil-
ity of various PD diagnoses have been shown to be
as reliable as other accepted disorders (e.g., GAD
and bipolar disorder; Brown et al., 2001). Another
achievement consists of increased validity and clini-
cal utility of the PD concept, such that many of the
individual PDs are now well established (Pilkonis
et al., 1991). Various PD diagnoses have been shown
to be stable over time, particularly when compared
196
with episodic disorders like major depression.
Moreover, PDs have been differentiated from near-­
neighbor disorders and been determined to have
clinical utility in predicting course and outcome
when comorbid with the acute syndromal disorders.
Another key achievement has been the estab-
lished efficacy of a number of treatments for PDs
in RCTs. Several useful manualized treatments for
treating PD from both CBT and PDT traditions
have been tested in more than 40 RCTs combined.
Much of this work has focused on BPD and to a
lesser extent ASPD and mixed PDs, particularly
Cluster C disorders. In contrast to dismal prognosis
in the past, individuals with PDs now have access
to a range of structured and empirically supported
treatments that are likely to provide at least a mod-
erate decrease in symptoms and improvement in
functioning.
Finally, the field has also generated improve-
ments in both research and training surrounding
the PDs and their treatment. Published treatment
manuals for evidence-based therapies allow for
training in efficient and standardized ways across
training programs that may help avoid conceptual
drift or miscommunication. Research has now
documented prevalence of PDs, their comorbid-
ity, etiology, differential diagnosis, and efficacy of
treatments, providing a solid foundation for future
research in this area. Research has begun to explore
and elaborate on theoretical conceptualizations of
PD development in the hopes of one day delineating
the progression of PD features and providing early
intervention and prevention for these serious mental
disorders.
FUTURE DIRECTIONS
Radical shifts in practice have evolved since the
early 20th century. From the 1930s through the
1990s, practice with individuals with PDs was pri-
marily carried out from a psychodynamic orienta-
tion and often involved intermittent short- and
long-term hospitalizations. Diagnosis became
increasingly based on signs and symptoms that were
articulated by a few clinical theorists and integrated
into the various versions of the DSM. The 1990s and
early part of the 21st century saw the dominance

of DBT rapidly emerge based on a combination of
empirical assessment and aggressive dissemination
and outreach. In the beginning of the 21st century,
other treatments slowly began to be examined. At
present, a number of empirically supported treat-
ments for PDs, particularly BPD, have derived from
both CBT and PDT traditions. These treatments
tend to be quite integrative. Although few direct
comparisons exist, the ones that do exist, as well as
a host of meta-analytic reviews, strongly suggest that
no one current treatment is better than any other.
Moreover the effects of these treatments tend to be
smaller than hoped.
Copyright American Psychological Association. Not for further distribution.
As the equivalence among treatments has
emerged, the similarities between treatments, rather
than the differences, have been stressed. As we move
forward, an emphasis on empirical support contin-
ues. These different approaches need further study,
however, and clinicians may need to be trained in
multiple approaches to best serve their patients. It
is unclear at this point whether or not one treat-
ment might be better than another for a particu-
lar patient or type of patient or whether a better
approach might be to combine aspects of treatments
to develop more powerful interventions. Clinical
practice is thus moving toward becoming more
integrative.
Training in PDs is becoming more concrete and
explicit. Before the rise of DBT, training in PDs
tended to occur through supervision by experts,
typically through clinical training experiences at a
handful of internship and residency training pro-
grams that had specialized programs in PDs, such as
Cornell Medical College or McLean Hospital. Train-
ing in PDs was even less common in clinical psy-
chology training programs (Magnavita et al., 2010).
Among the many innovations ushered in by Linehan
with DBT was the explication and standardization of
training procedures that allowed them to be trans-
ported widely into the community independent of
one-on-one supervision. This model has been taken
up by developers of various other empirically sup-
ported treatments, such as MBT, SFT, and TFP.
Given the success of these methods of training clini-
cians, the future of training most likely will include
the broad dissemination of training in psychother-
apy techniques for those with PDs. As we learn more
Personality Disorders
about the similarities and differences in the various
treatments and make gains in their integration,
we also should see more principle-based training,
instead of training in treatment packages.
With regard to research, there are a number of
important directions for the field. Research is mov-
ing toward better understanding the relationship
between genotype, endophenotype, and phynotype,
especially as they relate to diagnostic and etiologi-
cal issues. A number of diagnostic issues need be
resolved over the coming decade with regard to PDs.
This includes better defining, or even redefining, the
phenotypes underlying PDs. Debates about reliance
on categories, prototypes, or dimensions—or some
combination of these—remain unresolved. There
has been some attempt to incorporate developments
from a breadth of theoretical domains; for example,
the Research Domain Criteria (RDoC; Insel et al.,
2010) initiative begun by the National Institute of
Mental Health (NIMH) is designed to address this
issue. The RDoCs, with their exclusive focus on
neurobiologically based markers of psychopathol-
ogy, may not effectively capture all the necessary
areas of PD research (Lilienfeld, 2014). Thus, there
is a call to better integrate other conceptual models,
such as dimensional trait models, into the diagnostic
system.
Another important direction for PDs is a fuller
understanding of their etiology and development.
Over the past few decades, conceptions of PD devel-
opment have evolved from being primarily focused
on psychosocial contributions (e.g., parenting,
trauma) to broader conceptions that include a wide
array of biological, psychosocial, and cultural factors
often in interaction with each other. The data sug-
gest that each of these contribute a relatively small
effect, and none appear to be necessary or sufficient
to cause a PD. Future research will focus on expli-
cating the relative parameters and contributing fac-
tors as well as the interaction between genetic and
environmental contributions to the development
of PDs.
In terms of treatment, we foresee developing
and examining treatments for PDs beyond BPD,
specifically NPD, given its prevalence, distress
caused, and toll on society. Only a small portion of
the treatments developed and tested thus far have
197
 Levy and Johnson
been widely disseminated. Given that even effective
treatments tend to show only about 60% of patients
improve, broader dissemination and establishment
of the various empirically supported treatments
is needed to better serve our patients. Consistent
with the goals of research funding agencies and the
NIMH’s focus on mechanisms, in the future, the
field will move beyond a race-to-the-end mentality
toward studying underlying change mechanisms.
Those who study PDs have been interested in mech-
anisms that include not only processes elucidated by
neuroscience but also those involving social cogni-
tion and therapy techniques.
Copyright American Psychological Association. Not for further distribution.
The field has come a long way with regards to
training, research, and practice in the area of PDs;
nonetheless, the familiar claim that more research
is needed is clearly true in the case of PDs. The field
has defined important domains for further investiga-
tion. The answers to these questions and those that
arise in the course of research hold promise in help-
ing psychologists understand and treat the relatively
large segment of the population suffering from PDs.
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