Personality Disorders (Antisocial Personality Disorder)

A personality disorder is a persistent pattern of emotions, cognitions, and behavior that results in
enduring emotional distress for the person affected and/or for others and may cause difficulties
with work and relationships (American Psychiatric Association, 2013). DSM-5 notes that having
a personality disorder may distress the affected person. Individuals with personality disorders may
not feel any subjective distress, however; indeed, it may in fact be others who acutely feel distress
because of the actions of the person with the disorder. This is particularly common with antisocial
personality disorder, because the individual may show a blatant disregard for the rights of others
yet exhibit no remorse (Hare, Neumann, & Widiger, 2012). In certain cases, someone other than
the person with the personality disorder must decide whether the disorder is causing significant
functional impairment, because the affected person often cannot make such a judgment.

DSM-5 lists 10 specific personality disorders that have been divided into three groups, or clusters;
this will probably continue until a strong scientific basis is established for viewing them differently
(APA, 2013).The cluster division is based on resemblance. Cluster A is called the odd or eccentric
cluster; it includes paranoid, schizoid, and schizotypal personality disorders. Cluster B is the
dramatic, emotional, or erratic cluster; it consists of antisocial, borderline, histrionic, and
narcissistic personality disorders. Cluster C is the anxious or fearful cluster; it includes avoidant,
dependent, and obsessive-compulsive personality disorders. Prior to DSM-5, most disorders were
in Axis I of the DSM-IV-TR, which included the traditional disorders. The personality disorders
were included in a separate axis, Axis II, because as a group they were seen as distinct. It was
thought that the characteristic traits were more ingrained and inflexible in people who have
personality disorders, and the disorders themselves were less likely to be successfully modified.
With the changes made with DSM-5, these separate axes were eliminated and now the personality
disorders are listed with the rest of the DSM-5 disorders (American Psychiatric Association, 2013).

Because many people with these problems do not seek help on their own as do those with many
of the other DSM-5 disorders, gathering information about the prevalence of personality disorders
is difficult and therefore varies a great deal. Numbers vary somewhat across countries due to
different survey methods but worldwide about 6% of adults may have at least one personality
disorder (Huang et al., 2009). Similarly, gender differences in the disorders—for example, more
women diagnosed with borderline personality disorder and more men identified with antisocial
personality disorder—are highly variable when surveying the general population. There may be
several reasons for these differences in diagnoses, including bias in diagnoses and differences in
help-seeking behavior and tolerance of behavior in a culture. Personality disorders were thought
to originate in childhood and continue into the adult years (Cloninger & Svakic, 2009). More
sophisticated analyses suggest that personality disorders can remit over time, however, they may
be replaced by other personality disorders (Torgersen, 2012). In other words, a person could
receive a diagnosis of one personality disorder at one point in time but years later no longer meet
the criteria for his original problem but now have characteristics of a second (or third) personality
disorder.

Antisocial Personality Disorder (ASPD)

To be anti-social is to be against society: against rules, norms, laws and acceptable behavior.
People with antisocial personality disorder are among the most puzzling of the individuals a
clinician will see in a practice and are characterized as having a history of failing to comply with
social norms. They perform actions most of us would find unacceptable, such as stealing from
friends and family. They also tend to be irresponsible, impulsive, and deceitful (De Brito &
Hodgins, 2009).

Diagnostic criteria according to the DSM-5:

A pervasive pattern of disregard for and violation of the rights of others, occurring since age 15
years, as indicated by three (or more) of the following:
1. Failure to conform to social norms with respect to lawful behaviors, as indicated by repeatedly
performing acts that are grounds for arrest.
2. Deceitfulness, as indicated by repeated lying, use of aliases, or conning others for personal
profit or pleasure.
3. Impulsivity or failure to plan ahead.
4. Irritability and aggressiveness, as indicated by repeated physical fights or assaults.
5. Reckless disregard for safety of self or others.
6. Consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior
 or honor financial obligations.
7. Lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated,
or stolen from another.
B. The individual is at least age 18 years.
C. There is evidence of conduct disorder with onset before age 15 years.
D. The occurrence of antisocial behavior is not exclusively during the course of schizophrenia or
bipolar disorder.

Onset
The DSM-5 notes that Antisocial Personality Disorder cannot be diagnosed before age 18, so while
an adolescent may display antisocial features, prior to age 18, if diagnostic criteria are met, the
appropriate diagnosis would be Conduct Disorder (American Psychiatric Association, 2013).

Prevalence
According to the DSM-5, the annual prevalence of Antisocial Personality Disorder is .02% to
3.3.% (APA, 2013). According to some estimates, the prevalence of ASPD in the general
population is about 3 percent for males and about 1 percent for females but other studies have
reported that the preponderance of men is even greater such as 5 to 1 (Hare et al., 2012). However,
a recent, very large epidemiological study has shown that the real prevalence may be as low as 1
percent (Lenzenweger et al., 2007).

Comorbidity
ASPD is comorbid with substance abuse disorder, and other personality disorders (APA, 2013).

Differential Diagnosis
There are diagnostic rule-outs for the clinician to consider, in the DSM-5, disorders such as
schizophrenia and bipolar disorder, as well as substance abuse disorders should be considered.
Even very violent offenders may not be sociopaths, but sociopathy should be considered on a
continuum, rather than a dichotomy of present or absent.
Impact on Functioning
Antisocial Personality Disorder will typically have strong impacts on most areas of functioning.
According to the DSM-5, persons with ASPD may face incarceration as a result of their criminal
actions, premature death from violence or accidents, or loss of assets or property from reckless
spending (APA, 2013) or civil forfeiture of assets. Divorce, separation, unemployment, financial
dependency on state relief sources, homelessness, anxiety, depression, and suicide rates are all
elevated in individuals with ASPD when compared to the general population (Goldstein, Dawson,
Smith, & Grant, 2012). People with ASPD also have the potential to cause great harm to those
around them, including family, associates, neighbors, and complete strangers, through financial
exploitation, theft, emotional abuse, assault, sexual assault, and homicide.

Although first identified as a “medical” problem and labeled as manie sans delire (mania without
delirium), by Philippe Pinel at the start of the nineteenth century (1801/1962), descriptions of
individuals with these antisocial tendencies can be found in ancient stone texts found in
Mesopotamia dating as far back as 670 B.C. (Abdul-Hamid & Stein, 2012).

The use of the term antisocial personality disorder dates back only to 1980 when personality
disorders first entered DSM-III. However, many of the central features of this disorder have long
been labeled psychopathy or sociopathy. Although several investigators identified the syndrome
in the nineteenth century using such terms as “moral insanity” (Prichard, 1835), the most
comprehensive early description of psychopathy was made by Cleckley (1941, 1982) in the 1940s.

Hervey Cleckley (1941/1982), a psychiatrist who spent much of his career working with the
“psychopathic personality,” identified a constellation of 16 major characteristics, most of which
are personality traits and are sometimes referred to as the “Cleckley criteria.” Hare and his
colleagues, building on the descriptive work of Cleckley, researched the nature of psychopathy (
Hare, 1970; Harpur, Hare, & Hakstian, 1989) and developed a 20-item checklist that serves as an
assessment tool. Six of the criteria that Hare (Hare et al., 2012; p. 480) includes in his Revised
Psychopathy Checklist (PCL-R) are as follows:

1. Glibness/superficial charm

2. Grandiose sense of self-worth

3. Pathological lying

4. Conning/manipulative

5. Lack of remorse or guilt

6. Callous/lack of empathy

With some training, clinicians are able to gather information from interviews with a person, along
with material from significant others or institutional files (for example, prison records), and assign
the person scores on the checklist, with high scores indicating psychopathy (Hare & Neumann,
2006).

The Cleckley/Hare criteria focus primarily on underlying personality traits (for example, being
self-centered or manipulative). Earlier versions of the DSM criteria for antisocial personality
focused almost entirely on observable behaviors (for example, “impulsively and repeatedly
changes employment, residence, or sexual partners”). The framers of the previous DSM criteria
felt that trying to assess a personality trait—for example, whether someone was manipulative—
would be more difficult than determining whether the person engaged in certain behaviors, such
as repeated fighting. The DSM-5, however, moved closer to the trait-based criteria and includes
some of the same language included in Hare’s PCL-R (e.g., callousness, manipulativeness, and
deceitfulness). Unfortunately, research on identifying persons with antisocial personality disorder
suggests that this new definition reduces the reliability of the diagnosis (Regier et al., 2013) and
hence DSM-5 has made no change in the criteria listed by DSM-IV-TR. {An alternative approach
to the diagnosis of ASPD appears in Section III of the DSM-5 manual and is considered to be in
need of further study}. With their strong emphasis on behavioral criteria that can be measured
reasonably objectively, the features included in the DSM do not fully map onto the construct of
psychopathy as originally described.

Research suggests that ASPD and psychopathy are related but differ in significant ways. The
Revised Psychopathy Checklist (PCL-R) by Hare et al. (2012) has shown that there are two related
but separable dimensions of psychopathy, each predicting different types of behavior:
1. The first dimension involves the affective and interpersonal core of the disorder and reflects
traits such as lack of remorse or guilt, callousness/lack of empathy, glibness/superficial charm,
grandiose sense of self-worth, and pathological lying.

2. The second dimension reflects behavior—the aspects of psychopathy that involve antisocial or
impulsive acts, social deviance, as well as a need for stimulation, poor behavior controls,
irresponsibility, and a parasitic lifestyle. The second dimension is much more closely related than
the first to the DSM diagnosis of ASPD (Hare et al., 1999; Widiger, 2006).

The Clinical Picture in Psychopathy and Antisocial Personality Disorder

Often charming, spontaneous, and likable on first acquaintance, psychopaths are deceitful and
manipulative, callously using others to achieve their own ends. Many of them seem to live in a
series of present moments without consideration for the past or future. But also included in this
general category are hostile people who are prone to acting out impulses in remorseless and often
senselessly violent ways. Following are the major characteristics of psychopaths and antisocial
personalities. Though all these characteristics may not be found in any one particular case, they
are typical of psychopaths as first described by Cleckley (1941, 1982). A subset of these
characteristics occurs in ASPD as well:
Inadequate Conscience Development:
Psychopaths appear unable to understand and accept ethical values except on a verbal level. They
may glibly claim to adhere to high moral standards that have no apparent connection with their
behavior. In short, their conscience development is severely retarded or nonexistent, and they
behave as though social regulations and laws do not apply to them (Frick & Marsee, 2006; Salekin,
2006). These characteristics of psychopathy are most strongly related to the interpersonal and
affective core of psychopathy (Fowles & Dindo, 2006). In spite of their stunted conscience
development, their intellectual development is typically normal. Nevertheless, intelligence is one
trait that has different relationships with the two dimensions of psychopathy. The first, affective
and interpersonal dimension is positively related to verbal intelligence (Salekin et al., 2004); the
second, antisocial dimension is negatively related to intelligence (Frick, 1998; Hare et al., 1999).
Irresponsible and Impulsive Behavior
Psychopaths learn to take rather than earn what they want. Prone to thrill seeking and deviant and
unconventional behavior, they often break the law impulsively and without regard for the
consequences. They seldom forgo immediate pleasure for future gains and long-range goals. These
aspects of psychopathy are most closely related to the second, antisocial dimension of psychopathy
(Patrick, 2005). Many studies have shown that antisocial personalities and some psychopaths have
high rates of alcohol abuse and dependence and other substance-abuse/dependence disorders (e.g.,
Taylor & Lang, 2006; Waldman & Slutske, 2000). Alcohol abuse is related only to the antisocial
or deviant dimension of the PCL-R (Patrick, 2005; Reardon al., 2002). Antisocial personalities
also have elevated rates of suicide attempts and completed suicides, which are also associated only
with the second, antisocial dimension of psychopathy and not with the first, affective dimension
(Verona et al., 2001).

Ability to Impress and Exploit Others

Some psychopaths are superficially charming and likable, with a disarming manner that easily
wins new friends (Cleckley, 1941, 1982; Patrick, 2006). They seem to have good insight into other
people’s needs and weaknesses and are adept at exploiting them. These frequent liars usually seem
sincerely sorry if caught in a lie and promise to make amends they—but they do not do so. Not
surprisingly, then, psychopaths are seldom able to keep close friends. They seemingly cannot
understand love in others or give it in return. Manipulative, exploitative, and sometimes coercive
in sexual relationships, psychopaths are irresponsible and unfaithful mates.

Psychopathy, Antisocial Personality Disorder and Criminality

Although Cleckley did not deny that many psychopaths are at elevated risk for criminal and
antisocial behaviors, he did emphasize that some have few or no legal or interpersonal difficulties.
Not surprisingly, it is typically found that about 70 to 80 percent of imprisoned inmates qualify for
a diagnosis of ASPD but that only about 25 to 30 percent meet the criteria for psychopathy (Patrick,
2005). In other words, only about half of imprisoned individuals diagnosed with ASPD also meet
the criteria for psychopathy, but most imprisoned individuals with a diagnosis of psychopathy also
meet the criteria for ASPD (Widiger, 2006). That is, a significant number of inmates show the
antisocial and aggressive behaviors necessary for a diagnosis of ASPD but do not show enough
selfish, callous, and exploitative behaviors to qualify for a diagnosis of psychopathy (Hare et al.,
1999). The issues surrounding these diagnoses remain highly controversial.

What separates many in this group from those who get into trouble with the law may be their
intelligence quotient (IQ). In a classic prospective, longitudinal study, White, Moffitt, and Silva
(1989) followed approximately 1,000 children, beginning at age 5, to see what predicted antisocial
behavior at age 15. They found that, of the 5-year-olds determined to be at high risk for later
delinquent behavior, 16% did indeed have run-ins with the law by the age of 15 and 84% did not.
What distinguished these two groups? In general, the at-risk children with lower IQs were the ones
who got in trouble. This suggests that having a higher IQ may help protect some people from
developing more serious problems, or may at least prevent them from getting caught.

Many researchers continue to use the Cleckley/Hare psychopathy diagnosis rather than the DSM
ASPD diagnosis because the psychopathy diagnosis has been shown to be a better predictor of a
variety of important facets of criminal behavior than the ASPD diagnosis (Hare et al., 2012).
Overall, a diagnosis of psychopathy appears to be the single best predictor of violence and
recidivism (offending again after imprisonment; Douglas et al., 2006; Gretton et al., 2004; Hart,
1998). For example, one review estimated that people with psychopathy are three times more likely
to reoffend and four times more likely to reoffend violently following prison terms than are people
without a psychopathy diagnosis (Hemphill et al., 1998). Moreover, adolescents with higher
psychopathy scores are not only more likely to show violent reoffending but are also more likely
to reoffend more quickly (Gretton et al., 2004).

An additional concern about the current conceptualization of ASPD is that it fails to include people
who show many of the features of the first, affective and interpersonal dimension of psychopathy
but not as many features of the second, antisocial dimension, or at least few enough that these
individuals do not generally get into trouble with the law. Cleckley did not believe that aggressive
behavior was central to the concept of psychopathy (Patrick, 2006). This group might include, for
example, unprincipled and predatory business or financial professionals, manipulative lawyers,
high-pressure evangelists, and crooked politicians (Hall & Benning, 2006; Hare et al., 1999).
Unfortunately, because they are difficult to find to study, little research has been conducted on
psychopathic people who manage to stay out of correctional institutions.
Difference between Psychopath and Sociopath

Source: Encyclopedia Brittanica

Psychopath and sociopath are often used interchangeably in common speech to describe a person
who is pathologically prone to criminal or violent behavior and who lacks any regard for the
feelings or interests of others and any feelings of remorse or guilt for his crimes. Although the
terms are also used in the scientific literature (including the Diagnostic and Statistical Manual of
Mental Disorders, or DSM), they are not well defined there; mental health professionals instead
prefer to understand both psychopathy and sociopathy as types of antisocial personality
disorders (APDs), each condition being distinguished by a few characteristic features but both
having many features in common.

Both psychopathy and sociopathy, then, are characterized by an abiding pattern of disregard for
and violation of the rights of others, as manifested through three or more of the following habitual
or continual behaviors: (1) serious violations of criminal laws; (2) deceitfulness for personal gain
or pleasure, including lying, swindling, or trickery; (3) impulsiveness or failure to plan ahead; (4)
irritability and aggressiveness often resulting in physical assaults; (5) reckless disregard for the
safety of oneself or others; (6) failure to meet important adult responsibilities, including job- and
family-related duties and financial obligations; and (7) lack of meaningful remorse or guilt—to the
point of complete indifference—regarding the serious harm or distress one’s actions cause other
people.

Other characteristics associated with APD are a pronounced lack of empathy; a tendency to be
contemptuous of the rights, interests, or feelings of others; and an excessively high self-appraisal—
i.e., arrogance, conceitedness, or cockiness.

Psychologists and psychiatrists emphasize that APD cannot be properly diagnosed in children,
because it is by definition a condition that abides for many years and because the personalities of
children are constantly evolving. Nevertheless, adults who develop APD typically displayed what
is called conduct disorder as children, generally characterized by aggressive behavior toward
people or animals, destruction of property, deceitfulness or theft, and serious infractions of
criminal laws or other norms.
Among persons who display APD, those called psychopaths are distinguished by a nearly complete
inability to form genuine emotional attachments to others; a compensating tendency to form
artificial and shallow relationships, which the psychopath cynically exploits or manipulates to
benefit himself; a corresponding ability to appear glib and even charming to others; an ability in
some psychopaths to maintain the appearance of a normal work and family life; and a tendency to
carefully plan criminal activities to avoid detection. Sociopaths, in contrast, are generally capable
of developing a close attachment to one or a few individuals or groups, though they too generally
have severe difficulties in forming relationships. Sociopaths are also usually incapable of anything
even remotely resembling a normal work or family life, and, in comparison to psychopaths, they
are exceptionally impulsive and erratic and more prone to rage or violent outbursts. Accordingly,
their criminal activities tend to be spur-of-the-moment rather than carefully premeditated.

Although both biological and environmental factors play a role in the development of psychopathy
and sociopathy, it is generally agreed that psychopathy is chiefly a genetic or inherited condition,
notably related to the underdevelopment of parts of the brain responsible for emotional regulation
and impulse control. The most-important causes of sociopathy, in contrast, lie in physical or
emotional abuse or severe trauma experienced during childhood. To put the matter
simplistically, psychopaths are born, and sociopaths are made.

The Differences Between Psychopaths and Sociopaths: There are vital differences between them.

Author: Scott A. Bonn

The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), released
by the American Psychiatric Association in 2013, lists both sociopathy and psychopathy under the
heading of Antisocial Personality Disorders (ASPD). These disorders share many common
behavioral traits, which leads to some of the confusion. Key traits that sociopaths and psychopaths
share include:

• A disregard for laws and social mores

• A disregard for the rights of others

 • A failure to feel remorse or guilt

• A tendency to display violent or aggressive behavior

In addition to their commonalities, sociopaths and psychopaths also have their own unique
behavioral characteristics and origins.

Sociopaths tend to be nervous and easily agitated. They are volatile and prone to emotional
outbursts, including fits of rage. They are more likely than are psychopaths to be uneducated and
live on the fringes of society. They are sometimes unable to hold down a steady job or to stay in
one place for very long. It is often difficult, but not entirely impossible, for sociopaths to form
attachments with others.

Many sociopaths are able to form an attachment to a particular individual or group, although they
have no regard for society or its rules in general. Therefore, the meaningful attachments of any
sociopath will be few in number and limited in scope. As a rule, they will struggle with
relationships.

In the eyes of others, sociopaths will generally appear to be disturbed or erratic. Any crimes they
commit, including murder, will tend to be haphazard and spontaneous rather than planned. Because
of their seemingly erratic behavior, sociopaths are easier for both professionals and
nonprofessionals to identify than are psychopaths.

Unlike sociopaths, psychopaths are unable to form emotional attachments. Psychopaths tend to be
aggressive and predatory in nature. They view others as objects for their amusement. Although
they lack empathy, psychopaths often have disarming or even charming personalities. They are
manipulative and can easily gain people’s trust. They learn to mimic emotions, despite their
inability to actually feel them and will appear normal to unsuspecting people. Psychopaths are
often well-educated and hold steady jobs.

Some psychopaths are so good at manipulation and mimicry that they have families and other
long-term relationships without those around them ever suspecting their true nature. When
committing crimes, psychopaths carefully plan every detail in advance and often have contingency
plans in place. They will seem unflappable in a crisis.
Unlike their sociopathic counterparts, psychopathic criminals are cool, calm, and meticulous.
From a law-enforcement perspective, the “cold-blooded” nature of psychopaths makes them very
effective criminals. As such, they are generally more difficult to identify than are sociopaths.
Unfortunately, it can be hard to know when a psychopathic predator has targeted you for
exploitation.

From a diagnostic standpoint, the etiology or cause of psychopathy is different from that of
sociopathy. Psychopathy is the result of “nature” (genetics), while sociopathy is the result of
“nurture” (environment). Psychopathy is related to a physiological defect that results in the
underdevelopment of the part of the brain responsible for impulse control and emotions (1).

Sociopathy, on the other hand, is more likely the product of childhood trauma and physical
or emotional abuse. Because sociopathy appears to be learned rather than innate, sociopaths are
capable of empathy in certain circumstances, and with certain individuals, but not others.

Ultimately, psychopathy is rarer than sociopathy and is considered to be the most dangerous of
antisocial personality disorders. Not surprisingly, many serial killers, including Ted Bundy,
Dennis Rader (BTK), and John Wayne Gacy, have been unremorseful psychopaths. Indeed, it is
estimated that nearly 50 percent of all serial killers are psychopaths.
DSM-IV-TR General Diagnostic Criteria
for a Personality Disorder
A. An enduring pattern of inner experience and behavior that deviates markedly from
the expectations of the individual’s culture. This pattern is manifested in two (or more)
of the following areas:
(1) cognition (i.e., ways of perceiving and interpreting self, other people, and events)
(2) affectivity (i.e., the range, intensity, lability, and appropriateness of emotional
response)
(3) interpersonal functioning
(4) impulse control
B. The enduring pattern is infl exible and pervasive across a broad range of personal and
social situations.
C. The enduring pattern leads to clinically signifi cant distress or impairment in social,
occupational, or other important areas of functioning.
D. The pattern is stable and of long duration and its onset can be traced back at least to
adolescence or early adulthood.
E. The enduring pattern is not better accounted for as a manifestation or consequence
of another mental disorder.
F. The enduring pattern is not due to the direct physiological effects of a substance
(e.g., a drug of abuse, a medication) or a general medical condition (e.g., head trauma).
Prevalence

Between 1% and 4% of Americans are diagnosed with antisocial disorder (APA, 2000; Grant,
Hasin, et al., 2004).

Around 60% of male prisoners in a number of countries have antisocial personality disorder
(Moran, 1999).

Comorbidity

The most common comorbid Axis I disorders are anxiety disorders, mood disorders, substance-
related disorders, and somatization disorders (APA, 2000; Compton et al., 2005).

In a clinical setting, most patients who meet the criteria for antisocial personality disorder also are
diagnosed with at least one other personality disorder, typically another dramatic/erratic
personality disorder (Widiger & Corbitt, 1997).

Onset

As required by the DSM-IV-TR criteria, symptoms of conduct disorder emerge before age 15, and
specific symptoms of antisocial behavior occur since age 15. The specific antisocial behaviors then
continue into adulthood.

Course

Antisocial personality disorder has a chronic course, but symptoms may improve as patients age,
particularly in their 40s (Seivewright, Tyrer, & Johnson, 2002)

Gender Differences

Antisocial personality disorder is diagnosed three times more often in men than in women.
Cluster A involves odd or
eccentric behaviors:
Paranoid personality disorder is characterized by mistrust and suspicion of others.
Schizoid personality disorder is characterized by few close relationships and a
limited range of emotional expression.
Schizotypal personality disorder is characterized by few close relationships and
eccentric perceptions, thoughts, and behaviors.
Cluster B involves
emotional, dramatic, or
erratic behaviors:
Antisocial personality disorder is characterized by repeated violation of or
disregard for the rights of others.
Borderline personality disorder is characterized by rapidly changing emotions,
unstable relationships, and impulsivity.
Histrionic personality disorder is characterized by exaggerated emotions and
excessive attention-seeking behaviors.
Narcissistic personality disorder is characterized by an excessive sense of selfimportance
and diffi culty appreciating other people’s perspectives.
Cluster C involves anxious
and fearful behaviors:
Avoidant personality disorder is characterized by a heightened sensitivity to
rejection and social inhibition.
Dependent personality disorder is characterized by submissive, clingy behavior
intended to elicit care from others, along with dependence on others for decision
making and reassurance.
Obsessive-compulsive personality disorder is characterized by orderliness,
perfectionism, and control at the expense of spontaneity and fl exibility.