Personality Disorders
TA Widiger and WL Gore, University of Kentucky, Lexington, KY, USA
r 2016 Elsevier Inc. All rights reserved.
Glossary
Antisocial personality disorder A pervasive pattern of
disregard for, and violation of, the rights of others.
Avoidant personality disorder A pervasive pattern of
timidity, inhibition, inadequacy, and social hypersensitivity.
Borderline personality disorder A pervasive pattern of
impulsivity and instability in interpersonal relationships,
affect, and self-image.
Dependent personality disorder A pervasive and
excessive need to be taken care of that leads to
submissiveness, clinging, and fears of separation.
Histrionic personality disorder A disposition to be
emotionally manipulative, intolerant of delayed
gratification, and uncomfortable when not the center of
attention.
Introduction
Everybody has a personality, or a characteristic manner of
thinking, feeling, behaving, and relating to others. Some per-
sons are invariably conscientious and efficient, whereas
others might be consistently undependable and negligent.
Some persons are characteristically anxious and apprehensive,
whereas others are typically relaxed and unconcerned. These
personality traits are integral to each person’s sense of self
because the traits involve what persons value, what they like to
do, and how they behave most every day throughout much of
their lives.
Personality traits have long been the focus of scientific re-
search. Their heritability, childhood antecedents, temporal
stability, universality, and relevance to important life out-
comes, such as success at work, wellbeing, marital stability,
and even physical health have been well established (Ozer and
Benet-Martinez, 2006). It is when personality traits “cause
significant functional impairment or subjective distress”
(American Psychiatric Association (APA) 2013, p. 648) that
they constitute a personality disorder (PD). The APA’s
Diagnostic and Statistical Manual of Mental Disorders, fifth edi-
tion (DSM-5; APA, 2013) provides diagnostic criteria for 10
PDs organized into three clusters: (a) paranoid, schizoid, and
schizotypal (placed within an odd–eccentric cluster); (b)
antisocial, borderline, histrionic, and narcissistic (dramatic–
emotional–erratic cluster); and (c) avoidant, dependent, and
obsessive–compulsive (anxious–fearful cluster).
PDs have perhaps become one of the more controversial,
or polarized, sections of the APA diagnostic manual. It was the
intention of the chair and vice chair of DSM-5 that the latest,
fifth, edition of the diagnostic manual would provide a para-
digm shift (Regier, 2008). They suggested in particular that the
primary contribution of DSM-5 would be a shift toward a
dimensional model of classification, particularly for the PDs
270 Encyclopedia of Mental Health, Volume 3
Narcissistic personality disorder A pervasive pattern of
grandiosity, need for admiration, and lack of empathy.
Obsessive–Compulsive personality disorder A
preoccupation with orderliness, perfectionism, and mental
and interpersonal control.
Paranoid personality disorder A pervasive and
continuous distrust and suspiciousness of the motives of
others.
Schizoid personality disorder A pervasive pattern of
social detachment and restricted emotional expression.
Schizotypal personality disorder A pervasive pattern of
interpersonal deficits, cognitive–perceptual aberrations, and
eccentricities of behavior.
(Rounsaville et al., 2002). A dimensional model of classifi-
cation would enable clinicians and researchers to provide de-
scriptions of personality traits across a continuum ranging
from adaptive traits to maladaptive traits. The DSM-5 per-
sonality and PDs work group, therefore, proposed shifting the
classification toward a dimensional trait model. Their proposal
was approved by the DSM-5 Task Force but rejected by the
APA Board of Trustees. DSM-5 retained all of the PD diagnoses
and criterion sets from the prior edition of the diagnostic
manual, effectively making no revisions to the PD section.
However, the proposals of the work group are included in
Section 3 of DSM-5 for emerging models and measures. Pro-
vided in this article will be a brief discussion of the dimen-
sional trait model proposal and the 10 PDs retained in DSM-5.
DSM-5 Dimensional Trait Model
Mental disorders, including the PDs, appear to be the result of
a progressively developing interaction of an array of biological
vulnerabilities and dispositions with a number of significant
environmental and psychosocial events that occur over time
(Widiger and Gore, 2014). The symptoms and pathologies of
PDs are responsive to a wide variety of neurobiological,
interpersonal, cognitive, and other mediating and moderating
variables that help to develop, shape, and form a particular
individual's personality profile. This complex etiological his-
tory is unlikely to be well described by single diagnostic cat-
egories that attempt to make distinctions at nonexistent
discrete joints. Patients rarely meet diagnostic criteria for just
one PD; there is no clear boundary between their presence
versus absence; specific etiologies, pathologies, and treatments
are not being discovered for most of the PDs; and patients who
meet the criteria for the same PD are often different from one
another in very important ways (Widiger and Gore, 2014).
doi:10.1016/B978-0-12-397045-9.00092-6

As acknowledged in the introduction to DSM-5, “the once
plausible goal of identifying homogeneous populations for
treatment and research resulted in narrow diagnostic categories
that did not capture clinical reality, symptom heterogeneity
within disorders, and significant sharing of symptoms across
multiple disorders” (APA, 2013, p. 12).
The DSM-5 Workgroup, therefore, proposed shifting the
classification of PD to a 5-domain dimensional trait model
(Krueger et al., 2012). The five domains were negative affect-
ivity, detachment, psychoticism (or peculiarity), antagonism,
and disinhibition. Within these five broad domains are 25
relatively more specific traits. For example, within the domain
of negative affectivity are the traits emotional lability, anx-
iousness, separation anxiety, hostility, and depressivity. This
5-domain model is said in DSM-5 to represent “maladaptive
variants of the five domains of the extensively validated and
replicated personality model known as the ‘Big Five,’ or the
Five Factor Model of personality” (APA, 2013, p. 773).
The five-factor model (FFM) of personality is the pre-
dominant dimensional model of general personality structure
within psychology (John et al., 2008). One of the strengths of
the FFM is its robustness. Vast bodies of personality trait re-
search may be readily integrated as traits may be understood
by where they fall within the FFM structure of neuroticism (or
emotional instability), extraversion, openness (or un-
conventionality), agreeableness, and conscientiousness. In-
deed, research indicates as well that the FFM successfully
accounts for the symptoms and traits of the DSM-IV/5 PDs
(Samuel and Widiger, 2008; Widiger et al., 2013). DSM-IV/5
PDs do appear to be maladaptive variants of general person-
ality structure.
There are a number of advantages of integrating the psy-
chiatric PD nomenclature with the FFM. First, as a dimensional
model, the problems of heterogeneity within the diagnostic
categories and the excessive diagnostic co-occurrence are largely
resolved. Rather than force an individual into a category that
fails to provide a fully accurate description, fails to capture
important personality traits, and includes traits that the person
does not have, the FFM would allow the clinician to provide an
individualized profile of precisely the traits that are present. This
type of diagnostic description is considerably more precise and
accurate than a diagnostic category and, as a result, would have
obvious benefits for treatment, research, insurance, and other
social, clinical decisions. In addition, to the extent that the
DSM-IV/5 PDs are maladaptive variants of the domains and
facets of the FFM, all that has become known about the
etiology, course, assessment, correlates, and outcome of FFM
traits can be applied to an understanding of the APA PDs, some
of which have received very little empirical research.
A further advantage of the FFM is the inclusion of normal,
adaptive traits. PDs are among the more stigmatizing labels
within the diagnostic manual. Other mental disorders are
events or experiences that happen to the person during the
course of his or her life, whereas a PD is who that person is. A
PD suggests that who you are and always have been is dis-
ordered (Millon, 2011). The FFM of PD provides a more
complete description of each person’s self that recognizes that
a person is more than just the disorder and that other aspects
of the self can be adaptive, even commendable, despite the
presence of some maladaptive personality traits. Some of these
Personality Disorders 271
personality strengths may be quite relevant to treatment, such
as openness to experience indicating an interest in exploratory
psychotherapy or agreeableness indicating an engagement in
group therapy.
However, as noted earlier, the proposal of the DSM-5
Workgroup and DSM-5 Task Force to shift the classification of
PDs toward the FFM was vetoed by the APA Board of Trustees.
However, the dimensional trait model developed by the
Workgroup was included within Section 3 of the diagnostic
manual for emerging models and measures.
DSM-5 Personality Disorders
There is consensus within the field that antisocial, borderline,
and schizotypal are the most heavily researched PDs. There is
general agreement that there is relatively little research con-
cerning the paranoid, schizoid, and histrionic PDs. However,
there is disagreement within the field concerning the extent of
empirical support concerning the narcissistic, dependent, avoi-
dant, and obsessive–compulsive PDs (Mullins-Sweatt et al.,
2012; Skodol, 2012). Each of these PDs will be discussed in turn.
Antisocial Personality Disorder
Antisocial personality disorder (ASPD) is a pervasive pattern of
disregard for, and in violation of, the rights of others. Its pri-
mary diagnostic criteria include criminal activity, deceitfulness,
impulsivity, recklessness, aggressiveness, callouosness, ir-
responsibility, and indifference to the mistreatment of others
(APA, 2013). DSM-5 ASPD overlaps substantially with the
diagnosis of psychopathy, the latter typically assessed by the
psychopathy checklist revised (PCL-R; Hare et al., 2012).
Psychopathy includes such additional traits as glib charm, ar-
rogance, and lack of empathy. Much of the research literature
is now predomninated by studies of psychopathy rather than
ASPD. Recent formulations of psychopathy have also included
further additional traits such as fearlessness, feelings of in-
vincibility, and boldness (Lilienfeld et al., 2012; Lynam et al.,
2011). There is also interest in the identification of the ‘suc-
cessful psychopath;’ that is, psychopathic persons who have
successfully avoided legal or ethical scrutiny. Whereas un-
successful psychopaths are characterized by such traits as low
conscientiousness (e.g., irresponsibility, rashness, and neg-
ligence), successful psychopaths are characterized by traits of
high conscientiousness, such as self-discipline, achievement-
striving, and competence (Mullins-Sweatt et al., 2010).
ASPD is much more common in men than in women. A
sociobiological explanation is a potential genetic advantage for
social irresponsibility, infidelity, superficial charm, and deceit
in males (i.e., males with these traits are more likely to pro-
duce offspring than males without these traits). Approximately
20–30% of male prisoners meet the PCL-R criteria for
psychopathy.
ASPD is one PD for which much is known about childhood
antecedents. Approximately 40% of persons diagnosed with
childhood-onset conduct disorder meet DSM-5 ASPD criteria
as an adult (APA, 2013). ASPD is a relatively chronic disorder,
although as the person reaches middle to older age, research
272 Personality Disorders
suggests that the frequency of criminal acts tends to decrease.
Nevertheless, the core personality traits (e.g., lack of empathy,
callousness, and glib charm) may remain largely stable (Hare
et al., 2012).
Twin, family, and adoption studies indicate a genetic con-
tribution for ASPD. Exactly what is inherited in ASPD, how-
ever, is not known. It could be traits such as impulsivity,
antagonistic callousness, abnormally low anxiousness, or all of
these dispositions combined. Numerous environmental fac-
tors have also been implicated. Low family income, inner city
residence, poor parental supervision, single-parent house-
holds, rearing by antisocial parents, delinquent siblings, par-
ental conflict, harsh discipline, neglect, large family size, and
having a young mother have all been implicated as risk factors
for antisocial behavior. Nonshared environmental influences
(i.e., influences not shared by siblings) include: delinquent
peers; individual, social and academic experiences; and sexual
or physical abuse.
The interactive effects of genetic and environmental influ-
ences are difficult to tease apart and likely create confusion
about what these estimates mean in terms of causation (Hare
et al., 2012). For example, an individual who is genetically
disposed to psychopathic behavior will elicit environmental
factors associated with antisocial outcomes, such as peer
problems, academic difficulties, and harsh discipline from
parents. In addition, psychopathic individuals may receive their
genes from psychopathic parents who also exhibit delinquent
and irresponsible behavior, thus creating an immediate home
environment that models instability and criminality.
Considerable research effort has been focused on trying to
isolate the primary pathology of psychopathy and antisocial
behavior. A variety of potential deficits have been implicated,
including a deficiency or inability to (1) have feelings of
sympathy or empathy, (2) anticipate negative consequences,
(3) suppress reward seeking behavior in the presence of
negative consequences, (4) feel anxious or fearful, and/or (e)
anticipate or respond to punishment (Hare et al., 2012).
ASPD is considered to be the most difficult PD to treat.
Persons who meet criteria for ASPD are at times excluded from
substance use treatment programs because they are unlikely to
be responsive and may interfere with or complicate the treat-
ment of fellow patients. Some ASPD treatment programs put
less emphasis on personality change and focus instead on
‘harm reduction,’ or a reduction in risk for recidivism and
violent behavior. Residential programs that provide a carefully
controlled environment of structure and supervision, com-
bined with peer confrontation, have also been used. These
treatment programs will demonstrate short-term success, but it
is unknown what benefits are sustained after the ASPD indi-
vidual leaves this environment.
Borderline Personality Disorder
Borderline personality disorder (BPD) was a new addition to
DSM-III (APA, 1980) and has since become the single most
frequently diagnosed and studied PD. BPD is a pervasive
pattern of impulsivity and instability in interpersonal
relationships, affect, and self-image (APA, 2013). Its primary
diagnostic criteria include frantic efforts to avoid
abandonment, unstable and intense relationships, impulsivity
(e.g., substance abuse, binge eating, or sexual promiscuity),
recurrent suicidal thoughts and gestures, self-mutilation, and
episodes of rage and anger. It is a disorder of extreme emo-
tional instability, coupled with some secondary features of
antagonism and disinhibition.
BPD is the most prevalent PD within clinical settings. Ap-
proximately 75% of persons with BPD are female (APA, 2013),
consistent with the substantially higher levels of negative af-
fectivity in women compared to men. Individuals with BPD
are likely to have been emotionally unstable, impulsive, and
perhaps oppositional as children but there is in fact little
longitudinal research on the childhood antecedents of BPD
(De Fruyt and De Clercq, 2012). As adolescents, their intense
affectivity and impulsivity may contribute to involvement with
rebellious groups, along with a variety of forms of psycho-
pathology including eating, substance, and mood disorders.
BPD is at times diagnosed in children and adolescents but
considerable caution should be used when doing so, as some
of the symptoms of BPD (e.g., identity disturbance, hostility,
and unstable relationships) could be confused with normal
adolescent turmoil. It is also true that, at times, the criteria may
not be developmentally appropriate for children and ado-
lescents (e.g., it may be difficult to demonstrate identity dis-
turbance in a young person).
As adults, persons with BPD may be repeatedly hospital-
ized, due to their affective instability, impulse dyscontrol,
psychotic-like and dissociative symptomatology, and suicidal
gestures and attempts (Hooley et al., 2012). Intimate rela-
tionships tend to be very unstable, even explosive, and em-
ployment history can be quite poor. Persons with BPD are said
to be manipulative with respect to their suicidal gestures,
threats, and attempts, but the risk of death from suicide in
people who suffer from BPD is quite high. Further, Linehan
(1993) has cautioned against the use of the word ‘manipu-
lative’ when referring to individuals suffering from BPD, ar-
guing that individuals with BPD resort to these gestures when
in extreme pain and do not do so with the intent to ma-
nipulate others. Managing severe suicidal ideation and suicidal
behavior presents many challenges for mental health pro-
fessionals who work with BPD patients. As the person reaches
middle age, the most severe expressions of affective lability
and impulsivity may begin to diminish.
There are studies supportive of BPD as a disorder with a
distinct genetic disposition but many studies have also sug-
gested a shared genetic association with mood and impulse
control disorders as well as the general personality tempera-
ment of negative affectivity (Hooley et al., 2012). There is also
a childhood history of physical and/or sexual abuse, parental
conflict, loss, emotional abuse, and/or neglect (Silk et al.,
2005). BPD is perhaps best understood as an interaction of an
emotionally unstable temperament with a cumulative and
evolving series of intensely stressful relationships.
The pathological mechanisms of BPD are addressed in
numerous theories. Most concern issues of abandonment,
separation, and/or exploitative abuse. Persons with BPD will
often describe quite intense, disturbed, and/or abusive rela-
tionships with the significant persons in their life. A growing
literature also suggests that BPD patients show differences
relative to healthy controls in cortical structure and

functioning (Hooley et al., 2012). A primary area of interest
has been the limbic system. This includes reduction in the size
of the hippocampus and amygdala. These brain areas are in-
volved in the regulation of emotion and aggressive behavior.
Patients with BPD may form relationships with therapists
that are similar to their other significant relationships; that is,
the therapeutic relationship can often be tremendously un-
stable, intense, and volatile (APA, 2001). Ongoing consult-
ation with colleagues is recommended. Treatment programs
have been developed for BPD, along with empirical support
for their effectiveness. The two most well validated are dia-
lectical behavior therapy (Chapman and Linehan, 2005) and
mentalization-based therapy (Bateman and Fonagy, 2012).
Schizotypal Personality Disorder
Schizotypal personality disorder (STPD) was a new addition to
DSM-III (APA, 1980). It was developed originally through
interviews of biological relatives of persons diagnosed with
schizophrenia. STPD is a pervasive pattern of interpersonal
deficits, cognitive–perceptual aberrations, and eccentricities of
behavior (APA, 2013). The interpersonal deficits are charac-
terized in large part by an acute discomfort with and reduced
capacity for close relationships. The diagnosis criteria involve
odd beliefs or magical thinking (e.g., superstitiousness or
clairvoyance) that is not delusional; unusual perceptual ex-
periences that do not meet the threshold for a hallucination;
peculiar thinking or speech; suspiciousness; inappropriate or
constricted affect; odd, eccentric, or peculiar appearance or
behavior; social withdrawal; and excessive social anxiety (APA,
2013).
STPD occurs somewhat more often in males (Parnas et al.,
2005). There is insufficient research to describe the childhood
precursors of STPD. Persons with STPD would be expected to
appear peculiar and odd to their peers during adolescence, and
may have been teased or ostracized. As adults, they may drift
toward esoteric, fringe groups that support their magical
thinking and aberrant beliefs. The symptomatology of STPD
does not appear to remit with age (Raine, 2006). The course
appears to be relatively stable, with some proportion of schi-
zotypal persons remaining marginally employed, withdrawn,
and transient throughout their lives.
An initial concern of many clinicians when confronted with
a person with STPD is whether the more appropriate diagnosis
is schizophrenia. Persons with STPD can resemble closely
persons within the prodromal phase (i.e., the initial phase,
before symptomatology is fully developed) of schizophrenia.
This differentiation is determined largely by the absence of a
recent deterioration in functioning that is seen in persons who
are in the prodromal phase. Studies examining cortical ab-
normalities in individuals with STPD suggest abnormalities in
the superior temporal gyrus, parahippocampus, temporal horn
of the lateral ventricles, thalamus, septum pellucidum, and
cerebrospinal fluid which are similar to abnormalities found
in individuals with schizophrenia (New et al., 2008). Correl-
ates of central nervous system dysfunction seen in persons
with schizophrenia have also been observed in laboratory tests
of persons with STPD, including performance on tests of visual
and auditory attention (Parnas et al., 2005). The World Health
Personality Disorders 273
Organization (1992) in fact considers STPD to be a form of
schizophrenia rather than a PD. There is compelling empirical
support for a genetic association of STPD with schizophrenia
(Kwapil and Barrantes-Vidal, 2012; South et al., 2012). How-
ever, schizotypal symptomatology is evident within the gen-
eral population in persons with no apparent genetic
relationship to schizophrenia, and persons with STPD very
rarely develop schizophrenia (Raine, 2006).
A predominant model for the psychopathology of STPD is
deficits in the attention and selection processes that organize a
person’s cognitive–perceptual evaluation of and relatedness to
his or her environment (Raine, 2006). These deficits may lead
to discomfort within social situations, misperceptions, and
suspicions, and to a coping strategy of social isolation. Persons
with STPD may seek treatment for their feelings of anxiousness
and perceptual disturbances. Treatment of persons with STPD
should be cognitive, behavioral, supportive, and/or pharma-
cologic, as they will often find the intimacy and emotionality
of reflective, exploratory psychotherapy to be too stressful
(Kwapil and Barrantes-Vidal, 2012). Practical advice and social
skills training are usually helpful and often necessary, as their
social decision-making may itself be problematic. Low doses
of neuroleptic medications (e.g., thiothixene) have shown
some effectiveness in the treatment of schizotypal symptoms,
particularly the perceptual aberrations and social anxiousness
(Silk and Feurino, 2012).
Narcissistic Personality Disorder
Narcissistic personality disorder (NPD) was new to the third
edition of the APA (1980) diagnostic manual. It has not been
included within the World Health Organization’s (1992)
International Classification of Diseases as it has been perceived
internationally as largely an American concept (Ronningstam,
2005). NPD was proposed for deletion in DSM-5, due in part
to the perception that there was little credible research (Sko-
dol, 2012). However, there is a considerable body of empirical
research on narcissism that is directly relevant to the validity of
the NPD diagnosis (Miller et al., 2010; Ronningstam, 2005).
The DSM-5 Workgroup eventually rescinded their proposal for
its deletion.
NPD is a pervasive pattern of grandiosity, need for admir-
ation, and lack of empathy (APA, 2013). Persons with NPD are
quite vulnerable to threats to self-esteem. They may react de-
fensively with rage, disdain, or indifference but are in fact
struggling with feelings of shock, humiliation, and/or shame
(Miller et al., 2010). The APA diagnostic criteria include a
grandiose sense of self-importance; arrogance; a preoccupation
with fantasies of success, power, or brilliance; a sense of en-
titlement; a lack of empathy; interpersonal exploitation; and a
need for excessive admiration (APA, 2013).
There has been some concern that the DSM-5 criterion set
places too much emphasis on a grandiose narcissism, which is
often associated with success in work and career, failing to
adequately recognize a vulnerable narcissism suggested by
feelings of vulnerability, humiliation or rage in response to
criticism or rebuke, shame, need for admiration, and self-de-
valuation (Pincus and Lukowitsky, 2010). It is suggested that
narcissistic persons fluctuate between states of grandiosity and
274 Personality Disorders
vulnerability. This may indeed be the case but there is, as yet,
little research to support this belief.
NPD is also one of the more difficult PDs to assess, as
persons are unlikely to acknowledge being arrogant, boastful,
or hypersensitive to rebuke, failure, or criticism. Narcissistic
persons tend to perceive themselves as being extraverted,
popular, and engaging, whereas others will perceive them as
being arrogant and conceited (Oltmanns and Lawton, 2011).
DSM-5 NPD is diagnosed more frequently in males (APA,
2013). Persons with this disorder might be seemingly well
adjusted and even successful as a young adult, having experi-
enced substantial achievements in education, career, and per-
haps even within relationships. However, relationships with
colleagues and friends become strained over time as their lack
of consideration for others, self-serving promotion, infidelity,
and even exploitative use of others becomes cumulatively
evident (Miller et al., 2010).
There is empirical support for the heritability of NPD (South
et al., 2012) but it is not clear what precisely is being inherited.
There is quite a bit of clinical speculation as to the psychosocial
etiology. One hypothesis that does have some empirical sup-
port is that there has been an excessive idealization by parental
figures (Horton, 2011). Another theory suggests that devaluing
parental figures have failed to adequately nurture a child’s
natural need for positive regard. Such a child may find that the
perceived love of a parent is contingent largely on achievements
or successes. However, there is little systematic research to
support this theory (Horton, 2011).
Conflicts and deficits with respect to self-esteem are
considered to be central to the pathology of the disorder
(Ronningstam, 2005). Narcissistic persons seek and embrace
signs and symbols of recognition to compensate for conscious
or perhaps even unconscious feelings of inadequacy. Narcis-
sism is not simply arrogant self-confidence, as it can be more
highly correlated with instability in self-esteem than with a
consistently high self-confidence (Wallace, 2011).
Persons rarely seek treatment for their narcissism perhaps
because they may not feel as though they are functioning
poorly. Individuals with NPD enter treatment-seeking assist-
ance for another mental disorder, such as mood disorder
(secondary to career setback), substance abuse (often second-
ary to career stress), or some other form of psychopathogy,
such as pathological gambling. There are few empirical studies
on the treatment of narcissism, although much has been
written on the basis of clinical experience.
Dependent Personality Disorder
Dependent personality disorder (DPD) was proposed for de-
letion from DSM-5 (Skodol, 2012), yet there is a considerable
body of research to support the clinical relevance and validity
of dependent personality traits (Bornstein, 2012; Gore and
Pincus, 2013; Mullins-Sweatt et al., 2012). DPD involves a
pervasive and excessive need to be taken care of that leads to
submissiveness, clinging, and fears of separation (APA, 2013).
Persons with DPD also have low self-esteem and are often self-
critical and self-denigrating. Its primary diagnostic criteria in-
clude extreme difficulty making decisions without others’
input; need for others to assume responsibility for most
aspects of daily life; extreme difficulty disagreeing with others;
inability to initiate projects due to lack of self-confidence; and
going to excessive lengths to obtain the approval of others
(APA, 2013; Gore et al., 2012).
DPD is among the most prevalent of the PDs (APA, 2013).
A controversial issue has been its differential sex prevalence
(Oltmanns and Powers, 2012). DPD is diagnosed more fre-
quently in females but there is some concern that there might
be a failure to adequately recognize the extent of dependent
personality traits within males. Nevertheless, when objective
assessments are used, women are 40% more likely to meet
diagnostic criteria (Bornstein, 2012).
DPD is associated with a number of clinically significant
problematic behaviors, including excessive help-seeking, sug-
gestibility, trait anxiety, insecurity, fear of abandonment, fear
of negative evaluation, loneliness, eating disorders, and
somatoform disorders (Bornstein, 2012). Dependency is re-
lated to increased risk for suicide, increased risk for medical
disorders and complaints, and when receiving medical treat-
ment, excessive use of health and mental health services
(Bornstein, 2012). Dependency is also one of the few per-
sonality traits with a well established role in the prospective
etiology of depression. Multiple prospective, longitudinal
studies have indicated that the presence of dependent cog-
nitions and traits increase the risk for clinically significant
levels of depressed mood years later in reaction to inter-
personal loss or rejection (Hammen, 2005).
The self-esteem of a person with DPD depends sub-
stantially on the maintenance of a supportive and nurturant
relationship (Bornstein, 2005; Hammen, 2005), and yet these
intense needs for reassurance can have the paradoxical effect of
driving the needed person away. The dependent person may
even engage in self-harm as a means to discourage a partner
from leaving (Bornstein, 2012). However, engaging in such
acts to avoid abandonment might suggest that the more ap-
propriate diagnosis is BPD. Once separated, the person with
DPD might indiscriminately select a readily available but un-
reliable, undependable, and perhaps even abusive person
simply to be with someone.
Central to the etiology and pathology of DPD is thought to
be an insecure interpersonal attachment (Bornstein, 2012).
Insecure attachment may be generated through a parent–child
relationship, perhaps by a clinging parent or a continued
infantilization during a time in which individuation and
separation normally occurs. However, DPD may also represent
an interaction of an anxious-inhibited temperament with in-
consistent or overprotective parenting (Bornstein, 2005). There
is, however, limited empirical research on the developmental
history of persons with DPD.
Avoidant Personality Disorder
Avoidant personality disorder (AVPD) was a new addition to
DSM-III (APA, 1980). A criticism of its inclusion was that it
had little prior recognition within the PD literature. However,
it is now one of the more frequently diagnosed PDs, as timid,
anxious, and insecure introversion is a common social and
clinical problem (Sanislow et al., 2012; Millon, 2011).
AVPD is a pervasive pattern of timidity, inhibition, in-
adequacy, and social hypersensitivity (APA, 2013). Persons
 Personality Disorders 275

with AVPD will have a strong desire to develop close, personal Obsessive–Compulsive Personality Disorder
relationships but will also feel too insecure and uncertain to
Obsessive–compulsive personality disorder (OCPD) has been
approach others or to express their feelings. Its diagnostic
included in every edition of the APA diagnostic manual.
criteria include an inhibition within interpersonal situations
OCPD involves a preoccupation with orderliness, perfection-
because of feelings of inadequacy, preoccupation with fears of
ism, and mental and interpersonal control, as indicated by
being criticized or rejected, an unwillingness to get involved
such diagnostic criteria as a preoccupation with details, rules,
with others unless certain of being accepted, and fears of being
lists, and order; perfectionism; workaholism; inflexibility
shamed and ridiculed (APA, 2013).
about matters of morality; rigidity; and stubbornness (APA,
The most difficult differential diagnosis for AVPD is with
2013). Persons with OCPD may also display such additional
social anxiety disorder (Sanislow et al., 2012). Both involve
traits as coldness, risk aversion, and ruminative deliberation
an avoidance of social situations, social anxiety, and timidity,
(Samuel et al., 2012).
and both are said to emerge from a childhood of shyness
OCPD resembles to some extent obsessive–compulsive
and introversion (APA, 2013). There is perhaps no mean-
disorder (OCD), which is an anxiety disorder characterized by
ingful distinction between them. There is an ongoing
intrusive thoughts (e.g., that there are germs on one’s hand)
debate over whether this condition is best conceptualized as
and ritualistic compulsions (e.g., repeatedly washing one’s
an anxiety or a PD. In any case, it is readily understood
hands). For example, persons with OCD may also be pre-
as a combination of the fundamental personality traits of
occupied with orderliness and organization. However, many
introversion and neuroticism (APA, 2013; Sanislow et al.,
persons with OCPD fail to develop OCD, and vice versa. An
2012).
important distinction is that the behavior of persons with
Many persons with AVPD may also meet the criteria for
OCPD is not driven by a need to reduce or control feelings of
DPD (Trull et al., 2012). This might at first glance seem un-
anxiousness. Persons can develop OCD at any point in their
usual, given that AVPD involves social withdrawal, whereas
lives, whereas OCPD involves personality traits that have been
DPD involves social clinging. However, once persons with
evident throughout the persons’ lives. OCPD traits, such as
AVPD are able to obtain a relationship, they will often cling to
perfectionism, are also seen in persons with anorexia. OCPD
this relationship in a dependent manner. A distinction be-
is, to a great extent, a maladaptive variant of the general per-
tween these disorders is best made when the person is seeking
sonality trait of conscientiousness. Persons who are high in
a relationship. Avoidant persons tend to be very shy, inhibited,
conscientiousness will have the discipline, diligence, and de-
and timid (and are, therefore, slow to get involved with
termination to engage in extreme diet restrictions.
someone), whereas dependent persons urgently seek another
Only 1–2% of the general community may meet the
relationship as soon as one ends.
diagnostic criteria for the disorder (Torgersen, 2012) but this
Timidity, shyness, and social insecurity are not uncommon
could be an underestimation. OCPD is one of the less fre-
problems within the general population and AVPD is one of
quently diagnosed PDs within inpatient settings, but its
the more prevalent PDs within clinical settings (Torgersen,
prevalence may be much higher in private practice. This dis-
2012). It appears to occur equally among males and females.
order does appear to occur more often in males than in
Persons with AVPD often were shy, timid, and anxious chil-
females.
dren. Adolescence may have been a particularly difficult de-
As mentioned above, OCPD is to a large extent an extreme,
velopmental period, due to the importance of social status and
maladaptive variant of conscientiousness, which appears to
dating.
develop via a childhood temperament of attentional self-
AVPD may involve elevated peripheral sympathetic activity
regulation (De Fruyt and De Clercq, 2012). OCPD is at times
and adrenocortical responsiveness, resulting in excessive
associated with occupational success as the trait of conscien-
autonomic arousal, fearfulness, and inhibition (Roussos and
tiousness, including its more extreme variants of perfectionism
Siever, 2012). The pathology of AVPD, however, may be as
and workaholism, can contribute to periods of occupational
much psychological as neurochemical, with the timidity,
and work success that is not seen in other PDs (with the ex-
shyness, and insecurity being a natural result of a cumulative
ception of NPD).
history of denigrating, embarrassing, and devaluing experi-
ences (Millon, 2011; Sanislow et al., 2012). Underlying AVPD
may be excessive self-consciousness, feelings of inadequacy or Three Additional Personality Disorders
inferiority, and irrational cognitive schemas that perpetuate
introverted, avoidant behavior. Three additional PDs are paranoid, schizoid, and histrionic,
Persons with AVPD will seek treatment for their avoidant for which there has been relatively little direct research
personality traits, although many will initially seek treatment (Blashfield and Intoccia, 2000). Each will be discussed briefly
for symptoms of anxiety, particularly social anxiety disorder. It in turn.
is perhaps important in such cases, though to consider that the
shyness might not be due simply to a neurochemical dysre- Paranoid personality disorder
gulation or dyscontrol of anxiousness (Sanislow et al., 2012). Paranoid personality disorder (PPD) has been in every edition
There may instead be a more pervasive psychopathology, in- of the APA diagnostic manual. However, it was proposed for
volving beliefs of interpersonal insecurity and inadequacy deletion in DSM-5 (Skodol, 2012). The limited research in this
(Millon, 2011). Hence it may be important to address area may not necessarily suggest an invalid diagnosis (Shedler
underlying fears and insecurities regarding attractiveness, de- et al., 2010), but it does indicate a relative lack of interest of
sirability, rejection, or intimacy. researchers in the disorder (Hopwood and Thomas, 2012).
276 Personality Disorders
Trust versus suspiciousness is a fundamental dimension along
which all persons vary, and there are persons who are char-
acteristically mistrustful and suspicious (McCrae and Costa,
2008).
PPD includes a pervasive and continuous distrust and
suspiciousness of the motives of others (APA, 2013), but the
disorder is more than just suspiciousness. Persons with this
disorder are also hypersensitive to criticism, they respond with
anger to threats to their autonomy, they bear grudges, they
incessantly seek out confirmations of their suspicions, and
they tend to be quite rigid in their beliefs and perceptions of
others (Millon, 2011).
PPD paranoid ideation is inconsistent with reality and is
resistant to contrary evidence, but the ideation is not psych-
otic, absurd, inconceivable, or bizarre. PPD will also lack other
features of psychotic and delusional disorders (e.g., hallucin-
ations) and will be evident since early adulthood, whereas a
psychotic disorder will occur later in life (e.g., adulthood) and
will often remit after a relatively brief period of time.
Persons with PPD may become socially isolated or perhaps
fanatic members of groups that encourage or at least accept
their paranoid ideation. They might maintain a steady em-
ployment but will be difficult coworkers, as they will tend to
be rigid, controlling, critical, blaming, and prejudicial. They
are said to become involved in lengthy, acrimonious, and li-
tigious disputes (Millon, 2011). Persons with PPD would
rarely seek treatment for their feelings of suspiciousness and
distrust (Millon, 2011).
Schizoid personality disorder (SZPD)
SZPD has been in every edition of the APA diagnostic manual,
but has received limited empirical research due in part perhaps
to the attention of researchers shifting from SZPD to STPD
when the latter was added to the 1980 third edition of the
diagnostic manual (Parnas et al., 2005). It was originally slated
for deletion in DSM-5 (Skodol, 2012).
SZPD involves a pervasive pattern of social detachment and
restricted emotional expression. Introversion (vs. extraversion)
is one of the fundamental dimensions of general personality
functioning (McCrae and Costa, 2008). Facets of introversion
involved include low warmth (e.g., cold, detached, and im-
personal), low gregariousness (socially isolated and with-
drawn), and low positive emotions (reserved, constricted, flat
affect, and anhedonia), all of which define well the central
features of SZPD.
Persons with SZPD are likely to have been socially isolated
and withdrawn as children. They may not have been accepted
by their peers. As adults, they often have few friends. They
often have had few sexual relationships and may never marry.
Some persons with SZPD may do well and even excel within
an occupation, as long as substantial social interaction is not
required (Millon, 2011).
There is only limited research on the heritability of SZPD
but quite a number of studies have indicated a genetic con-
tribution for the fundamental personality dimension of
introversion (South et al., 2012). The pathology of SZPD is
considered to be anhedonic deficits, or an excessively low
ability to experience positive affect, which is also central to the
general personality trait of extreme introversion (Hopwood
and Thomas, 2012).
Histrionic personality disorder
Histrionic personality disorder (HPD) was not included
within the first edition of the APA diagnostic manual. It has
been one of the more controversial of the PD diagnoses, given
its close association with stereotypic feminine traits contrib-
uting to concerns regarding a potential gender bias (Oltmanns
and Powers, 2012). HPD was proposed to be deleted in DSM-
5 due in large part to the absence of much research specifically
concerned with its etiology, pathology, or treatment (Blash-
field et al., 2012; Skodol, 2012). Although HPD was recom-
mended for deletion, attention-seeking, a trait central to the
conceptualization of HPD, is included within the DSM-5 di-
mensional trait model (APA, 2013).
With respect to the criticism of the gender bias involved in
HPD, it is not that the diagnosis is characterizing normal
femininity as a PD but instead an exaggerated, stereotypic
form of femininity, similar to how NPD and APD involve, in
part, maladaptively extreme variants of traits associated with
stereotypic masculinity. However, women are at times in-
correctly diagnosed with the disorder by clinicians who do not
use a semi-structured interview for its assessment (Oltmanns
and Powers, 2012).
Histrionic persons tend to be emotionally manipulative
and intolerant of delayed gratification. They are uncomfortable
when not the center of attention, they are inappropriately
sexually seductive, and they demonstrate a shallow self-
dramatization (APA, 2013).
Conclusions
Everybody has a personality and perhaps most persons have at
least one problematic personality trait. Some persons, how-
ever, have a number of very dysfunctional personality traits
and are therefore considered to have a disorder of personality.
The APA currently recognizes the existence of 10 PDs. There is
a substantial body of research concerning five of them (i.e., the
antisocial, borderline, schizotypal, narcissistic, and dependent
PDs), although systematic psychotherapy treatment research
has been confined largely to the borderline PD. There is con-
siderable disagreement surrounding how best to conceptualize
these mental disorders, albeit the field does appear to be
shifting to the belief that these conditions are maladaptive
and/or extreme variants of general personality structure.
See also: Borderline Personality Disorder. Dialectical Behavior
Therapy. Mindfulness. Narcissistic Personality Disorder. Personality
and Personality Development. Psychopathy
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