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P

Personality Disorder
Chloe F. Bliton, Emily A. Dowgwillo,
Sindes Dawood and Aaron L. Pincus
Department of Psychology, Pennsylvania State
University, University Park, PA, USA
Synonyms
Personality impairment; Personality pathology
Definition
Personality disorders are a form of psychopathol-
ogy arising from impairments in self- and rela-
tional functioning resulting in identity problems
and maladaptive social behavior.
Introduction
Introduction and History
Personality disorders are a form of psychopathol-
ogy arising from impairments in self- and rela-
tional functioning. Core identity problems and
maladaptive social behavior are what differentiate
personality disorders from anxiety disorders,
mood disorders, etc. However, personality disor-
der symptoms contribute to a wide variety of
urgent secondary complaints including anxiety,
depression, disordered eating, self-harm,
# Springer International Publishing AG 2017
V. Zeigler-Hill, T.K. Shackelford (eds.), Encyclopedia of Personality and Individual Differences,
DOI 10.1007/978-3-319-28099-8_923-1
substance abuse, etc. In the first half of the twen-
tieth century, personality disorders were identified
and discussed in Freud’s (1914) psychoanalytic
theory, Reich’s (1949) character analysis, and
other early psychodynamic formulations. By the
1950s, a taxonomy of personality disorders
emerged in descriptive psychiatry (Schneider
1950) that evolved into the contemporary taxon-
omies found in the ICD-11 and the DSM-5 and
their prior versions. Here, we focus on the DSM.
DSM-I
The publication of DSM-I (American Psychiatric
Association, APA 1952) provided the first widely
adopted psychiatric nomenclature in the United
States. The personality disorders section included
three subsections: personality pattern distur-
bances (paranoid, schizoid, cyclothymic, inade-
quate), personality trait disturbances (passive-
aggressive, compulsive, emotionally unstable),
and sociopathic personality disturbances
(antisocial, dyssocial, sexual deviation, addic-
tion). This initial taxonomy was based entirely
on clinical observation and opinion, and the entire
DSM-I was problematic in terms of reliability and
validity of its diagnoses. One particularly prob-
lematic aspect of DSM-I was the requirement that
the clinician choose between a primarily neurotic
(symptom) disorder or a primary characterologi-
cal (personality) disorder. This is inconsistent
with the common pan-symptomatic presentation
of personality disorders in clinical settings.
2 Personality Disorder
DSM-II
Although the publication of DSM-II (APA 1968)
was an improvement in terms of organization, it
continued to be based on clinical observation in
the tradition of descriptive psychiatry. Addictions
and sexual deviations were moved from the per-
sonality disorders section, personality disorder
labels were revised, and new personality disorder
diagnoses were added. The personality disorders
included paranoid, schizoid, cyclothymic, inade-
quate, hysterical, obsessive-compulsive, passive-
aggressive, explosive, aesthenic, and antisocial.
Arising from the new attitudes toward mental
health diagnoses based in the patient advocacy
movements of the times, as well as continued
problems with DSM-II diagnostic reliability, a
major shift to highly specific diagnostic criteria
and an emphasis on diagnostic reliability were the
foundation of the major revision found in DSM-
III (Decker 2013).
DSM-III/DSM-III-R
The dramatic revision found in DSM-III (APA
1980) included many innovations, the most
important being provision of highly specific and
explicit diagnostic criteria for each disorder with
the aim of improving reliability of psychiatric
diagnoses. Another important structural change
was the shift to a multiaxial format and the place-
ment of personality disorders on Axis II. This
ensured that clinicians would consider personality
disorder diagnoses for all patients, even in the
presence of urgent symptoms and complaints.
Four personality disorders were deleted
(aesthenic, cyclothymic, explosive, inadequate)
and five new personality disorder diagnoses
were added (borderline, narcissistic, avoidant,
dependent, schizotypal). These diagnostic catego-
ries were grouped into Cluster A – odd/eccentric
(paranoid, schizoid, schizotypal), Cluster B – dra-
matic/erratic (borderline, narcissistic, antisocial,
histrionic), and Cluster C – anxious (avoidant,
obsessive-compulsive, dependent). The changes
to personality disorder diagnoses in DSM-III
stimulated increased interest in treatment and
research. However, only a subset of diagnostic
criterion sets were based on empirical findings
(e.g., antisocial personality disorder, borderline
personality disorder) and problems with various
criteria were quickly identified. The revisions
found in the DSM-III-R (APA 1987) were limited
to edits aimed at improving consistency, clarity,
and conceptual accuracy of the diagnostic criteria.
The personality disorders included schizoid, para-
noid, schizotypal, histrionic, borderline,
obsessive-compulsive, dependent, passive-
aggressive, avoidant, narcissistic, and antisocial.
DSM-IV
The revisions found in DSM-IV (APA 1994)
included reducing the length and complexity of
the diagnostic criteria and a more rigorous and
systematic empirical evaluation of the document
using comprehensive research literature reviews,
reanalyses of existing data, and field trials. The
results included deletions and revisions to most of
the personality disorder diagnostic criteria and the
deletion of passive-aggressive personality
disorder.
DSM-5
At the time the revision process for DSM-5 began,
a neurobiological and genetic paradigm shift was
taking hold in the study of psychopathology.
Lofty aims for major changes in the basis for
classification and diagnosis were announced at
the outset of the revision process, which can be
traced to Kupfer et al. (2002) in A Research
Agenda for DSM-V. Eleven conferences took
place over several years in which concepts,
research, and proposals were reviewed. By the
time the revision was due (and needed), the sci-
ence had not yet caught up to the ambitions. With
the exceptions of moving some disorders around
and discontinuing the multiaxial format, the ulti-
mate revisions were more modest. Nowhere is that
more evident than for the personality disorders. In
fact, the DSM-5 (APA 2013) contains two
completely separate diagnostic systems for per-
sonality disorders. The main “Section II” diagnos-
tic chapter simply reprints the DSM-IV diagnostic
criteria. This is unfortunate as it ignores years of
accumulating research suggesting that these DSM
personality disorder categories have limited valid-
ity and clinical utility, and an even more abundant
research literature indicating that individual
Personality Disorder
differences in personality are best assessed and
understood using dimensional trait models.
An Alternative Model for Personality Disor-
ders (AMPD; Skodol 2012) appears in DSM-5
Section III. Zachar et al. (2016) provide a fasci-
nating “oral history” of the genesis of the AMPD
compiled from interviews with many of the par-
ticipants involved in revising the personality dis-
order diagnosis for the DSM-5. The Personality
and Personality Disorder Work Group (PPDWG)
examined complex and competing issues and pro-
posals such as prototype versus dimensional diag-
nosis and the evidential value of clinical
experience versus empirical data. The PPDWG
concluded a hybrid approach to personality disor-
der diagnosis (Krueger et al. 2007) could enhance
acceptance by striking a balance between intro-
ducing dimensional elements, which have sub-
stantial empirical support, while preserving
continuity with extant DSM categories with dem-
onstrated clinical traction. For example, in the
DSM-5, antisocial personality disorder, a categor-
ical concept, can be viewed as dysfunctional
behavior related to a combination of pathological
trait dimensions including manipulativeness, cal-
lousness, deceitfulness, hostility, risk taking,
impulsivity, and irresponsibility.
The AMPD was approved by the DSM-5 Task
Force, but the Board of Trustees of the American
Psychiatric Association rejected it and retained
the traditional categorical approach (the DSM-IV
personality disorders) in Section II. The AMPD is
an official alternative and a recognized competitor
to the traditional categorical model. It legitimately
complements the DSM-5 Section II personality
disorder diagnoses and has practical relevance
for clinicians (Waugh et al. 2017). Indeed, the
DSM-5 allows for formal coding of the AMPD
through use of the DSM-5 code Other Specified
Personality Disorder (301.89).
Diagnosis with the AMPD requires fulfilling
seven general criteria for personality disorder.
Most innovative are the first two criteria: Criterion
A (level of personality functioning) and criterion
B (maladaptive personality traits). Criterion
A involves assessment of disturbance in self func-
tioning (identity and self-direction) and interper-
sonal functioning (empathy and intimacy).
3
Criterion B involves assessment of pathological
personality traits which are organized into 5 broad
trait domains composed of 25 specific trait facets.
Criteria C through G cover issues of pervasiveness,
stability, early emergence, discrimination from
other mental disorders, effects of substances, and
developmental stage or sociocultural environment.
The AMPD permits diagnosis of six specific
personality disorder categories through algorithms
for combining ratings of maladaptive traits and
specific forms of Criteria A dysfunction. These are
antisocial, avoidant, borderline, narcissistic,
obsessive-compulsive, and schizotypal personality
disorders (these were chosen for inclusion on the
bases of empirical support and clinical relevance,
and their diagnostic algorithms were calibrated with
known prevalence rates of the personality disor-
ders). Maladaptive personality patterns not covered
by these algorithms (such as paranoid, schizoid,
histrionic, and dependent) are diagnosed as Person-
ality Disorder-Trait Specified (PD-TS). In a PD-TS
diagnosis, the specific clinically significant traits are
stated in lieu of an overarching category (e.g.,
PD-TS with suspiciousness, restricted affectivity,
and hostility may diagnose “paranoid” personality
disorder). This aims to correct the problem of the
ambiguous and ubiquitous “PD Not Otherwise
Specified” diagnosis by providing a scheme for
clearly characterizing the numerous patients who
do not fit well into available personality disorder
categories. In a related manner, additional signifi-
cant traits can be included with categorical diagno-
ses when indicated, conveniently providing the
clinician with information about patient personali-
ties that is not captured by the specific personality
disorder category.
Presentation, Development, and Course
In the following sections we describe various
aspects of the presentation, development, and
course of personality disorders.
Epidemiology
Epidemiology of personality disorders aims to
identify the distribution and prevalence of person-
ality disorders in a population. Torgersen (2012)
4 Personality Disorder
conducted an analysis of personality disorder
prevalence rates across numerous studies with
varying populations and estimated that personal-
ity disorders affect 10.5–12% of community
dwelling adults. When divided into DSM-5 clus-
ters, Cluster A has a prevalence rate of 4%, and
Cluster B has a prevalence rate ranging from 3.5%
to 4%. Cluster C occurs the most frequently with a
prevalence rate of 7–7.5% (APA 2013). It is also
valuable to consider the clinical prevalence rates
of diagnosed personality disorders among patients
receiving psychiatric care as clinical prevalence
rates are higher than those observed in the com-
munity. Calculated from various epidemiological
studies, Torgersen (2012) reports a clinical popu-
lation prevalence rate of about 66%. The DSM
clusters of personality disorders mirror this
increase in frequency: Cluster A (11%), Cluster
B (32%), and Cluster C (28%). Moreover, border-
line personality disorder is the most common per-
sonality disorder in clinical populations.
According to the DSM-5 Section II diagnostic
criteria, personality disorders are marked by sig-
nificant distress or impairment in interpersonal
functioning, cognition, behavior, and emotional
response (APA 2013). It follows that individuals
diagnosed with personality disorders would expe-
rience pervasive dysfunction and diminished
quality of life. In a meta-analysis of studies inves-
tigating maladjustment and outcomes of person-
ality disorders, individuals diagnosed with Cluster
A personality disorders, borderline personality
disorder, avoidant personality disorder, and
dependent personality disorder were observed to
experience the most dysfunction and reduced
quality of life, possibly from the rampant interper-
sonal issues that afflict each disorder.
In addition to considering the prevalence and
consequences of personality disorders, it is crucial
to consider their distribution across age and gen-
der. Personality disorders are diagnosed in indi-
viduals who are at least 18 years old due to the
pervasive pattern of maladaptive behavior
required for a diagnosis. Cluster B personality
disorders are more common in younger adults,
especially antisocial personality disorder and bor-
derline personality disorder. There are no signifi-
cant differences regarding age and personality
disorders generally, Cluster A personality disor-
ders, and Cluster C personality disorders. There-
fore, personality disorders are relatively evenly
distributed among age groups. Mirroring the uni-
formity in age, personality disorders do not vary
greatly by gender. Some specific personality disor-
ders may be more prevalent in men, like antisocial
personality disorder, or in women, like dependent
personality disorder, but globally speaking, person-
ality disorders occur equally in men and women. In
sum, personality disorders are present in commu-
nity dwellers, with higher prevalence rates in clin-
ical samples. Due to the nature of personality
disorders, poor behavioral, interpersonal, and emo-
tional functioning paired with a reduced quality of
life is common among individuals diagnosed with
personality disorders. Finally, personality disorders
are a universal issue that equally affects age groups
and genders. In order to gain a better understanding
of personality disorders, it is imperative to consider
genetic and heritability factors that can give rise to
their manifestation.
Genetic Factors
A major goal in behavioral genetic research is to
parse out the influence of both genes and environ-
ment on the manifestation of personality disor-
ders. This manifestation takes the form of
observable behaviors or characteristics and is
often referred to as a phenotype, a visible expres-
sion of genes. These phenotypic expressions largely
influence how personality disorders are conceptu-
alized and classified. According to a meta-analysis
conducted by South et al. (2012), both genes and
environment play significant roles in trait expres-
sion in personality disorders. Furthermore, South
et al. (2012) found that the heritability of personal-
ity disorders falls between 40% and 50%. Through
a behavioral genetics perspective, personality dis-
orders can be conceptualized as resulting from
about equal genetic and environmental factors.
Notable progress in identifying the genetic
loading of personality disorders has also occurred.
By identifying common genes that predispose an
individual to a specific dysfunction, the dimen-
sionality and overlap of personality disorders is
identified, providing a deeper understanding of
cause and conceptualization. Comparing the
Personality Disorder
identical genes and dissimilar environments of
twins, shared genetic risk factors for Cluster
A personality disorders were identified (Kendler
et al. 2006). Moreover, personality disorders in
Cluster B and Cluster C have common genetic
liability within clusters (Reichborn-Kjennerud
et al. 2007; Torgersen et al. 2008). This common-
ality among clusters illuminates the similarities of
personality disorders within a grouping as well as
how genes impact observable traits and, therefore,
classification. A study conducted by Kendler et al.
(2008) provides an example of how environment
can shape gene expression and ultimately lead to a
specific manifestation of noticeable traits. In a
community-based twin study, a gene was identified
to be present in each personality disorder cluster
and have high loading onto paranoid, borderline,
narcissistic, histrionic, obsessive-compulsive, and
dependent personality disorders (Kendler et al.
2008). Because this one gene is associated with
multiple personality disorders, the gene most likely
is indicative of a broad and general vulnerability to
personality disorders in which the observable man-
ifestation of symptoms is significantly influenced
by environment. Progress in genetic research
regarding personality disorders paints a clearer pic-
ture of how and why personality disorders develop
in terms of heritability and environmental influ-
ence. This development can begin as early as child-
hood and persist into adulthood.
Childhood and Adolescent Development
Traditionally, personality disorders are diagnosed
in adulthood due to the rigid and pervasive mal-
adaptive patterns of cognition, affect, and behav-
ior. During childhood and adolescence,
personality characteristics are malleable, change
over the developmental course from childhood to
adulthood, and prove difficult to distinguish
between transitory and appropriate developmental
stages and enduring, maladaptive personality
traits (APA 2013). Although personality disorders
are unlikely to be diagnosed before adulthood,
pathological personality traits that are present
regardless of development stage throughout child-
hood and adolescence are critical markers of later
personality disorder diagnosis. Some assert that
personality disorders can be recognized in
5
adolescence because the structure of dysfunc-
tional characteristics at that stage is similar to the
structure of the personality disorder in adulthood
(Westen et al. 2003). Similarly, each personality
disorder of the DSM-5 has a “development and
course” clause to be used when pinpointing per-
sonality disorder features in childhood and ado-
lescence. In the Children in the Community (CIC)
Study, a group of children was assessed for per-
sonality disorder features at various time points
(Cohen and Cohen 1996). Mothers and children
in two New York counties participated in the study
due to mothers expressing need for children’s ser-
vices. Beginning in adolescence, the children were
assessed for personality disorders. Individuals
who reported greater personality disorder traits
significantly differed in functioning than those
who did not (Crawford et al. 2005). This longitu-
dinal example of stable impairment suggests the
need for early identification of personality disorder
traits due to the maintained risk over time.
Because personality disorders are generally
diagnosed in adulthood, an epidemiological
study of prevalence rates of personality disorders
in adolescence does not exist; however, the prev-
alence of personality disorders in adolescence is
estimated to be 6–17% based off of the data from
the CIC Study (Johnson et al. 2006). Personality
disorder characteristics may be present in adoles-
cence, but the characteristics may not yet be stable
and enduring patterns of behavior. Furthermore, it
is generally accepted that mood and anxiety dis-
orders in childhood are predictive of personality
disorders in adulthood (De Fruyt and De Clercq
2012). In sum, early manifestation of dysfunc-
tional traits is associated with increased genetic
loading for disorders and inability to fully recover
from related impairments. This chronic and per-
vasive pattern can last into adulthood where a
personality disorder diagnosis can then be
applied. Just as genes can predispose an individ-
ual to choose a specific environment, experiences
can mitigate or exacerbate the influence of genes
and serve as protective or accelerating factors on
the later development of personality disorders.
Thus, features of dysfunction in childhood and
adolescence are indicative of greater dysfunction
later in life and should be identified early.
6 Personality Disorder
Course
Personality disorders are characterized as being
enduring and stable patterns of behavior with an
onset in late adolescence or early adulthood (APA
2013). However, recent findings suggest that per-
sonality disorders may not be as untreatable and
unmalleable as previously thought. Data from the
CIC Study, a longitudinal study collecting infor-
mation regarding personality disorders from
childhood to adulthood, were used to estimate a
point-prevalence rate (i.e., an estimate of preva-
lence based on a single time point) ranging from
about 13% to 15% and a lifetime prevalence rate
(i.e., cumulative assessment across all time
points) of about 28% (Johnson et al. 2008).
Because the prevalence rates differ, there is evi-
dence that the course of personality disorders is
not completely stable across the lifespan. Simi-
larly, the data from the Longitudinal Study of
Personality Disorders, comprised of 250 college
students assessing the stability of personality dis-
orders over time, found variable improving and
declining trajectories of personality dysfunction
across participants (Wright et al. 2011). The
McLean Study of Adult Development, consisting
of 290 in-patient participants diagnosed with bor-
derline personality disorder illustrating that severe
personality disorders could remit, and a reduction
in severity and number of symptoms could occur
(Zanarini et al. 2003). Finally, 85% of patients
assessed in the Collaborative Longitudinal Per-
sonality Disorder Study remitted after a 10-year
period (Gunderson et al. 2011). These examples,
paired with identifiable dysfunctional traits in
childhood and adolescence, illustrate that person-
ality disorders may not be as stable and consistent
as originally thought supporting the need for fur-
ther research into the variable development,
course, and treatment outcomes for personality
disorders.
Comorbidity
Co-occurring psychological disorders are often
the rule rather than the exception, and personality
disorders are no different. Personality disorders
are extensively comorbid with each other as well
as other psychopathology. It is estimated that 50%
of individuals who have one diagnosed
personality disorder also meet the criteria neces-
sary for a diagnosis of multiple personality disor-
ders (Zimmerman et al. 2005). Trull et al. (2012)
analyzed the prevalence rates of co-occurring per-
sonality disorders in clinical samples in order to
discern correlations between personality disor-
ders. Results indicate that narcissistic personality
disorder was the most likely to occur alongside
other disorders while antisocial personality disor-
der was the least likely, and personality disorders
within Cluster A and Cluster B were highly cor-
related. The comorbidity among personality dis-
orders suggests marked overlap in diagnostic
criteria as well as severity of symptomatology.
Personality disorders are also commonly comor-
bid with other forms of psychological disorders.
The widespread comorbidity of personality disor-
ders with other psychological disorders signifies
the complexity of interactions between mecha-
nisms driving dysfunction as well as the shared
symptomatology criteria of various disorders.
Cultural Considerations
Considering the cultural aspects of personality
disorders proves to be a critical yet difficult task.
Cultural considerations of personality disorders
are lacking an overarching, cohesive theory and
research. One central issue rests in how culture is
defined as the chosen definition of culture directly
influences how cultural aspects relate to personal-
ity disorders. Without a consensus, there is vari-
ability in piecemeal findings. Additionally,
research regarding culture and personality disor-
ders is lacking; thus, the findings to consider and
compare are sparse. The majority of personality
disorders and culture research uses the distinction
between individualism and collectivism (Mulder
2012). It is clearly important to consider differ-
ences in societies that endorse personal unique-
ness and those that promote cooperativeness,
interpersonal relationships, and social roles. Addi-
tionally, cross-culturally reliable personality
traits, as well as culturally unique characteristics
that constitute dysfunctional behavior should be
identified when forming classification standards
for and diagnosis of personality disorders (Mulder
2012; Ryder et al. 2015).
Personality Disorder
Conceptualization
Major approaches to conceptualizing the nature of
personality disorders are reviewed in the follow-
ing sections.
Neurobiological Conceptualization
Neurobiological approaches to personality disor-
ders have primarily focused on identifying endo-
phenotypes (observable characteristics with clear
genetic connections that are associated with a
larger disorder without themselves being direct
symptoms of the disorder) associated with mal-
adaptive personality dimensions and traits. Person-
ality disorders then are conceptualized as complex
combinations of these endophenotypes. Thus far,
endophenotypes associated with a number of per-
sonality dimensions have been examined (Depue
and Lenzenweger 2006; Roussos and Siever
2012). These dimensions include but are not lim-
ited to psychotic-like perceptual distortions and
cognitive impairment (commonly associated with
DSM-5 Cluster A), affective instability, aggres-
sion, and impulsivity (commonly associated with
DSM-5 Cluster B), and anxiety and compulsivity
(commonly associated with DSM-5 Cluster C).
Cluster A. Most of the research on possible
endophenotypes associated with Cluster A has
focused on schizotypal personality disorder. As
part of the schizophrenia spectrum, schizotypal
personality disorder is characterized by
psychotic-like perceptual distortions and cognitive
and social impairments. Higher dopamine neuro-
transmission is consistently associated with per-
ceptual distortions and is often found in
individuals with schizophrenia. Although they
have consistently less dopaminergic activity than
acutely schizophrenic patients, individuals with
schizotypal personality disorder seem to exhibit
modestly increased dopaminergic activity (Siever
and Davis 2004). It is possible that reduced striatal
and caudate volumes and elevated relative glucose
metabolic rate in the striatum (Levitt et al. 2004;
Shihabuddin et al. 2001) may protect schizotypal
patients from more apparent psychosis.
Unlike other personality disorders, schizotypal
personality disorder is associated with deficits in
sustained attention, working memory, and verbal
7
learning that may contribute to the interpersonal
impairments characteristic of the diagnosis
(Mitropoulou et al. 2002). Deficient prepulse inhi-
bition and impaired P50 wave suppression suggest
that these deficits may result from an inability to
filter out irrelevant information early on in infor-
mation processing (Cadenhead et al. 2000; Kumari
et al. 2005). Although schizotypal personality dis-
order is more generally associated with increases in
dopamine activity, decreases in dopamine activity
in the prefrontal cortex may explain deficits in
working memory, executive functioning, and to a
lesser degree, sustained attention and verbal learn-
ing (Roussos and Siever 2012). Dopamine agonists
have been found to improve performance in these
domains (Rosell et al. 2015). Additionally,
although findings are inconsistent, qualitative def-
icits in smooth pursuit eye movement measures
have been proposed as a candidate endophenotype
for schizotypal personality disorder.
Cluster B. Research on possible endo-
phenotypes associated with Cluster B personality
disorders has focused on the dimensions of affec-
tive instability, aggression, and impulsivity, par-
ticularly in borderline personality disorder
populations. Research on the limbic system, an
area of the brain associated with encoding,
inhibiting, and regulating emotions, has also
been examined. Although results across studies
are inconsistent, a meta-analysis on limbic system
structures in borderline patients suggests that
these patients have reduced bilateral hippocampal
and amygdala volumes compared to healthy con-
trols (Nunes et al. 2009). Functionally, borderline
patients have shown increased amygdala activity
when viewing aversive stimuli (Koenigsberg et al.
2009) and similar amygdala responses across
aversive and neutral stimuli (Schnell et al. 2007).
This suggests a possible neural explanation for the
heightened emotional responsiveness characteris-
tic of borderline personality disorder.
Research on the neurobiological correlates of
impulsive aggression has found evidence of
increased limbic reactivity paired with a
decreased ability to control aggressive impulses
and behaviors. Among borderline patients,
aggression has been associated with a heightened
relative glucose metabolic rate in limbic
8 Personality Disorder
structures, including the amygdala and
orbitofrontal cortex (OFC), and a lower glucose
metabolic rate in more dorsal brain regions asso-
ciated with cognitive control (Roussos and Siever
2012). Additionally, amygdala and OFC activa-
tion is only weakly correlated in patients with
Cluster B personality disorders (New et al. 2007)
suggesting decreased functional connectedness
between emotion related and inhibitory regions
of the brain, making it difficult to modulate
aggressive impulses.
Evidence of a diminished capacity of the sero-
tonergic system, which plays an important role in
the top-down regulation of aggression, was asso-
ciated with intense anger, impulsivity, and self-
damaging behavior (but not affective instability)
in borderline patients (Coccaro et al. 1989). These
abnormalities may be due to a number of poly-
morphisms in genes related to the synthesis,
metabolism, and receptor responsiveness of the
serotonergic system that have been implicated in
aggression. In addition to the diminished activa-
tion in areas of the frontal cortex involved in
impulse control and diminished capacity of the
serotonergic system, impulsivity more generally
has also been associated with variations in dopa-
minergic genes.
Cluster C. Very few neurobiological studies
have examined Cluster C personality disorders.
The limited work has identified altered dopamine
and serotonin activity in social anxiety disorders
more generally, which are highly comorbid with
avoidant personality disorder (Mathew et al.
2001), as well as links between serotonin deficits
and impulsive aggressive symptoms in obsessive
compulsive personality disorder (Stein et al.
1996). Allelic variants of the dopamine receptors
D3 and D4 have also been associated with
increased rates of avoidant and obsessive compul-
sive personality disorder symptomatology (Joyce
et al. 2003).
Cognitive Conceptualization
A cognitive theory of personality disorders
assumes that humans are constantly and continu-
ously perceiving, interpreting, recalling, and
learning from information in their environment
(Pretzer and Beck 2005). To facilitate processing
this information, individuals develop schemas or
cognitive frameworks that help the individual
organize and interpret incoming information,
decide what information to attend to, and antici-
pate and navigate similar situations in the future.
Ideally, an individual will accurately perceive and
correctly interpret the situation using their
schemas and as a result have adaptive and appro-
priate cognitive, emotional, and behavioral
responses. However, schemas can also bias the
way an individual processes information by
influencing three important aspects of cognition:
automatic thoughts (an immediate and spontane-
ous appraisal of the situation), interpersonal strat-
egies (beliefs and assumptions about how to
respond when certain automatic thoughts occur),
and cognitive distortions (systematic errors in rea-
soning that can contribute to misinterpretations of
events). When an individual’s perception or inter-
pretation is biased, their cognitive, emotional, and
behavioral responses will be inappropriate to
some extent. Given the ambiguity of many inter-
personal interactions and the complexity of daily
life, isolated misperceptions are inevitable and
can be addressed by corrective feedback and sub-
sequent experience. Psychopathology, and in par-
ticular, personality pathology, occurs when an
individual experiences the world in a chronically
distorted and systematically biased way that
results in large discrepancies between their sub-
jective experience and objective reality. Once this
occurs, an individual’s schemas tend to bias their
perception of events, including feedback, such
that counterevidence is overlooked, discounted,
or misinterpreted. Additionally, consistently
distorted responses may create a self-fulfilling
prophecy, where others begin to act in ways con-
sistent with the original distortion.
Thus from a cognitive perspective, the term
personality disorder applies to individuals with
pervasive, self-perpetuating, cognitive interper-
sonal cycles that cause significant distress and
are resistant to change (Pretzer and Beck 2005).
Personality disorders can be differentiated from
one another based on differences in the content of
the individual’s commonly activated schemas,
beliefs, assumptions, and distortions. Core mal-
adaptive beliefs and schemas associated with
Personality Disorder
different types of personality disorders have been
systematized (Beck et al. 2015; Young
et al. 2003).
Psychodynamic Conceptualization
A psychodynamic perspective is inherently broad
and encapsulates a number of different
approaches and theories. The current discussion
will focus predominately on an object-relations
theory perspective on personality pathology
(Yeomans et al. 2015), which predominates in
contemporary discussions and most directly
relates to the dynamic treatment approaches pre-
sented below. More information on alternative
psychodynamic conceptualizations can be found
elsewhere (e.g., McWilliams 2011).
From an object-relations perspective, a
description of personality disorders begins with
the symptoms or descriptive features of the disor-
der, including an individual’s presenting prob-
lems, maladaptive personality traits, and the
quality of their interpersonal relationships. This
understanding then deepens to include a struc-
tural formulation (i.e., persistent ways the indi-
vidual organizes experience of self and other) that
underlies those symptoms. The structural formu-
lation provides information about the severity of
the individual’s personality pathology (ranging
from healthy and neurotic levels of functioning
to borderline and psychotic levels of functioning).
Because the structural formation is integral in
determining whether personality pathology is pre-
sent and if so, its severity, the structural formula-
tion is described in greater detail below. Finally, a
comprehensive description of personality pathol-
ogy includes developing a theory about the indi-
vidual, including what might be motivating the
individual’s behavior without their awareness and
what internal conflicts might be present, to give
meaning to the descriptive and structural features.
The structural formulation begins by examin-
ing how an individual views themselves and other
people. When identity is integrated, individuals
have the capacity to pull together different aspects
(both good and bad) of the self and/or other to
comprise a coherent, complex, and whole picture
of a person that is consistent over time and across
experiences. Lower levels of functioning are
9
characterized by identity diffusion. When identity
diffusion occurs, an individual’s sense of self and
other is loosely organized, lacks depth and sub-
tlety, is polarized (very good or very bad with few
shades of gray in between), and is unstable across
time and situations. Individuals with diffuse iden-
tities tend to have inconsistent tastes, opinions,
and values that are often adopted from those
around them and have trouble accurately under-
standing other people and responding appropri-
ately to social cues. Personality rigidity, a second
component of a structural formulation, refers to
the automatic, repeated, and inflexible activation
of particular behaviors across situations regard-
less of whether they are appropriate to the situa-
tion. Generally, greater rigidity is associated with
greater personality pathology.
Additionally, the structural formulation is
determined by how an individual responds to dis-
tress and can the person accurately decide what is
real and what is not. Defenses are the strategies a
person uses to minimize distress. Individuals that
use predominately mature defenses, like humor or
anticipating and preparing for potentially stressful
situations, tend to be higher functioning. Mature
defenses involve minimal reality distortion and do
not keep distressing information out of awareness.
Neurotic defenses avoid unpleasant feelings by
repressing or keeping distressing parts of experi-
ence from awareness, distorting internal but not
external reality. Primitive defenses make use of
dissociation or splitting to avoid emotional dis-
tress. Splitting refers to a process in which two
aspects of experience that are in conflict (often the
positive, idealized aspects of experience and neg-
ative, persecutory aspects of experience) are com-
partmentalized. That is, both are allowed to
emerge into awareness but not at the same time,
distorting a person’s external reality and often
leading to affectively charged, rapid, and chaotic
shifts in experience.
Thus, according to object-relations theory,
healthy individuals are characterized by an inte-
grated identity, flexible adaptation, mature
defenses, and intact and stable reality testing. At
the neurotic level of personality organization,
individuals are characterized by maladaptive per-
sonality rigidity in the presence of normal identity,
10
a predominance of higher level, repression based
defenses, and intact reality testing. The more
severe, borderline organization is associated with
clinically significant identity pathology, a pre-
dominance of lower level splitting based defenses,
and reality testing that deteriorates in affectively
intense situations.
Interpersonal Conceptualization
According to Contemporary Integrative Interper-
sonal Theory (CIIT; Dawood et al. in press;
Pincus 2005), the most important expressions of
personality and personality pathology occur in
situations involving more than one person.
These interpersonal situations can occur in the
external world via observable, in-person
(proximal) interactions, or within an individual
via memories of past experiences, fantasies, or
expectations of future experiences. According to
CIIT, both proximal and internal interactions can
be described and conceptualized in terms of
agency and communion. Agency refers to an indi-
vidual’s ability to differentiate themselves and is
manifested in strivings for autonomy, power, and
achievement. Communion refers to an individ-
ual’s ability to integrate themselves into a larger
social entity and is manifested in strivings for
intimacy, union, and solidarity.
Within an interaction, behavior is not random.
Rather, perceived behaviors, which vary in their
level of distortion, tend to pull, elicit, invite, or
evoke particular responses. One pattern of behav-
ior that has been well articulated and can be con-
sidered a common baseline for healthy
socialization is interpersonal complementarity.
In interpersonal complementarity, dominant
behavior pulls for submissive behavior on the
agency dimension and friendliness pulls for
friendliness while hostility pulls for hostility on
the communal dimension. Other patterns of
behavior are unique to the individual and develop
based on past experience and learning history.
These patterns can be adaptive and help the indi-
vidual navigate their social world or can be prob-
lematic and disrupt an individual’s interpersonal
functioning.
CIIT proposes that healthy individuals gener-
ally have an undistorted internal situation that
Personality Disorder
closely matches the unfolding proximal situation
and are, therefore, able to accurately respond to
the agentic and communal bids offered by others.
Personality pathology occurs when an individual
chronically distorts the agentic and communal
behavior of self and others resulting in maladap-
tive interpersonal functioning. Because they often
distort reality, individual with personality disor-
ders may react chaotically, self-protectively, or
rigidly pull for complementary responses, but
have difficulty responding to others in comple-
mentary ways. This reduces the likelihood that
the agentic and communal needs of both people
will be satisfied in the interpersonal situation and
create disturbed interpersonal relations (Hopwood
et al. 2013; Pincus and Hopwood 2012).
Integrative Conceptualizations
According to an integrative perspective, a person-
ality disorder develops when personality traits
become extreme and begin to interfere with occu-
pational and interpersonal functioning. This com-
plex process cannot be fully explained from a
purely biological, psychological, or social per-
spective. Thus, an integrative perspective tends
to follow a biopsychosocial model that attributes
the development of personality disorders to the
interaction between biological (temperament),
psychological, and social factors (Paris 2012).
Temperament is composed of the in-born ten-
dencies that underlie individual differences in
traits related to reactivity and self-regulation,
including emotionality (in how a person experi-
ences and expresses negative emotions), activity
level, sociability, and shyness. While tempera-
ment itself is not sufficient for the development
of a personality disorder, the genetic vulnerabil-
ities associated with temperament do appear to
link personality traits and psychopathology
(vulnerability model). There is also evidence that
a person’s temperament may influence the sever-
ity of personality pathology when present
(pathoplasiticity model).
Although there are a number of psychological
factors that can influence the development of a
personality disorder, childhood adversity has
received particular attention in the literature.
Research on the effects of childhood physical
Personality Disorder
and sexual abuse, early separations or losses, bul-
lying and violence in school, and abnormal par-
enting behavior has identified these variables as
possible risk factors. However, given that many
children who experience these risk factors never
develop a personality disorder, the etiological sig-
nificance of any one risk factor remains unclear.
Rather, the cumulative experience of adversity in
childhood seems to best explain the lower thresh-
olds for psychopathology in this population
(Rutter et al. 2006).
In addition to biological and psychological
considerations, personality disorders develop in a
sociocultural context and appear to be socially
sensitive. Although the role of social factors has
not been widely studied, a number of theoretical
models have been proposed. One hypothesis sug-
gests that modernity and social change have
increased the risk for impulsive personality disor-
ders (Paris 2004) and is supported by cross-
cultural studies that have found lower rates of
antisocial personality disorder in more traditional
societies (Hwu et al. 1989). Researchers also
hypothesize that cohort effects (changes in person-
ality disorder prevalence rates over brief periods of
time) could be due to difficulty adapting to a
changing, less supportive society and propose
that acting impulsively may be one way to deal
with emotional dysregulation (Linehan 1993).
An integrative perspective then suggests that
the biological, psychological, and social risk fac-
tors for personality disorders be integrated within a
single interactive and integrative model. Heritable
factors influence individual variability in tempera-
ment and trait dimensions. However, this variabil-
ity usually only becomes maladaptive when
amplified by cultural context and cumulative life
stressors. Thus, according to the integrative model,
temperamentally predisposed individuals who
experience multiple risk factors would be most
likely to develop a personality disorder later in life.
Empirically Supported Treatment
Over the past several decades, evidence-based
treatments have emerged for treating personality
disorders. We briefly describe the most researched
11
and well-validated treatments, including symp-
tom-oriented psychopharmacology, dialectical
behavioral therapy, schema-focused therapy,
mentalization-based therapy, transference-focused
psychotherapy, and interpersonal psychotherapy.
Psychopharmacology
Although there are no medications specifically
approved by the United States Food and Drug
Administration for the treatment of personality
disorders, medications are regularly used in their
treatments. Randomized controlled trials for per-
sonality disorders, of which most focus on bor-
derline personality disorder (BPD), show that
mood stabilizers and anticonvulsants are useful
in treating depression and affective instability in
BPD as well as specific symptoms in personality
disorders more generally, particularly aggression
and impulsivity, characteristics of both BPD and
antisocial personality disorder (see Paris 2011;
Ripoll et al. 2011 for reviews). Antidepressants
are also efficacious in reducing anger, aggression,
and impulsivity in personality disorders; antipsy-
chotics are efficacious for decreasing psychotic-
like symptoms in both BPD and schizotypal per-
sonality disorder; and monoamine oxidase inhib-
itors for reducing social anxiety in avoidant
personality disorder. Overall, medications may
be useful in treating specific symptoms of person-
ality disorders, but they should be considered an
adjunctive rather than as a stand-alone interven-
tion, as psychotherapy is considered the gold stan-
dard for treatment of personality disorders.
Dialectical Behavior Therapy
Dialectical behavior therapy (DBT) is a specific
type of cognitive-behavioral therapy (CBT)
developed in the late 1980s by Linehan (1993),
initially to treat chronically suicidal, multi-
problem patients (e.g., BPD), but has since been
extended to patients with traditionally difficult-to-
treat disorders (e.g., eating disorders, substance
dependence; Lungu and Linehan 2016). DBT is
based on the biosocial theory of the etiology of
BPD, and it draws on principles of Zen and dia-
lectical philosophies, blending cognitive-
behavioral methods with more acceptance-based
strategies. This treatment consists of four main
12
components: weekly individual therapy sessions,
weekly skills training groups, weekly therapist
consultation team meetings, and between-session
telephone coaching is offered to patients in
moments of crisis.
One of the most importance aspects of DBT is
the “dialectics” of acceptance and change. That is,
therapists accept the patient as they are (in the
context of emotional validation), but also actively
encourage the patient’s need for behavioral
change. The goals of treatment are to reduce
acute life-threatening behaviors (suicide, self-
harm), reduce behaviors that interfere with ther-
apy (noncompliance, lateness), reduce behaviors
that interfere with quality of life (mental illness,
psychosocial factors), and increase behavioral
skills (mindfulness, emotional regulation, inter-
personal effectiveness, distress tolerance). The
patient uses the new learned skills to deal with
problem behaviors and adversity and to facilitate
achievement of personal goals.
Schema-Focused Therapy
Schema-focused therapy (SFT) also derives
mainly from CBT and was originally developed
in the early 1990s by Young (1994) for patients
who did not respond to standard CBT, most often
those with personality disorders and character-
ological problems. SFT is more integrative than
standard CBT, combining principles and tech-
niques from CBT with psychodynamic, attach-
ment, gestalt, and emotion-focused therapies.
Although first developed for BPD, SFT has since
been elaborated for most personality disorders.
SFT is based on the idea that aversive childhood
experiences and unmet basic childhood needs
(e.g., safety, autonomy, love, acceptance, respect)
lead to the development of early maladaptive
schemas, which are negative thoughts and feel-
ings individuals have about themselves and their
relations with others. Young described 18 mal-
adaptive schemas; examples of schemas in per-
sonality disorders include abandonment, mistrust/
abuse, shame/defectiveness, and unrelenting stan-
dards (Young et al. 2003). If a schema becomes
triggered, associated negative emotions result and
a maladaptive coping response arises (e.g., avoid-
ance, surrender, overcompensation). Though
Personality Disorder
these coping strategies may mitigate intense neg-
ative emotions, they inadvertently reinforce the
underlying schema and cause problems in self
and interpersonal functioning. SFT focuses on
helping patients identify their schemas and
replace them with more adaptive ones. To accom-
plish this, SFT uses four core mechanisms: (1) lim-
ited reparenting, (2) experiential imagery and
chair dialogue work, (3) education and cognitive
restructuring, and (4) behavioral pattern breaking.
A major component of SFT is the therapeutic
relationship, which is conceptualized as limited
reparenting. That is, the therapist creates a good,
healthy parent-like relationship with the patient
that is characterized by empathy, warmth, care,
protection, limit setting, and careful self-
disclosure (Young et al. 2003). The corrective
therapeutic experience works to disconfirm and
reshape the patient’s maladaptive schemas and
enhance the patient’s capacity to relate to others
beyond the therapist. Throughout different points
in the therapy, the therapist will use techniques
such as role-playing, letter writing, assertiveness
training, anger management, guided imagery,
relaxation exercises, gradual exposure to
anxiety-provoking situations, and challenge neg-
ative thoughts and beliefs about the self, others,
and the world.
Mentalization-Based Therapy
Mentalization-based therapy (MBT) is a specific
type of psychodynamically oriented therapy,
developed and manualized by Bateman and
Fonagy (2012). They argue that the effectiveness
of all treatments involves increasing the patient’s
capacity to mentalize. Mentalization refers to
one’s ability to think about the mental states (i.e.,
beliefs, desires, needs, feelings, intentions) of
one’s own and others. According to Bateman
and Fonagy, a key problem for individuals with
BPD is a deficit in mentalization, especially
within interpersonal contexts, which leaves them
vulnerable to emotional dysregulation and impul-
sivity. Thus, the focus of MBT is on stabilizing
emotional expression, promoting the exploration
of one’s internal world and that of others, and
strengthening the patient’s sense of self. Specifi-
cally, the therapist follows a series of steps to
Personality Disorder
engage the patient in the process of mentalizing:
(1) empathize and support the patient’s present
subjective state; (2) clarify, elaborate, and chal-
lenge; (3) focus on intense affect states and the
expression of emotions; and (4) mentalize the
therapist-patient relationship. Individual gains
from MBT include more gratifying relationships,
greater tolerance of distress and negative emo-
tions, and a reduction in impulsive behaviors.
MBT can be delivered in individual, group, or
family settings.
Transference-Focused Psychotherapy
Transference-focused-psychotherapy (TFP) is a
highly structured, once to twice weekly, psycho-
dynamic treatment designed for patients with
BPD and other severe personality disorders
(Yeomans et al. 2015). TFP, based on Kernberg’s
(1984) object relation’s model of identity diffu-
sion in borderline personality organization, con-
ceptualizes the disorder in terms of
undifferentiated and unintegrated representations
of self and others and their affective valence. The
aim of TFP is to help patients “integrate all aspects
of their internal world. . .in order to experience
themselves and others in a coherent and balanced
way” (Yeomans et al. 2015, p. 42). As the patient
develops the capacity to think more flexibly, real-
istically, and benevolently about their own mental
states and those of important others, he or she
tends to experience a reduction in self-defeating
and self-destructive behaviors, increased emotion
regulation and behavioral control, increased
coherence of identity, greater capacity for inti-
macy, and general improvement in symptoms
(e.g., depression, anxiety) and functioning.
TFP begins with establishing a treatment frame
or contract, which outlines the responsibilities and
roles of the patient and therapist, the method of
treatment, and the conditions of the therapy,
including the management of self-harming and
suicidal urges and behavior. As treatment pro-
gresses, the focus shifts to affect-laden themes
that emerge in the “here-and-now” relationship
between the patient and therapist (i.e., transfer-
ence). During the first year of treatment, TFP
focuses on the following hierarchy of goals:
containing suicidal and self-destructive behaviors,
13
recognizing and addressing threats to the treat-
ment, and identifying and recapitulating the
patient’s predominant relational patterns as they
are expressed and experienced outside the con-
sulting room and within the transference. The
therapist repeatedly uses the techniques of clarifi-
cation, confrontation, and interpretation to pro-
vide the patient with the opportunity to integrate
split off and disorganized motives, thoughts, and
feelings, thereby leading to changes in both symp-
toms and personality structure over time.
Interpersonal Psychotherapy
There is no single interpersonal psychotherapy,
but rather interpersonal therapy encompasses a
variety of therapeutic approaches that stem from
the shared view that interpersonal processes are
fundamental to the development and maintenance
of pathology and to the patient’s experience of
distress (Pincus and Cain 2008). The major aim
of interpersonal psychotherapy is to clarify and
increase the personality disorder patient’s under-
standing of how he or she views their maladaptive
communication patterns with others. This new
insight brings about new interpersonal awareness
and social learning; thereby, leading to improved
relational capacity and a reduction in symptoms.
Kiesler’s (1988) interpersonal meta-
communication (IM) is an exemplar of an inter-
personal approach to psychotherapy. IM focuses
on exploring the unfolding relationship between
the patient and therapist, as the therapeutic rela-
tionship is thought to contain important informa-
tion about how the patient views his or her self and
their relationships with others. In the initial phase
of IM, the therapist becomes “hooked” and reacts
to the patient in ways that others do. The therapist
must become aware of this pattern and should
question his or her experience of the patient by
asking questions such as “What is this patient
doing to me?” and/or “What am I feeling when
I’m with this patient?” (Pincus and Cain 2008).
Once attuned to the patient’s maladaptive inter-
personal behavior and communication, the thera-
pist should disrupt it by disengaging or choosing
to respond in an asocial manner (e.g., silence,
reflection of content or feeling, delayed
responses). Doing so provides the patient with a
14
corrective emotional experience and models more
adaptive ways of communicating with others.
Other interpersonal psychotherapies share similar
goals and features to IM but also differ by specific
intervention techniques (see Anchin and Pincus
2010; Cain and Pincus 2016).
Conclusion
Future Directions
The diagnosis and classification of personality
disorders is in flux, as reflected in the two distinct
diagnostic alternatives found in the DSM-5. The
two most important and interrelated challenges
facing the field are transitioning to a dimensional
model of personality disorder and developing
effective treatments for these challenging patients.
Over the last century, based on accumulating
empirical evidence, the study of personality and
individual differences has generally abandoned
typological approaches in favor of hierarchically
arranged dimensional models of personality traits
such as the Five-Factor Model (Digman 1990). In
contrast, the classification of personality disorders
in the psychiatric nomenclature has remained
steadfast in its categorical description of discrete
personality disorder diagnoses (APA 2013).
Although a dimensional representation of person-
ality disorders is possible (Widiger and Simonsen
2005), objections have been raised regarding its
clinical utility and the loss of important clinical
conceptualizations that have a long history in the
field. Although long-standing categorical person-
ality disorder conceptualizations are more familiar
to practitioners, research demonstrates that
dimensional alternatives are actually easier to
use and favored by a majority of clinicians
(Morey et al. 2014). Of the current categorical
diagnoses, the research base on BPD and antiso-
cial personality disorder far exceeds that of the
remaining diagnoses, perhaps because of the
social, medical, economic, and legal costs of
these disorders. Thus the empirical support for
these other categorical diagnoses is weaker and
empirically supported treatments for them are lim-
ited. As reflected in the DSM-5 AMPD, the tide is
now shifting (Krueger 2013), but resistance
Personality Disorder
remains entrenched. We believe that the future of
personality disorder classification and diagnosis
will require a further shift toward dimensional
models and away from categorical
conceptualizations.
The second major challenge for the field is the
development of more effective treatments for per-
sonality disorders. It is notable that virtually all
major therapeutic approaches began as treatments
for BPD and the majority of empirical support for
these treatments involves studies of patients with
BPD. Although the treatments have been
extended to other personality disorders, there has
been little research on their efficacy and effective-
ness for such patients. It remains problematic that
there are no empirically supported treatments
developed specifically for categories of personal-
ity disorder other than BPD, limiting the treatment
implications of these diagnoses. However, this is
likely due to the lack of validity of the current
categories. As conceptualizations shift toward
dimensional models, new treatments will need to
focus on the core impairments of personality dis-
order common across all patients with modifica-
tions directed at working with individual
differences in prominent pathological traits and
their maladaptive behavioral expressions. This
can be conceived of as distinguishing the genus
(personality disorder) and the species (prominent
traits) of individual patients (Pincus 2011). Fortu-
nately, the existing treatments for BPD actually
target many manifestations of the personality dis-
order genus and can likely be further modified and
extended to address problems associated with a
consensus dimensional model describing the indi-
vidual differences of various species that present
for treatment (Pincus et al. 2016). As the field
shifts its perspectives on the conceptualization
and nature of personality disorders, intervention
models will need to shift in concurrence as well.
Cross-References
▶ Antisocial Personality Disorder
▶ Avoidant Personality Disorder
▶ Borderline Personality Disorder
▶ Dependent Personality Disorder
Personality Disorder
▶ Diagnostic and Statistical Manual of Mental
Disorders (DSM-5)
▶ Histrionic Personality Disorder
▶ Narcissistic Personality Disorder
▶ Obsessive-Compulsive Personality Disorder
▶ Schizoid Personality Disorder
▶ Schizotypal Personality Disorder
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