Chapter 16 — Personality Disorders Slides, handouts, and answers keys created by Karen Clay Rhines, Ph. D. , Seton Hall University Handout 2: What is Psychological Abnormality? What is personality? Personality is a unique and long-term pattern of inner experience and outward behavior Personality tends to be consistent and is often described in terms of “traits” These traits may be inherited, learned, or both Personality is also flexible, allowing us to adapt to new environments For those with personality disorders, however, that flexibility is usually missing Handout 3: Personality Disorders
What is a personality disorder? A very rigid pattern of inner experience and outward behavior This pattern is seen in most interactions, differs from the experiences and behaviors usually expected, and continues for years Handout 4: Classifying Personality Disorders A personality disorder is diagnosed only when it causes impairments in social or occupational functioning, or when it causes personal distress Personality disorders typically become recognizable in adolescence or early adulthood . Generally, the affected person does not regard his or her behavior as undesirable or problematic
It has been estimated that 9 to 13% of all adults may have a personality disorder Handout 5: Classifying Personality Disorders Classifying these disorders is difficult because little is known about their origins or development They are diagnosed on Axis II of the DSM-IV Handout 6: Classifying Personality Disorders Those diagnosed with personality disorders are often also diagnosed with an Axis I disorder This relationship is called “comorbidity” Axis II disorders my predispose people to develop an Axis I disorder, or Axis I disorders may set the stage for Axis II disorders, or some biological condition may set the stage for both!
Whatever the reason, research indicates that the presence of a personality disorder complicates and reduces a person’s chances for a successful recovery Handout 8: Classifying Personality Disorders The various personality disorders overlap each other so much that it can be difficult to distinguish one from another The frequent lack of agreement between clinicians and diagnosticians has raised concerns about the validity and reliability of these categories Handout 10: “Odd” Personality Disorders People with these disorders display behaviors similar to, but not as extensive as, schizophrenia
Behaviors include extreme suspiciousness, social withdrawal, and peculiar ways of thinking and perceiving things Such behaviors leave the person isolated Some clinicians believe that these disorders are actually related to schizophrenia, and thus call them “schizophrenia spectrum disorders” Handout 11: “Odd” Personality Disorders Clinicians have learned much about the symptoms of odd personality disorders but little about effective treatment for these disorders In fact, people with these disorders rarely seek treatment Handout 14: How Do Theorists Explain Paranoid Personality Disorder?
The proposed explanations of this disorder, like those of most other personality disorders, have received little systematic research Psychodynamic theorists trace the pattern back to early interactions with demanding parents Cognitive theorists suggest that maladaptive assumptions such as “People are evil and will attack you if given the chance” are to blame Biological theorists propose genetic causes and have looked at twin studies to support this model Handout 15: Treatments for Paranoid Personality Disorder People with paranoid personality disorder do not typically see themselves as needing help
Few come to treatment willingly Those who are in treatment often distrust and rebel against their therapists As a result, therapy for this disorder, as for most of the other personality disorders, has limited effect and moves slowly Handout 16: Treatments for Paranoid Personality Disorder Object relations therapists try to see past the patient’s anger and work on the underlying wish for a satisfying relationship Behavioral and cognitive therapists try to help clients control anxiety and improve interpersonal skills Cognitive therapists also try to restructure client’s maladaptive assumptions and interpretations
Drug therapy is generally ineffective Handout 17: Schizoid Personality Disorder This disorder is characterized by persistent avoidance of social relationships and limited emotional expression Withdrawn and reclusive, people with this disorder are not interested in relationships with others People with schizoid personality disorder focus mainly on themselves and are often seen as flat and cold The disorder is estimated to affect less than 1% of the population It is slightly more likely to occur in men than in women Handout 22: Schizotypal Personality Disorder
This disorder is characterized by odd (even bizarre) ways of thinking and perceiving, and behavioral eccentricities These symptoms may include ideas of reference and/or bodily illusions People with the disorder often have great difficulty keeping their attention focused; conversation is typically digressive and vague Handout 23: Schizotypal Personality Disorder Socially withdrawn, people with this disorder seek isolation and have few friends This disorder is the most severe of the three in this cluster It has been estimated that 2 to 4% of all people (slightly more males than females) may have the disorder
Handout 24: How Do Theorists Explain Schizotypal Personality Disorder? Because the symptoms of schizotypal personality disorder so often resemble those of schizophrenia, researchers have hypothesized that similar factors are at work in both disorders Schizotypal symptoms are often linked to poor family communication and to psychological disorders in parents Researchers have also begun to link schizotypal personality disorder to some of the same biological factors found in schizophrenia The disorder also has been linked to mood disorders Handout 27: “Dramatic” Personality Disorders
The behaviors of people with these disorders are so dramatic, emotional, or erratic that it is almost impossible for them to have relationships that are truly giving and satisfying These personality disorders are more commonly diagnosed than the others Only antisocial and borderline personality disorders have received much study The causes of the disorders are not well understood Handout 28: Antisocial Personality Disorder Sometimes described as “psychopaths” or “sociopaths,” people with antisocial personality disorder persistently disregard and violate others’ rights
Aside from substance-related disorders, this is the disorder most linked to adult criminal behavior The DSM-IV requires that a person be at least 18 years of age to receive this diagnosis Most people with an antisocial personality disorder displayed some patterns of misbehavior before they were 15 years old Handout 30: Antisocial Personality Disorder Surveys indicate that up to 3. 5% of people in the U. S. meet the criteria for this disorder Caucasians are somewhat more likely to be diagnosed than are African Americans
The disorder is four times more common in men than women Because people with this disorder are often arrested, researchers frequently look for people with antisocial patterns in prison populations Studies also indicate higher rates of alcoholism and other substance-related disorders among this group Handout 33: How Do Theorists Explain Antisocial Personality Disorder? The cognitive view says that people with the disorder hold attitudes that trivialize the importance of other people’s needs A number of studies suggest that biological factors may play a role
Findings suggest that people with antisocial personality disorder have lower levels of trait anxiety and arousal, leading them to be more likely than others to take risks and seek thrills Handout 34: Treatments for Antisocial Personality Disorder About 25% of all people with antisocial personality disorder receive treatment for it, yet no treatment appears to be effective A major problem is the individual’s lack of conscience or desire to change Most have been mandated to treatment Some cognitive therapists try to guide clients to think about moral issues and the needs of other people
Hospitals have attempted to create therapeutic communities Generally, most of today’s treatment approaches have little to no impact on the disorder Handout 35: Borderline Personality Disorder People with this disorder display great instability, including major shifts in mood, an unstable self-image, and impulsivity Interpersonal relationships also are unstable People with borderline personality disorder are prone to bouts of anger, which sometimes result in physical aggression and violence Just as often, however, they direct their impulsive anger inward and harm themselves
Handout 37: Borderline Personality Disorder Almost 2% of the general population are thought to suffer from this disorder Close to 75% of those diagnosed are women The course of the disorder varies In the most common pattern, the instability and risk of suicide reach a peak during young adulthood and then gradually lessen with advancing age Handout 39: How Do Theorists Explain Borderline Personality Disorder? Some features of the disorder also have been linked to biological abnormalities Sufferers who are particularly impulsive apparently have lower brain serotonin activity
Close relatives of those with borderline personality disorder are five times more likely than the general population to have the disorder Some sociocultural theorists suggest that cases of borderline personality disorder are particularly likely to emerge in cultures that change rapidly Handout 40: Treatments for Borderline Personality Disorder It appears that psychotherapy can eventually lead to some degree of improvement for people with this disorder It is not easy, though, for a therapist to strike a balance between empathizing with a patient’s dependency and anger and challenging his or her way of thinking
Furthermore, termination of therapy is often incredibly difficult Handout 42: Treatments for Borderline Personality Disorder Antidepressant, antibipolar, antianxiety, and antipsychotic drugs have helped some individuals to calm their emotional and aggressive storms Given the high risk of suicide attempts by these patients, their use of drugs on an outpatient basis is controversial Some patients have benefited from a combination of drug therapy and psychotherapy Handout 43: Histrionic Personality Disorder
People with histrionic personality disorder are extremely emotional and continually seek to be the center of attention They often engage in attention-getting behaviors Approval and praise are the lifeblood of these individuals People with histrionic personality disorder are often described as vain, self-centered, and demanding Some make suicide attempts, often to manipulate others Handout 44: Histrionic Personality Disorder This disorder was once believed to be more common in women than in men However, research has revealed gender bias in past diagnoses
The latest statistics suggest that around 2% percent of adults have this personality disorder, with males and females equally affected Handout 46: How Do Theorists Explain Histrionic Personality Disorder? Cognitive theorists look at the lack of substance and the extreme suggestibility seen in people with the disorder Some propose that people with histrionic personality disorder hold a general assumption that they are helpless to care for themselves Sociocultural theorists believe the disorder is caused in part by society’s norms and expectations
The vain, dramatic, and selfish behavior may be an exaggeration of femininity as defined by our culture Handout 47: Treatments for Histrionic Personality Disorder Unlike people with most other personality disorders, those with histrionic personality disorder often seek treatment on their own Working with them can be difficult because of their demands, tantrums, seductiveness, and attempts to please the therapist Handout 49: Narcissistic Personality Disorder People with narcissistic personality disorder are generally grandiose, need much admiration, and feel no empathy for others
Convinced of their own great success, power, or beauty, they expect constant attention and admiration from those around them People with this disorder exaggerate their achievements and talents, and often appear arrogant Handout 50: Narcissistic Personality Disorder People with this disorder are seldom interested in the feelings of others Many take advantage of others to achieve their own ends Probably less than 1% of adults display narcissistic personality disorder Up to 75% of these are men This type of behavior is common among teenagers and do not usually lead to adult narcissism
Handout 51: How Do Theorists Explain Narcissistic Personality Disorder? Psychodynamic theorists more than others have theorized about this disorder, focusing on cold, rejecting parents Object-relations theorists interpret the grandiose self-presentation as a way for these people to convince themselves that they are self-sufficient and without need of warm relationships In support of this theory, research has found increased risk for developing the disorder among abused children and those from divorced families Handout 52: How Do Theorists Explain Narcissistic Personality Disorder?
Behavioral and cognitive theorists propose that narcissistic personality disorder may develop when people are treated too positively rather than too negatively in early life Those with the disorder have been taught to “overvalue their self-worth” In support of this explanation, first-born and only children score higher on measures of narcissism Finally, many sociocultural theorists see a link between narcissistic personality disorder and “eras of narcissism” in society Handout 53: Treatments for Narcissistic Personality Disorder This disorder is one of the most difficult personality patterns to treat
Clients who consult therapists usually do so because of a related disorder, most commonly depression Once in treatment, the individuals may try to manipulate the therapist into supporting their sense of superiority None of the major treatment approaches has had much success Handout 55: “Anxious” Personality Disorders People with these disorders typically display anxious and fearful behavior Although many of the symptoms are similar to those of anxiety and depressive disorders, researchers have found no links between this cluster and those Axis I diagnoses As with most of the personality disorders, research is limited
But treatments for this cluster appear to be modestly to moderately helpful Handout 56: Avoidant Personality Disorder People with avoidant personality disorder are very uncomfortable and restrained in social situations, overwhelmed by feelings of inadequacy, and extremely sensitive to negative evaluation They believe themselves unappealing or inferior and often have few close friends Handout 57: Avoidant Personality Disorder The disorder is similar to social phobia, and many people with one disorder experience the other Similarities between the two disorders include a few of humiliation and low self-confidence
A key difference is that people with social phobia mainly fear social circumstances, while people with avoidant personality disorder tend to fear close social relationships Between 1 and 2% of adults have avoidant personality disorder Handout 60: How Do Theorists Explain Avoidant Personality Disorder? Cognitive theorists believe that harsh criticism and rejection in early childhood may lead people to assume that others will always judge them harshly In several studies, individuals reported memories that supported both the psychodynamic and cognitive theories
Handout 61: Treatments for Avoidant Personality Disorder People with avoidant personality disorder come to therapy seeking acceptance and affection Keeping them in therapy can be challenging because they often begin to avoid sessions A key task of the therapist is to build trust Beyond building trust, therapists tend to treat the disorder as they treat social phobia and anxiety These treatments have had modest success Group and drug therapy may also be useful Handout 62: Dependent Personality Disorder People with dependent personality disorder have a pervasive, excessive need to be taken care of
As a result, they are clinging and obedient, fearing separation from their loved ones They rely on others so much that they cannot make the smallest decision for themselves The central feature of the disorder is a difficulty with separation Handout 65: How Do Theorists Explain Dependent Personality Disorder? Behaviorists propose that parents of those with dependent personality disorder unintentionally rewarded their children’s clinging and “loyal” behavior while punishing acts of independence Alternatively, some parents’ own dependent behaviors may have served as models for their children
Handout 68: Treatments for Dependent Personality Disorder Treatment can be at least modestly helpful Psychodynamic therapy focuses on many of the same issues as therapy for people with depression Cognitive therapists try to help clients challenge and change their assumptions of incompetence and helplessness Antidepressant drug therapy has been helpful for those whose disorder is accompanied by depression Group therapy can be helpful because it provides clients an opportunity to receive support from a number of peers and because group members may serve as models for one another
Handout 70: Obsessive-Compulsive Personality Disorder Between 2 and 5% of the population has this disorder, with white, educated, married, and employed individuals receiving the diagnosis most often Men are twice as likely as women to display the disorder Many clinicians believe that obsessive-compulsive personality disorder and obsessive-compulsive disorder (the anxiety disorder) are closely related While the disorders share similar symptoms, researchers have not found a specific link between them Handout 72: How Do Theorists Explain Obsessive-Compulsive Personality Disorder?
Freudian theorists suggest that people with obsessive-compulsive personality disorder are anal regressive Because of overly harsh toilet training, people become angry and remain fixated at this stage of psychosexual development To keep their anger under control, they resist both their anger and their instincts to have bowel movements As a result, they become extremely orderly and restrained Handout 77: What Problems Are Posed by the DSM Categories? Some of the diagnostic criteria cannot be observed directly The diagnoses often rely heavily on the impressions of the individual clinician
Similarly, clinicians differ widely in their judgments about when a normal personality style crosses the line and deserves to be called a disorder Handout 79: What Problems Are Posed by the DSM Categories? Because of these problems, diagnosticians keep changing the criteria used to assess the personality disorders Further, some theorists believe that the personality disorders actually differ more in degree than in type of dysfunction Some theorists have proposed that the disorders be organized by how severe certain key traits are rather than by the presence or absence of specific traits