Abnormal Psychology An Integrative Approach, 7th Ed

Personality Disorders
CHAPTER OUTLINE
An Overview of Personality Disorders

Aspects of Personality Disorders
Categorical and Dimensional Models
Personality Disorder Clusters
Statistics and Development
Gender Differences
Comorbidity
Personality Disorders under Study
Cluster A Personality Disorders
Paranoid Personality Disorder
Schizoid Personality Disorder
Schizotypal Personality Disorder
Cluster B Personality Disorders
Antisocial Personality Disorder
Borderline Personality Disorder
Histrionic Personality Disorder
Narcissistic Personality Disorder
Cluster C Personality Disorders
Avoidant Personality Disorder
Dependent Personality Disorder
Obsessive-Compulsive Personality Disorder
©auremar/Shutterstock.com
8
12 Copyright 201 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).
Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
[ student learning outcomes*
]
• Use scientific reasoning to interpret behavior: • Identify basic biological, psychological, and social
components of behavioral explanations (e.g., inferences,
observations, operational definitions and interpretations)
(APA SLO 1.1a) (see textbook pages 456–457, 461–463)
• Engage in innovative and integrative thinking and • Describe problems operationally to study them empirically.
problem solving: (APA SLO 1.3a) (see textbook pages 441–471)
• Describe applications that employ discipline-based • Correctly identify antecedents and consequences of
problem solving: behavior and mental processes (APA SLO 5.3c) Describe
examples of relevant and practical applications of
psychological principles to everyday life (APA SLO 5.3a)
(see textbook pages 449–453, 460, 463–471)
* Portions of this chapter cover learning outcomes suggested by the American Psychological Association
(2012) in its guidelines for the undergraduate psychology major. Chapter coverage of these outcomes is
identified above by APA Goal and APA Suggested Learning Outcome (SLO).
An Overview of Personality Disorders sustain a lasting relationship if she can’t trust anyone), and even
where she lives (she may move often if she suspects her landlords
We all think we know what a personality is. It’s all the character- are out to get her).
istic ways a person behaves and thinks: “Michael tends to be shy”; A personality disorder is a persistent pattern of emotions,
“Mindy likes to be dramatic”; “Juan is always suspicious of cognitions, and behavior that results in enduring emotional distress
others”; “Annette is outgoing”; “Bruce seems to be sensitive and for the person affected and/or for others and may cause difficulties
gets upset easily over minor things”; “Sean has the personality of with work and relationships (American Psychiatric Association,
an eggplant!” We tend to type people as behaving in one way in 2013). DSM-5 notes that having a personality disorder may dis-
many situations. For example, like Michael, many of us are shy tress the affected person. Individuals with personality disorders
with people we don’t know, but we won’t be shy around our friends. may not feel any subjective distress, however; indeed, it may in
A truly shy person is shy even among people he has known for some fact be others who acutely feel distress because of the actions of
time. The shyness is part of the way the person behaves in most the person with the disorder. This is particularly common with
situations. We also have all probably behaved in all the other ways antisocial personality disorder, because the individual may show a
noted here (dramatic, suspicious, outgoing, easily upset). However, blatant disregard for the rights of others yet exhibit no remorse
when personality characteristics interfere with relationships with (Hare, Neumann, & Widiger, 2012). In certain cases, someone
others, cause the person distress, or in general disrupt activities of other than the person with the personality disorder must decide
daily living, we consider these to be “personality disorders” (Skodol, whether the disorder is causing significant functional impairment,
2012). In this chapter, we look at characteristic ways of behaving because the affected person often cannot make such a judgment.
in relation to a number of specific personality disorders. First we DSM-5 lists 10 specific personality disorders. Although the
examine how we conceptualize personality disorders and the issues prospects for treatment success for people who have personal-
related to them; then we describe the disorders themselves. ity disorders may be more optimistic than previously thought
(Nelson, Beutler, & Castonguay, 2012), unfortunately, as you will
Aspects of Personality Disorders see later, many people who have personality disorders in addition
What if a person’s characteristic ways of thinking and behaving to other psychological problems (for example, major depression)
cause significant distress to the self or others? What if the person tend to do poorly in treatment. One factor important to the suc-
can’t change this way of relating to the world and is unhappy? We cess (or lack of success) of treatment is how the therapist feels
might consider this person to have a personality disorder. Unlike about the client. The emotions of therapists brought out by clients
many of the disorders we have already discussed, personality (called “countertransference” by Sigmund Freud) tend to be neg-
disorders are chronic; they do not come and go but originate in ative for those diagnosed with personality disorders, especially
childhood and continue throughout adulthood (Widiger, 2012). those (as you will see next) in Cluster A (the odd or eccentric
Because these chronic problems affect personality, they pervade cluster) and Cluster B (the dramatic, emotional, or erratic cluster)
every aspect of a person’s life. For example, if a woman is overly (Liebman & Burnette, 2013). Therapists especially need to guard
suspicious (a sign of a possible paranoid personality disorder), against letting their personal feelings interfere with treatment
this trait will affect almost everything she does, including her when working with people who have personality disorders.
employment (she may change jobs often if she believes coworkers Prior to DSM-5, most disorders we discuss in this book
conspire against her), her relationships (she may not be able to were in Axis I of the DSM-IV-TR, which included the traditional
An O v e rv i ew of P ers ona l i t y D i s order s 441
Copyright 201 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).
disorders. The personality disorders were included in a separate categories leads clinicians to reify them; that is, to view disorders as
axis, Axis II, because as a group they were seen as distinct. It was real “things,” comparable to the realness of an infection or a broken
thought that the characteristic traits were more ingrained and arm. Some argue that personality disorders are not things that exist
inflexible in people who have personality disorders, and the disor- but points at which society decides a particular way of relating to
ders themselves were less likely to be successfully modified. With the world has become a problem. There is the important unresolved
the changes made with DSM-5, these separate axes were eliminat- issue again: Are personality disorders just an extreme variant of
ed and now the personality disorders are listed with the rest of the normal personality, or are they distinctly different disorders?
DSM-5 disorders (American Psychiatric Association, 2013). Some had proposed that the DSM-5 personality disorders sec-
You may be surprised to learn that the category of personality tion be replaced or at least supplemented by a dimensional model
disorders is controversial, because it involves a number of unre- (South et al., 2011; Widiger, 2012) in which individuals would not
solved issues. Examining these issues can help you understand all only be given categorical diagnoses but also would be rated on a
the disorders described in this book. series of personality dimensions. Widiger (1991) believes such a
system would have at least three advantages over a purely categori-
Categorical and Dimensional Models cal system: (1) It would retain more information about each indi-
vidual, (2) it would be more flexible because it would permit both
Most of us are sometimes suspicious of others and a little para-
categorical and dimensional differentiations among individuals,
noid, overly dramatic, too self-involved, or reclusive. Fortunately,
and (3) it would avoid the often arbitrary decisions involved in
these characteristics do not last long or are not overly intense; they
assigning a person to a diagnostic category. Currently, there is an
haven’t significantly impaired how we live and work. People with
alternative model of personality disorders included in the section
personality disorders, however, display problem characteristics
on “emerging measures and models” in DSM-5 that is included
over extended periods and in many situations, which can cause
for further study (American Psychiatric Association, 2013). This
great emotional pain for themselves, others, or both (Widiger,
model focuses on a continuum of disturbances of “self ” (i.e., how
2012). Their difficulty, then, can be seen as one of degree rather
you view yourself and your ability to be self directed) and inter-
than kind; in other words, the problems of people with personal-
personal (i.e., your ability to empathize and be intimate with oth-
ity disorders may just be extreme versions of the problems many
ers) functioning. It remains to be seen how this alternative model
of us experience temporarily, such as being shy or suspicious
will be used in the future.
(South, Oltmanns, & Krueger, 2011).
Although no general consensus exists about what the basic
The distinction between problems of degree and problems of
personality dimensions might be, there are several contenders
kind is usually described in terms of dimensions instead of catego-
(South et al., 2011). One of the more widely accepted is called the
ries. The issue that continues to be debated in the field is whether
five-factor model, or the “Big Five,” and is taken from work on nor-
personality disorders are extreme versions of otherwise normal
mal personality (Hopwood & Thomas, 2012; McCrae & Costa Jr.,
personality variations (dimensions) or ways of relating that are
2008). In this model, people can be rated on a series of personal-
different from psychologically healthy behavior (categories)
ity dimensions, and the combination of five components describes
(Widiger & Trull, 2007). You can see the difference between
why people are so different. The five factors or dimensions are extro-
dimensions and categories in everyday life. For example, we tend
version (talkative, assertive, and active versus silent, passive, and
to look at gender categorically. Our society views us as being in one
reserved); agreeableness (kind, trusting, and warm versus hostile,
category—”female”—or the other—”male.” Yet we could also
selfish, and mistrustful); conscientiousness (organized, thorough,
look at gender in terms of dimensions. For example, we know
and reliable versus careless, negligent, and unreliable); neuroticism
that “maleness” and “femaleness” are partly determined by hor-
(even-tempered versus nervous, moody, and temperamental); and
mones. We could identify people along testosterone, estrogen,
openness to experience (imaginative, curious, and creative versus
or both dimensions and rate them on a continuum of maleness
shallow and imperceptive) (McCrae & Costa Jr., 2008). On each
and femaleness rather than in the absolute categories of male or
dimension, people are rated high, low, or somewhere between.
female. We also often label people’s size categorically, as tall, aver-
Cross-cultural research establishes the universal nature of the
age, or short. But height, too, can be viewed dimensionally, in
five dimensions—although there are individual differences across
inches or centimeters.
cultures (Hofstede & McCrae, 2004). For example, one study
Many researchers and clinicians in this field see personality
found in general that Austrian, Swiss, and Dutch samples scored
disorders as extremes on one or more personality dimensions.
the highest on openness to experience, whereas the Danes, Malay-
Yet because of the way people are diagnosed with the DSM, the
sians, and Telugu Indians (India) scored the lowest on this factor
personality disorders—like most other disorders—end up being
(McCrae, 2002). A number of researchers are trying to determine
viewed in categories. You have two choices—either you do (“yes”)
whether people with personality disorders can also be rated in a
or you do not (“no”) have a disorder. For example, either you have
meaningful way along these dimensions and whether the system
antisocial personality disorder or you don’t. The DSM doesn’t rate
will help us better understand these disorders (Skodol et al., 2005).
how dependent you are; if you meet the criteria, you are labeled as
having dependent personality disorder. There is no “somewhat”
when it comes to personality disorders. Personality Disorder Clusters
There are advantages to using categorical models of behav- DSM-5 divides the personality disorders into three groups, or
ior, the most important being their convenience. With simplifica- clusters; this will probably continue until a strong scientific basis
tion, however, come problems. One is that the mere act of using is established for viewing them differently (American Psychiatric
442 C ha p ter 12 P ersonalit y D isorder s
Association, 2013) (see Table 12.1). The cluster division is based in clinical settings versus surveying the general population—even
on resemblance. Cluster A is called the odd or eccentric cluster; those not seeking assistance (Torgersen, 2012). Similarly, gender
it includes paranoid, schizoid, and schizotypal personality dis- differences in the disorders—for example, more women diag-
orders. Cluster B is the dramatic, emotional, or erratic cluster; it nosed with borderline personality disorder and more men identi-
consists of antisocial, borderline, histrionic, and narcissistic per- fied with antisocial personality disorder—are highly variable when
sonality disorders. Cluster C is the anxious or fearful cluster; it surveying the general population. There may be several reasons
includes avoidant, dependent, and obsessive-compulsive person- for these differences in diagnoses, including bias in diagnoses and
ality disorders. We follow this order in our review. differences in help-seeking behavior and tolerance of behavior in
a culture. We discuss several of these concerns later in the chapter.
Personality disorders were thought to originate in childhood
Statistics and Development and continue into the adult years (Cloninger & Svakic, 2009).
Because many people with these problems do not seek help on their More sophisticated analyses suggest that personality disorders
own as do those with many of the other DSM-5 disorders, gather- can remit over time, however, they may be replaced by other per-
ing information about the prevalence of personality disorders is sonality disorders (Torgersen, 2012). In other words, a person could
difficult and therefore varies a great deal. An important population receive a diagnosis of one personality disorder at one point in time
survey suggests that as many as 1 in 10 adults in the United States but years later no longer meet the criteria for his original prob-
may have a diagnosable personality disorder (Lenzenweger, Lane, lem but now have characteristics of a second (or third) personality
Loranger, & Kessler, 2007), which makes them relatively common disorder. Our relative lack of information about such important
(see Table 12.2). Numbers vary somewhat across countries, but features of personality disorders as their developmental course is
worldwide about 6% of adults may have at least one personality a repeating theme. The gaps in our knowledge of the course of
disorder (Huang et al., 2009). Differences in prevalence estimates about half these disorders are visible in Table 12.2. One reason
may be the result of different survey methods, surveying people for this dearth of research is that many individuals do not seek
Table 12.1 Personality Disorders

Personality Disorder Description
Cluster A—Odd or Eccentric Disorders
Paranoid personality disorder A pervasive distrust and suspiciousness of others such that their
motives are interpreted as malevolent.
Schizoid personality disorder A pervasive pattern of detachment from social relationships and a
restricted range of expression of emotions in interpersonal settings.
Schizotypal personality disorder A pervasive pattern of social and interpersonal deficits marked by
acute discomfort with reduced capacity for close relationships, as well
as by cognitive or perceptual distortions and eccentricities of behavior.
Cluster B—Dramatic, Emotional, or Erratic Disorders
Antisocial personality disorder A pervasive pattern of disregard for and violation of the rights of others.
Borderline personality disorder A pervasive pattern of instability of interpersonal relationships,

self-image, affects, and control over impulses.
Histrionic personality disorder A pervasive pattern of excessive emotion and attention seeking.
Narcissistic personality disorder A pervasive pattern of grandiosity (in fantasy or behavior), need for
admiration, and lack of empathy.
Cluster C—Anxious or Fearful Disorders
Avoidant personality disorder A pervasive pattern of social inhibition, feelings of inadequacy, and
hypersensitivity to negative evaluation.
Dependent personality disorder A pervasive and excessive need to be taken care of, which leads to
submissive and clinging behavior and fears of separation.
Obsessive-compulsive personality disorder A pervasive pattern of preoccupation with orderliness, perfectionism,

and mental and interpersonal control, at the expense of flexibility,
openness, and efficiency.
Source: Reprinted, with permission, from American Psychiatric Association. (2013). Diagnostic and statistical
manual of mental disorders (5th ed.). Washington, DC: Author, © 2013 American Psychiatric Association.
Table 12.2 Statistics and Development of Personality Disorders
Disorder Prevalence* Gender Differences* Course
Paranoid personality In the clinical population: 6.3%29.6% Approximately equal Insufficient information
disorder among men and women
In the general population: 1.5%21.8%
Schizoid personality In the clinical population: 1.4%21.9% Slightly more common Insufficient information
disorder among men
Schizotypal personality In the clinical population: 6.4%25.7% Slightly more common Chronic; some go on to
disorder among men develop schizophrenia
Antisocial personality In the clinical population: 3.9%25.9% Much more common Dissipates after age
disorder among men 40 (Hare, McPherson,
& Forth, 1988)
Borderline personality In the clinical population: 28.5% Approximately equal Symptoms gradually
disorder among men and women improve if individuals
survive into their 30s
(Zanarini et al., 2006);
approximately 6% die
by suicide (Perry, 1993)
Histrionic personality In the clinical population: 8.0%29.7% Slightly more common Chronic
disorder among women
Narcissistic personality In the clinical population: 5.1%210.1% Slightly more common May improve over
disorder among men time (Cooper &
Ronningstam, 1992;
Gunderson, Ronnings-
tam, & Smith, 1991)
Avoidant personality In the clinical population: 21.5%224.6% Slightly more common Insufficient information
Dependent personality In the clinical population: 13.0%215.0% Much more common Insufficient information
Obsessive-compulsive In the clinical population: 6.1%210.5% Slightly more common Insufficient information
personality disorder among men
*Population data and gender data reported in Torgersen, S. (2012). Epidemiology. In T. A. Widiger (Ed.), The Oxford
handbook of personality disorders (pp. 1862205). New York: Oxford University Press.
treatment in the early developmental phases of their disorder but 6% succeed in their attempts (Skodol & Gunderson, 2008). On the
only after years of distress. This makes it difficult to study people bright side, their symptoms gradually improve if they survive into
with personality disorders from the beginning, although a few their 30s (Zanarini, Frankenburg, Hennen, Reich, & Silk, 2006),
research studies have helped us understand the development of although elderly individuals may have difficulty making plans and
several disorders (Pulay et al., 2009; Stinson et al., 2008). may be disruptive in nursing homes (Hunt, 2007). People with
People with borderline personality disorder are characterized antisocial personality disorder display a characteristic disregard
by their volatile and unstable relationships; they tend to have for the rights and feelings of others; they tend to continue their
persistent problems in early adulthood, with frequent hospital- destructive behaviors of lying and manipulation through adult-
izations, unstable personal relationships, severe depression, and hood. Fortunately, some tend to “burn out” after the age of about
suicidal gestures. Almost 10% attempt suicide, and approximately 40 and engage in fewer criminal activities (Douglas, Vincent, &
Edens, 2006). As a group, however, the problems of people with Antisocial P.D. Histrionic P.D.
personality disorders continue, as shown when researchers follow
Antisocial personality Histrionic personality
their progress over the years (Torgersen, 2012). case case
80
Gender Differences
70
Men diagnosed with a personality disorder tend to display traits
characterized as more aggressive, structured, self-assertive, and 60
detached and women tend to present with characteristics that are
Percentage of cases
more submissive, emotional, and insecure (Torgersen, 2012). It is 50
not surprising, then, that antisocial personality disorder is present
more often in males and dependent personality disorder more often 40
in females. Historically, histrionic and borderline personality dis-
orders were identified by clinicians more often in women (Dulit, 30
Marin, & Frances, 1993; Stone, 1993), but according to more recent
20
studies of their prevalence in the general population, equal numbers
of males and females may have histrionic and borderline personal- 10
ity disorders (see Table 12.2). If this observation holds up in future
studies, why have these disorders been predominantly diagnosed 0
among females in general clinical practice and in other studies? Males Females Males Females
Do the disparities indicate differences between men and wom- Diagnosis
en in certain basic experiences that are genetic, sociocultural, or ● FIGURE 12.1 Gender bias in diagnosing personality disorders (P.D.).
both, or do they represent biases on the part of the clinicians who Data are shown for the percentage of cases clinicians rated as antisocial
make the diagnoses? Take, for example, a classic study by Maureen personality disorder or histrionic personality disorder, depending on
Ford and Thomas Widiger (1989), who sent fictitious case histo- whether the case was described as a male or a female. (From Ford, M. R.,
& Widiger, T. A. [1989]. Sex bias in the diagnosis of histrionic and antisocial
ries to clinical psychologists for diagnosis. One case described a personality disorders. Journal of Consulting and Clinical Psychology, 57,
person with antisocial personality disorder, which is characterized 301–305.)
by irresponsible and reckless behavior and usually diagnosed in
males; the other case described a person with histrionic person-
ality disorder, which is characterized by excessive emotionality reflects society’s inherent bias against females. (See Table 12.3 for a
and attention seeking and more often diagnosed in females. The humorous take on a male version of a personality disorder.) Inter-
subject was identified as male in some versions of each case and estingly, the “macho” personality (Mosher & Sirkin, 1984), in which
as female in others, although everything else was identical. As the individual possesses stereotypically masculine traits, is nowhere
the graph in ● Figure 12.1 shows, when the antisocial personal- to be found in the DSM.
ity disorder case was labeled male, most psychologists gave the The issue of gender bias in diagnosing personality disor-
correct diagnosis. When the same case of antisocial personality der remains highly controversial (Liebman & Burnette, 2013).
disorder was labeled female, however, most psy-
chologists diagnosed it as histrionic personal-
ity disorder rather than antisocial personality
disorder. In the case of histrionic personality
disorder, being labeled a woman increased the
likelihood of that diagnosis. Ford and Widiger
(1989) concluded that the psychologists
incorrectly diagnosed more women as having
histrionic personality disorder.
This gender difference in diagnosis has also
been criticized by other authors (see, for exam-
ple, Kaplan, 1983) on the grounds that histrionic
personality disorder, like several of the other per-
sonality disorders, is biased against females. As
Kaplan (1983) points out, many of the features of
histrionic personality disorder, such as overdra-
©Bonnie Kamin/PhotoEdit
matization, vanity, seductiveness, and overcon-

cern with physical appearance, are characteristic
of the Western “stereotypical female.” This disor-
der may simply be the embodiment of extremely
“feminine” traits (Chodoff, 1982); branding such
an individual mentally ill, according to Kaplan, Personality disorders tend to begin in childhood.
Table 12.3 Diagnostic Criteria for “Independent” Comorbidity
Personality Disorder Looking at Table 12.2 and adding up the prevalence rates across
Puts work (career) above relationships with loved ones the personality disorders, you might conclude that up to 25%
(for example, travels a lot on business, works late at night of all people are affected. In fact, the percentage of people in
and on weekends). the population with a personality disorder is likely closer to
10% (Huang et al., 2009; Lenzenweger et al., 2007). What
Is reluctant to take into account others’ needs when making
decisions, especially concerning the individual’s career accounts for this discrepancy? A major concern with the
or use of leisure time, for example, expects spouse and personality disorders is that people tend to be diagnosed with
children to relocate to another city because of individual’s more than one. The term comorbidity historically describes
career plans. the condition in which a person has multiple diseases (Caron
Passively allows others to assume responsibility for major
& Rutter, 1991). A fair amount of disagreement is ongoing
areas of social life because of inability to express necessary about whether the term should be used with psychological dis-
emotion (for example, lets spouse assume most childcare orders because of the frequent overlap of different disorders
responsibilities). (Skodol, 2005). In just one example, Zimmerman, Rothschild,
and Chelminski (2005) conducted a study of 859 psychiatric
Source: From Kaplan, M. (1983). A woman’s view of DSM-III. American outpatients and assessed how many had one or more person-
Psychologist, 38, 786–792.
ality disorders. Table 12.4 shows the odds that a person with
a particular personality disorder would also meet the criteria
Remember, however, that just because certain disorders are for other disorders. For example, a person identified with bor-
observed more in men or women doesn’t necessarily indicate derline personality disorder is also likely to receive diagnoses
bias (Lilienfeld, VanValkenburg, Larntz, & Akiskal, 1986). of paranoid, schizotypal, antisocial, narcissistic, avoidant, or
When it is present, bias can occur at different stages of the dependent personality disorders.
diagnostic process. Widiger and Spitzer (1991) point out that Do people really tend to have more than one personality
the criteria for the disorder may themselves be biased (criterion disorder? Are the ways we define these disorders inaccurate,
gender bias), or the assessment measures and the way they are and do we need to improve our definitions so that they do not
used may be biased (assessment gender bias). In general, the overlap? Or did we divide the disorders in the wrong way, and
criteria themselves do not appear to have strong gender bias, do we need to rethink the categories? Complicating this issue is
although there may be some tendency for clinicians to use their the phenomenon that people will change diagnoses over time
own bias when using the criteria and therefore diagnose males (Torgersen, 2012). Such questions about comorbidity are just
and females differently (Oltmanns & Powers, 2012). As studies a few of the important issues faced by researchers who study
continue, researchers will try to make the diagnosis of person- personality disorders.
ality disorders more accurate with respect to gender and more
useful to clinicians. Personality Disorders under Study
We started this chapter by noting difficul-
ties in categorizing personality disorders; for
example, there is much overlap of the catego-
ries, which suggests there may be other ways
to arrange these pervasive difficulties of char-
acter. It shouldn’t surprise you to learn that
other personality disorders have been studied
for inclusion in the DSM—for example, sadis-
tic personality disorder, which includes people
who receive pleasure by inflicting pain on
others (Morey, Hopwood, & Klein, 2007), and
passive-aggressive personality disorder, which
includes people who are defiant and refuse to
©Hill Street Studios/Blend Images/Jupiter Images
cooperate with requests—attempting to under-

mine authority figures (Wetzler & Jose, 2012).
The existence of these disorders as distinct
personality disorders remains controversial,
however, so they were not included in DSM-5
(Wetzler & Jose, 2012).
We now review the personality disor-
ders currently in DSM-5, 10 in all. Table 12.5
provides a simplified look at how people
Gender bias may affect the diagnosis of clinicians who associate certain behavioral charac- with different personality disorders view
teristics with one sex or the other. the world.
Table 12.4 Diagnostic Overlap of Personality Disorders
†
Odds Ratio of People Qualifying for Other Personality Disorder Diagnoses
Diagnosis Paranoid Schizoid Schizotypal Antisocial Borderline Histrionic Narcissistic Avoidant Dependent Obsessive-
Compulsive
Paranoid 2.1 37.3* 2.6 12.3* 0.9 8.7* 4.0* 0.9 5.2*
Schizoid 2.1 19.2 1.1 2.0 3.9 1.7 12.3* 2.9 5.5*
Schizotypal 37.3* 19.2 2.7 15.2* 9.4 11.0 3.9* 7.0 7.1
Antisocial 2.6 1.1 2.7 9.5* 8.1* 14.0* 0.9 5.6 0.2
Borderline 12.3* 2.0 15.2* 9.5* 2.8 7.1* 2.5* 7.3* 2.0
Histrionic 0.9 3.9 9.4 8.1* 2.8 13.2* 0.3 9.5 1.3
Narcissistic 8.7* 1.7 11.0 14.0* 7.1* 13.2* 0.3 4.0 3.7*
Avoidant 4.0* 12.3* 3.9* 0.9 2.5* 0.3 0.3 2.0 2.7
Dependent 0.9 2.9 7.0 5.6 7.3* 9.5 4.0 2.0 0.9
Obsessive- 5.2* 5.5* 7.1 0.2 2.0 1.3 2.0 2.7 0.9
compulsive
†
The “odds ratio” indicates how likely it is that a person would have both disorders. The odds ratios with an
asterisk (*) indicate that, statistically, people are likely to be diagnosed with both disorders—with a higher
number meaning people are more likely to have both. Some higher odds ratios are not statistically significant
because the number of people with the disorder in this study was relatively small.
Source: Reprinted, with permission, from Zimmerman, M., Rothschild, L., & Chelminski, I. (2005). The
prevalence of DSM-IV personality disorders in psychiatric outpatients. American Journal of Psychiatry,
162, 1911–1918, © 2005 American Psychiatric Association.
Table 12.5 Main Beliefs Associated with Specific

Personality Disorders Concept Check 12.1
Personality
Disorder Main belief Fill in the blanks to complete the following statements about
Paranoid I cannot trust people personality disorders.
Schizotypal It’s better to be isolated from others 1. ____________ refers to a condition in which people with
personality disorders are diagnosed with other disorders.
Schizoid Relationships are messy,
undesirable 2. The personality disorders are divided into three clusters
or groups: ____________ contains the odd or eccentric
Histrionic People are there to serve or disorders; ____________ contains the dramatic, emo-
admire me
tional, and erratic disorders; and ____________ contains
Narcissistic Since I am special, I deserve the anxious and fearful disorders.
special rules
3. It’s debated whether personality disorders are extreme
Borderline I deserve to be punished versions of otherwise normal personality variations
(therefore classified as dimensions) or ways of relating
Antisocial I am entitled to break rules
that are different from psychologically healthy behavior
Avoidant If people knew the “real” me, they (classified as ____________).
will reject me
4. Personality disorders are described as ____________
Dependent I need people to survive, be happy because unlike many disorders, they originate in child-
hood and continue throughout adulthood.
Obsessive-compulsive People should do better, try harder
5. Although gender differences are evident in the research
Source: Reprinted with permission from Lobbestael, J., & Arntz, A. (2012). of personality disorders, some differences in the findings
Cognitive contributions to personality disorders. In T. A. Widiger (Ed.), may be the result of ____________.
The Oxford handbook of personality disorders (p. 326). New York: Oxford
University Press.
Cluster A Personality Disorders disorder are suspicious in situations in which most other people
would agree their suspicions are unfounded. Even events that
Three personality disorders—paranoid, schizoid, and schizotypal— have nothing to do with them are interpreted as personal attacks
share common features that resemble some of the psychotic symp- (Bernstein & Useda, 2007). These people would view a neighbor’s
toms seen in schizophrenia. These odd or eccentric personality barking dog or a delayed airline flight as a deliberate attempt to
disorders are described next. annoy them. Unfortunately, such mistrust often extends to peo-
ple close to them and makes meaningful relationships difficult.
Paranoid Personality Disorder Imagine what a lonely existence this must be. Suspiciousness and
Although it is probably adaptive to be a little wary of other people mistrust can show themselves in a number of ways. People with
and their motives, being too distrustful can interfere with mak- paranoid personality disorder may be argumentative, may com-
ing friends, working with others, and, in general, getting through plain, or may be quiet. This style of interaction is communicated,
daily interactions in a functional way. People with paranoid per- sometimes nonverbally, to others, often resulting in discomfort
sonality disorder are excessively mistrustful and suspicious of among those who come in contact with them because of this
others, without any justification. They assume other people are volatility. These individuals are sensitive to criticism and have an
out to harm or trick them; therefore, they tend not to confide in excessive need for autonomy (Bernstein & Useda, 2007). Having
others. Consider the case of Jake. this disorder increases the risk of suicide attempts and violent
behavior, and these people tend to have a poor overall quality of
life (Hopwood & Thomas, 2012).
JAKE... Research Victim
J ake grew up in a middle-class neighborhood, and although

DSM
5
he never got in serious trouble, he had a reputation in TABLE 12.1 Diagnostic Criteria for Paranoid
high school for arguing with teachers and classmates. After Personality Disorder
high school he enrolled in the local community college, but
he flunked out after the first year. Jake’s lack of success in A. A pervasive distrust and suspiciousness of others
school was partly attributable to his failure to take respon- such that their motives are interpreted as malevolent,
sibility for his poor grades. He began to develop conspiracy beginning by early adulthood and present in a variety
theories about fellow students and professors, believing they of contexts, as indicated by four (or more) of the
worked together to see him fail. Jake bounced from job to following:
job, each time complaining that his employer was spying on 1. Suspects, without sufficient basis, that others are
him at work and at home. exploiting, harming, or deceiving him or her.
At age 25—and against his parents’ wishes—he moved out 2. Is preoccupied with unjustified doubts about
of his parents’ home to a small town out of state. Unfortunately, the loyalty or trustworthiness of friends or
the letters Jake wrote home daily confirmed his parents’ worst associates.
fears. He was becoming increasingly preoccupied with theories 3. Is reluctant to confide in others because of unwar-
about people who were out to harm him. Jake spent enormous ranted fear that the information will be used mali-
amounts of time on his computer exploring websites, and he ciously against him or her.
developed an elaborate theory about how research had been 4. Reads hidden demeaning or threatening meanings
performed on him in childhood. His letters home described his into benign remarks or events.
belief that researchers working with the CIA drugged him as a 5. Persistently bears grudges, i.e., is unforgiving of
child and implanted something in his ear that emitted micro- insults, injuries, or slights.
waves. These microwaves, he believed, were being used to 6. Perceives attacks on his or her character or reputa-
cause him to develop cancer. Over 2 years, he became increas- tion that are not apparent to others and is quick to
react angrily or to counterattack.
ingly preoccupied with this theory, writing letters to various
authorities trying to convince them he was being slowly killed. 7. Has recurrent suspicions, without justification,
regarding fidelity of spouse or sexual partner.
After he threatened harm to some local college administrators,
his parents were contacted and they brought him to a psychol- B. Does not occur exclusively during the course of schizo-
phrenia, a bipolar disorder or depressive disorder with
ogist, who diagnosed him with paranoid personality disorder
and major depression. • psychotic features, or another psychotic disorder and is
not attributable to the physiological effects of another
medical condition.
Note: If criteria are met prior to the onset of schizophrenia,
Clinical Description add “premorbid,” i.e., “paranoid personality disorder
(premorbid).”
The defining characteristic of people with paranoid personality
disorder is a pervasive unjustified distrust (Hopwood & Thomas, From American Psychiatric Association. (2013). Diagnostic and statistical
2012). Certainly, there may be times when someone is deceitful manual of mental disorders (5th ed.). Washington, DC.
and “out to get you”; however, people with paranoid personality
Causes other people are deceptive and malicious (Carroll, 2009). It is
Evidence for biological contributions to paranoid personality certainly true that people are not always benevolent and sincere,
disorder is limited. Some research suggests the disorder may be and our interactions are sometimes ambiguous enough to make
slightly more common among the relatives of people who have other people’s intentions unclear. Looking too closely at what other
schizophrenia, although the association does not seem to be strong people say and do can sometimes lead you to misinterpret them.
(Tienari et al., 2003). In other words, relatives of individuals with Cultural factors have also been implicated in paranoid per-
schizophrenia may be more likely to have paranoid personality sonality disorder. Certain groups of people, such as prisoners,
disorder than people who do not have a relative with schizophre- refugees, people with hearing impairments, and older adults, are
nia. In general, there appears to be a strong role for genetics in thought to be particularly susceptible because of their unique
paranoid personality disorder (Kendler et al., 2006). As you will experiences (Rogler, 2007). Imagine how you might view other
see later with the other odd or eccentric personality disorders in people if you were an immigrant who had difficulty with the lan-
Cluster A, there seems to be some relationship with schizophrenia guage and the customs of your new culture. Such innocuous things
causing some to suggest eliminating it as a separate disorder from as other people laughing or talking quietly might be interpreted
the DSM (Triebwasser, Chemerinski, Roussos, & Siever, 2012). as somehow directed at you. The late musician Jim Morrison of
Psychological contributions to this disorder are even less cer- The Doors described this phenomenon in his song “People Are
tain, although some interesting speculations have been made. Strange” (words and music by The Doors, © 1967 Doors Music
Retrospective research—asking people with this disorder to recall Co., used by permission): “People are strange, / When you’re a
events from their childhood—suggests that early mistreatment stranger, / Faces look ugly, / When you’re alone.”
or traumatic childhood experiences may play a role in the devel- You have seen how someone could misinterpret ambiguous
opment of paranoid personality disorder (Natsuaki, Cicchetti, & situations as malevolent. Therefore, cognitive and cultural factors
Rogosch, 2009). Caution is warranted when interpreting these may interact to produce the suspiciousness observed in some
results because, clearly, there may be strong bias in the recall of people with paranoid personality disorder.
these individuals, who are already prone to viewing the world
as a threat. Treatment
Some psychologists point directly to the thoughts (also referred Because people with paranoid personality disorder are mistrust-
to as “schemas”) of people with paranoid personality disorder as ful of everyone, they are unlikely to seek professional help when
a way of explaining their behavior. One view is that people with they need it and they have difficulty developing the trusting rela-
this disorder have the following basic mistaken assumptions about tionships necessary for successful therapy (Skodol & Gunderson,
others: “People are malevolent and deceptive,” “They’ll attack you 2008). Establishing a meaningful therapeutic alliance between the
if they get the chance,” and “You can be okay only if you stay on client and the therapist therefore becomes an important first step
your toes” (Lobbestael & Arntz, 2012). This is a maladaptive way (Bender, 2005). When these individuals finally do seek therapy,
to view the world, yet it seems to pervade every aspect of the lives the trigger is usually a crisis in their lives—such as Jake’s threats to
of these individuals. Although we don’t know why they develop harm strangers—or other problems such as anxiety or depression,
these perceptions, some speculation is that the roots are in their not necessarily their personality disorder (Kelly, Casey, Dunn,
early upbringing. Their parents may teach them to be careful about Ayuso-Mateos, & Dowrick, 2007).
making mistakes and may impress on them that they are different Therapists try to provide an atmosphere conducive to develop-
from other people. This vigilance causes them to see signs that ing a sense of trust (Bender, 2005). They often use cognitive therapy
to counter the person’s mistaken assumptions about others, focus-
ing on changing the person’s beliefs that all people are malevolent
and most people cannot be trusted (Skodol & Gunderson, 2008).
Be forewarned, however, that to date there are no confirmed dem-
onstrations that any form of treatment can significantly improve
the lives of people with paranoid personality disorder. A survey of
mental health professionals indicated that only 11% of therapists
who treat paranoid personality disorder thought these individu-
als would continue in therapy long enough to be helped (Quality
Assurance Project, 1990).
Henrik Sorensen/Riser/Getty Images
Schizoid Personality Disorder

Do you know someone who is a “loner”? Someone who would
choose a solitary walk over an invitation to a party? A person who
comes to class alone, sits alone, and leaves alone? Now, magnify
this preference for isolation many times over and you can begin to
grasp the impact of schizoid personality disorder (Hopwood &
People with paranoid personality disorder often believe that imper- Thomas, 2012). People with this personality disorder show a pat-
sonal situations exist specifically to annoy or otherwise disturb them. tern of detachment from social relationships and a limited range
C lu st e r A P ers ona l i t y D i s order s 449
of emotions in interpersonal situations. They seem aloof, cold, and seem to have the unusual thought processes that characterize
indifferent to other people. The term schizoid is relatively old, hav- the other disorders in Cluster A (Cloninger & Svakic, 2009)
ing been used by Bleuler (1924) to describe people who have a (see Table 12.6). For example, people with paranoid and schizo-
tendency to turn inward and away from the outside world. These typal personality disorders often have ideas of reference, mistaken
people were said to lack emotional expressiveness and pursued beliefs that meaningless events relate just to them. In contrast,
vague interests. Consider the case of Mr. Z. those with schizoid personality disorder share the social isolation,
poor rapport, and constricted affect (showing neither positive
nor negative emotion) seen in people with paranoid personality
MR.Z... All on His Own disorder. You will see in Chapter 13 that this distinction among
psychotic-like symptoms is important to understanding people
with schizophrenia, some of whom show the “positive” symptoms
A 39-year-old scientist was referred after his return from a
tour of duty in Antarctica where he had stopped coop-
erating with others, had withdrawn to his room, and had
(actively unusual behaviors such as ideas of reference) and others
only the “negative” symptoms (the more passive manifestations of
begun drinking on his own. Mr. Z. was orphaned at age 4, social isolation or poor rapport with others).
raised by an aunt until age 9, and subsequently looked after
by an aloof housekeeper. At university he excelled at phys- Causes and Treatment
ics, but chess was his only contact with others. Throughout Extensive research on the genetic, neurobiological, and psycho-
his subsequent life he made no close friends and engaged social contributions to schizoid personality disorder remains to
primarily in solitary activities. Until the tour of duty in be conducted (Phillips, Yen, & Gunderson, 2003). In fact, very
Antarctica, he had been quite successful in his research little empirical research has been published on the nature and
work in physics. He was now, some months after his return, causes of this disorder (Skodol et al., 2011). Childhood shyness
drinking at least a bottle of Schnapps each day, and his is reported as a precursor to later adult schizoid personality dis-
work had continued to deteriorate. He presented as self- order. It may be that this personality trait is inherited and serves
contained and unobtrusive and was difficult to engage effec- as an important determinant in the development of this disor-
tively. He was at a loss to explain his colleagues’ anger at der. Abuse and neglect in childhood are also reported among
his aloofness in Antarctica and appeared indifferent to individuals with this disorder (Johnson, Bromley, & McGeoch,
their opinion of him. He did not appear to require any 2005). Research over the past several decades point to biolog-
interpersonal relations, although he did complain of some ical causes of autism (a disorder we discuss in more detail in
tedium in his life and at one point during the interview Chapter 14), and parents of children with autism are more likely
became sad, expressing longing to see his uncle in Germany, to have schizoid personality disorder (Constantino et al., 2009).
his only living relation. • It is possible that a biological dysfunction found in both autism
and schizoid personality disorder combines with early learn-
(Cases and excerpts reprinted, with permission of the Royal Australian
and New Zealand College of Psychiatrists, from Quality Assurance
ing or early problems with interpersonal relationships to pro-
Project (1990). Treatment outlines for paranoid, schizotypal and schizoid duce the social deficits that define schizoid personality disorder
personality disorders. Australian and New Zealand Journal of Psychiatry, 24, (Hopwood & Thomas, 2012).
339–350.) It is rare for a person with this disorder to request treatment
except in response to a crisis such as extreme depression or los-
ing a job (Kelly et al., 2007). Therapists often begin treatment by
Clinical Description
Individuals with schizoid personality disorder seem neither to Table 12.6 Grouping Schema for Cluster A
desire nor to enjoy closeness with others, including romantic or Disorders
sexual relationships. As a result they appear cold and detached
Psychotic-like Symptoms
and do not seem affected by praise or criticism. One of the changes
in DSM-IV-TR from previous versions was the recognition that at Positive (for Negative
least some people with schizoid personality disorder are sensitive example, Ideas (for example,
of Reference, Social Isolation,
to the opinions of others but are unwilling or unable to express
Cluster a Magical Thinking, Poor Rapport,
this emotion. For them, social isolation may be extremely pain- Personality and Perceptual and Constricted
ful. Unfortunately, homelessness appears to be prevalent among Disorder Distortions) affect)
people with this personality disorder, perhaps as a result of
Paranoid Yes Yes
their lack of close friendships and lack of dissatisfaction about not
having a sexual relationship with another person (Rouff, 2000). Schizoid No Yes
The social deficiencies of people with schizoid personality
Schizotypal Yes No
disorder are similar to those of people with paranoid personality
disorder, although they are more extreme. As Beck and Freeman
Source: Adapted from Siever, L. J. (1992). Schizophrenia spectrum person-
(1990, p. 125) put it, they “consider themselves to be observers ality disorders. In A. Tasman & M. B. Riba (Eds.), Review of psychiatry
rather than participants in the world around them.” They do not (Vol. 11, pp. 25–42). Washington, DC: American Psychiatric Press.
in the next chapter—but without some of the more debilitating
DSM
5
TABLE 12.2 Diagnostic Criteria for Schizoid symptoms, such as hallucinations and delusions. In fact, because
Personality Disorder of this close connection, DSM-5 includes this disorder under both
the heading of a personality disorder as well as under the head-
A. A pervasive pattern of detachment from social relation- ing of a schizophrenia spectrum disorder (American Psychiatric
ships and a restricted range of expression of emotions Association, 2013). Consider the case of Mr. S.
in interpersonal settings, beginning by early adulthood
and present in a variety of contexts, as indicated by four
(or more) of the following: MR.S... Man with a Mission
1. Neither desires nor enjoys close relationships,
M
including being part of a family. r. S. was a 35-year-old chronically unemployed man who
2. Almost always chooses solitary activities. had been referred by a physician because of a vitamin
3. Has little, if any, interest in having sexual experi- deficiency. This was thought to have eventuated because
ences with another person. Mr. S. avoided any foods that “could have been contaminated
4. Takes pleasure in few, if any, activities. by machine.” He had begun to develop alternative ideas about
5. Lacks close friends or confidants other than diet in his 20s and soon left his family and began to study an
first-degree relatives. Eastern religion. “It opened my third eye; corruption is all
6. Appears indifferent to the praise or criticism of about,” he said.
others. He now lived by himself on a small farm, attempting to
7. Shows emotional coldness, detachment, or flattened grow his own food, bartering for items he could not grow
affectivity. himself. He spent his days and evenings researching the
B. Does not occur exclusively during the course of schizo- origins and mechanisms of food contamination and, because
phrenia, a bipolar disorder or depressive disorder with of this knowledge, had developed a small band who followed
psychotic features, another psychotic disorder, or autism his ideas. He had never married and maintained little contact
spectrum disorder and is not attributable to the physi- with his family: “I’ve never been close to my father. I’m a
ological effects of another medical condition.
vegetarian.”
Note: If criteria are met prior to the onset of schizophrenia, He said he intended to do a herbalism course to improve
add “premorbid,” e.g., “schizoid personality disorder
his diet before returning to his life on the farm. He had
(premorbid).”
refused medication from the physician and became uneasy
From American Psychiatric Association. (2013). Diagnostic and statistical
when the facts of his deficiency were discussed with him.
manual of mental disorders (5th ed.). Washington, DC. (Cases and excerpts reprinted, with permission of the
Royal Australian and New Zealand College of Psychiatrists,
from Quality Assurance Project, 1990. Treatment outlines
for paranoid, schizotypal and schizoid personality disorders.
pointing out the value in social relationships. The person with the Australian and New Zealand Journal of Psychiatry, 24,
disorder may even need to be taught the emotions felt by others to 339–350.) •
learn empathy (Skodol & Gunderson, 2008). Because their social
skills were never established or have atrophied through lack of
use, people with schizoid personality disorder often receive social Clinical Description
skills training. The therapist takes the part of a friend or significant
People given a diagnosis of schizotypal personality disorder have
other in a technique known as role-playing and helps the patient
psychotic-like (but not psychotic) symptoms (such as believing
practice establishing and maintaining social relationships (Skodol
everything relates to them personally), social deficits, and some-
& Gunderson, 2008). This type of social skills training is helped
times cognitive impairments or paranoia (Kwapil & Barrantes-
by identifying a social network—a person or people who will
Vidal, 2012). These individuals are often considered odd or bizarre
be supportive (Bender, 2005). Outcome research on this type of
because of how they relate to other people, how they think and
approach is unfortunately quite limited, so we must be cautious in
behave, and even how they dress. They have ideas of reference; for
evaluating the effectiveness of treatment for people with schizoid
example, they may believe that somehow everyone on a passing
personality disorder.
city bus is talking about them, yet they may be able to acknowl-
edge this is unlikely. Again, as you will see in Chapter 13, some
Schizotypal Personality Disorder people with schizophrenia also have ideas of reference, but they
People with schizotypal personality disorder are typically socially are usually not able to “test reality” or see the illogic of their ideas.
isolated, like those with schizoid personality disorder. In addition, Individuals with schizotypal personality disorder also have
they also behave in ways that would seem unusual to many of us, odd beliefs or engage in “magical thinking,” believing, for exam-
and they tend to be suspicious and to have odd beliefs (Kwapil ple, that they are clairvoyant or telepathic. In addition, they report
& Barrantes-Vidal, 2012). Schizotypal personality disorder is unusual perceptual experiences, including such illusions as feel-
considered by some to be on a continuum (that is, on the same ing the presence of another person when they are alone. Notice
spectrum) with schizophrenia—the severe disorder we discuss the subtle but important difference between feeling as if someone
C lu st e r A P ers ona l i t y D i s order s 451
else is in the room and the more extreme perceptual distortion
DSM
5
in people with schizophrenia who might report there is some- TABLE 12.3 Diagnostic Criteria for Schizotypal
one else in the room when there isn’t. Unlike people who simply Personality Disorder
have unusual interests or beliefs, those with schizotypal personal-
ity disorder tend to be suspicious and have paranoid thoughts, A. A pervasive pattern of social and interpersonal deficits
express little emotion, and may dress or behave in unusual ways marked by acute discomfort with, and reduced capac-
(for example, wear many layers of clothing in the summertime ity for, close relationships, as well as by cognitive or
or mumble to themselves) (Chemerinski, Triebwasser, Roussos, perceptual distortions and eccentricities of behavior,
& Siever, 2012). Prospective research on children who later develop beginning by early adulthood and present in a variety of
schizotypal personality disorder found that they tend to be contexts, as indicated by five (or more) of the following:
passive and unengaged and are hypersensitive to criticism (Olin 1. Ideas of reference (excluding delusions of reference).
et al., 1997). 2. Odd beliefs or magical thinking that influences
Because persons with schizotypal personality disorder often behavior and is inconsistent with subcultural norms
have beliefs around religious or spiritual themes (Bennett, (e.g., superstitiousness, belief in clairvoyance,
Shepherd, & Janca, 2013), clinicians must be aware that differ- telepathy, or “sixth sense”; in children and adoles-
cents, bizarre fantasies or preoccupations).
ent cultural beliefs or practices may lead to a mistaken diagnosis
of this disorder. For example, some people who practice certain 3. Unusual perceptual experiences, including bodily
illusions.
religious rituals—such as speaking in tongues, practicing voo-
doo, or mind reading—may do so with such obsessiveness as to 4. Odd thinking and speech (e.g., vague, circumstantial,
metaphorical, overelaborate, or stereotyped).
make them seem extremely unusual, thus leading to a misdiag-
nosis (American Psychiatric Association, 2013). Mental health 5. Suspiciousness or paranoid ideation.
workers have to be particularly sensitive to cultural practices 6. Inappropriate or constricted affect.
that may differ from their own and can distort their view of 7. Behavior or appearance that is odd, eccentric, or
certain seemingly unusual behaviors. peculiar.
8. Lack of close friends or confidants other than
first-degree relatives.
Causes 9. Excessive social anxiety that does not diminish with
Historically, the word schizotype was used to describe people who familiarity and tends to be associated with paranoid
were predisposed to develop schizophrenia (Meehl, 1962; Rado, fears rather than negative judgments about self.
1962). Schizotypal personality disorder is viewed by some to be B. Does not occur exclusively during the course of schizo-
one phenotype of a schizophrenia genotype. Recall that a pheno- phrenia, a bipolar disorder or depressive disorder with
type is one way a person’s genetics is expressed. A genotype is the psychotic features, another psychotic disorder, or autism
gene or genes that make up a particular disorder. Depending on a spectrum disorder.
variety of other influences, however, the way you turn out—your Note: If criteria are met prior to the onset of schizophrenia,
phenotype—may vary from other persons with a similar genetic add “premorbid,” e.g., “schizoid personality disorder
makeup. Some people are thought to have “schizophrenia genes” (premorbid).”
(the genotype) yet, because of the relative lack of biological influ-
ences (for example, prenatal illnesses) or environmental stresses
manual of mental disorders (5th ed.). Washington, DC.
(for example, poverty, maltreatment), some will have the less
severe schizotypal personality disorder (the phenotype) (Kwapil
& Barrantes-Vidal, 2012).
The idea of a relationship between schizotypal personality dis- with this disorder points to mild to moderate decrements in their
order and schizophrenia arises partly from the way people with ability to perform on tests involving memory and learning, sug-
the disorders behave. Many characteristics of schizotypal person- gesting some damage in the left hemisphere (Siever & Davis,
ality disorder, including ideas of reference, illusions, and para- 2004). Other research, using magnetic resonance imaging, points
noid thinking, are similar but milder forms of behaviors observed to generalized brain abnormalities in those with schizotypal
among people with schizophrenia. Genetic research also seems to personality disorder (Modinos et al., 2009).
support a relationship. Family, twin, and adoption studies have
shown an increased prevalence of schizotypal personality dis- Treatment
order among relatives of people with schizophrenia who do not Some estimate that between 30% and 50% of the people with
also have schizophrenia themselves (Siever & Davis, 2004). These schizotypal personality disorder who request clinical help also
studies also tell us, however, that the environment can strongly meet the criteria for major depressive disorder. Treatment includes
influence schizotypal personality disorder. Some research suggests some of the medical and psychological treatments for depression
that schizotypal symptoms are strongly associated with childhood (Cloninger & Svakic, 2009; Mulder, Frampton, Luty, & Joyce, 2009).
maltreatment among men, and this childhood maltreatment Controlled studies of attempts to treat groups of people with
seems to result in posttraumatic stress disorder (PTSD) symptoms schizotypal personality disorder are few. There is now growing
(see Chapter 5) among women (Berenbaum, Thompson, Milanak, interest in treating this disorder, however, because it is being viewed
Boden, & Bredemeier, 2008). Cognitive assessment of people as a precursor to schizophrenia (McClure et al., 2010). One study
used a combination of approaches, including antipsychotic medica- norms. They perform actions most of us would find unaccept-
tion, community treatment (a team of support professionals pro- able, such as stealing from friends and family. They also tend to be
viding therapeutic services), and social skills training, to treat the irresponsible, impulsive, and deceitful (De Brito & Hodgins, 2009).
symptoms experienced by individuals with this disorder. Research- Robert Hare, a pioneer in the study of people with psychopathy
ers found that this combination of approaches either reduced their (a subgroup of persons with antisocial personality disorder that
symptoms or postponed the onset of later schizophrenia (Nordentoft we outline later in the chapter), describes them as “social predators
et al., 2006). The idea of treating younger persons who have symp- who charm, manipulate, and ruthlessly plow their way through
toms of schizotypal personality disorder with antipsychotic medi- life, leaving a broad trail of broken hearts, shattered expecta-
cation and cognitive behavior therapy in order to avoid the onset tions, and empty wallets. Completely lacking in conscience and
of schizophrenia is proving to be a promising prevention strategy empathy, they selfishly take what they want and do as they please,
(Correll, Hauser, Auther, & Cornblatt, 2010; Weiser, 2011). violating social norms and expectations without the slightest sense
of guilt or regret” (Hare, 1993, p. xi). Although first identified as
a “medical” problem by Philippe Pinel at the start of the nine-
Concept Check 12.2 teenth century (1801/1962), descriptions of individuals with these
antisocial tendencies can be found in ancient stone texts found
Which personality disorders are described here? in Mesopotamia dating as far back as 670 B.C. (Abdul-Hamid &
Stein, 2012). Just who are these people with antisocial personality
1. Heidi trusts no one and wrongly believes other people disorder? Consider the case of Ryan.
want to harm her or cheat her out of her life earnings.
She is sure her husband is secretly planning to leave her
and take their three boys, although she has no proof. She
no longer confides in friends or divulges any information RYAN... The Thrill Seeker
to coworkers for fear that it will be used in a plot against
her. She is usually tense and ready to argue about harm-
less comments made by family members. ____________ I first met Ryan on his 17th birthday. Unfortunately, he
was celebrating the event in a psychiatric hospital. He
had been truant from school for several months and had
2. Rebecca lives alone out in the country with her birds and
gotten into some trouble; the local judge who heard his case
has little contact with relatives or any other individuals in
had recommended psychiatric evaluation one more time,
a nearby town. She is extremely concerned with pollution,
even though Ryan had been hospitalized six previous times,
fearing that harmful chemicals are in the air and water
all for problems related to drug use and truancy. He was a
around her. She has developed her own water purifica-
veteran of the system and already knew most of the staff. I
tion system and makes her own clothes. If it is necessary
interviewed him to assess why he was admitted this time and
for her to go outside, she covers her body with excessive
to recommend treatment.
clothing and wears a face mask to avoid the contaminated
My first impression was that Ryan was cooperative and
air. ____________
pleasant. He pointed out a tattoo on his arm that he had
3. Doug is a college student who has no close friends. He made himself, saying that it was a “stupid” thing to have
comes to class every day and sits in a corner and is some- done and that he now regretted it. He regretted many things
times seen having lunch alone on the park bench. Most and was looking forward to moving on with his life. I later
students find him difficult to engage and complain about found out that he was never truly remorseful for anything.
his lack of involvement in class activities but he appears Our second interview was quite different. In the 48 hours
indifferent to what others say. He has never had a girl- since our first interview, Ryan had done a number of things
friend, and expresses no desire to have sex. He is meet- that showed why he needed a great deal of help. The most
ing with a therapist only because his family tricked him serious incident involved a 15-year-old girl named Ann who
into going. ____________ attended class with Ryan in the hospital school. Ryan had
told her that he was going to get himself discharged, get in
trouble, and be sent to the same prison Ann’s father was in,
where he would rape her father. Ryan’s threat so upset Ann
Cluster B Personality Disorders that she hit her teacher and several of the staff. When I spoke
to Ryan about this, he smiled slightly and said he was bored
People diagnosed with the Cluster B personality disorders—
and that it was fun to upset Ann. When I asked whether it
antisocial, borderline, histrionic, and narcissistic—all have
bothered him that his behavior might extend her stay in the
behaviors that have been described as dramatic, emotional, or
hospital, he looked puzzled and said, “Why should it bother
erratic. These personality disorders are described next.
me? She’s the one who’ll have to stay in this hell hole!”
Just before Ryan’s admittance, a teenager in his town was
Antisocial Personality Disorder murdered. A group of teens went to the local cemetery at
People with antisocial personality disorder are among the most night to perform satanic rituals, and a young man was stabbed
puzzling of the individuals a clinician will see in a practice and are (Continued next page)
characterized as having a history of failing to comply with social
C lu st e r B P ers ona l i t y D i s order s 453
outcome for people with antisocial personality disorder is usu-
to death, apparently over a drug purchase. Ryan was in the ally poor, regardless of gender (Colman et al., 2009). One classic
group, although he did not stab the boy. He told me that they study, for example, followed 1,000 delinquent and nondelinquent
occasionally dug up graves to get skulls for their parties—not boys over a 50-year period (Laub & Vaillant, 2000). Many of the
because they really believed in the devil but because it was fun delinquent boys would today receive a diagnosis of conduct disor-
and it scared the younger kids. I asked, “What if this was the der, which you will see later may be a precursor to antisocial per-
grave of someone you knew, a relative or a friend? Would it sonality disorder in adults. The delinquent boys were more than
bother you that strangers were digging up the remains?” twice as likely to die an unnatural death (for example, accident,
He shook his head. “They’re dead, man; they don’t care. suicide, or homicide) as their nondelinquent peers, which may
Why should I?” be attributed to factors such as alcohol abuse and poor self-care
Ryan told me he loved PCP, or “angel dust,” and that he (for example, infections and reckless behavior).
would rather be dusted than anything else. He routinely Antisocial personality disorder has had a number of names
made the 2-hour trip to New York City to buy drugs in a over the years. Philippe Pinel (1801/1962) identified what he
particularly dangerous neighborhood. He denied that he called manie sans délire (mania without delirium) to describe peo-
was ever nervous. This wasn’t machismo; he really seemed ple with unusual emotional responses and impulsive rages but no
unconcerned. deficits in reasoning ability (Charland, 2010). Other labels have
Ryan made little progress. I discussed his future in family included moral insanity, egopathy, sociopathy, and psychopathy.
therapy sessions and we talked about his pattern of showing A great deal has been written about these labels; we focus on the
supposed regret and remorse and then stealing money from two that have figured most prominently in psychological research:
his parents and going back onto the street. Most of our dis- psychopathy and DSM-5’s antisocial personality disorder. There
cussions centered on trying to give his parents the courage to continues to be debate in the field if these really are two distinct
say no to him and not to believe his lies. disorders (Hare et al., 2012; Lynam & Vachon, 2012).
One evening, after many sessions, Ryan said he had seen
the “error of his ways” and that he felt bad he had hurt his
parents. If they would only take him home this one last time, Defining Criteria
he would be the son he should have been all these years. His Hervey Cleckley (1941/1982), a psychiatrist who spent much of
speech moved his parents to tears, and they looked at me his career working with the “psychopathic personality,” identi-
gratefully as if to thank me for curing their son. When Ryan fied a constellation of 16 major characteristics, most of which are
finished talking, I smiled, applauded, told him it was the best personality traits and are sometimes referred to as the “Cleckley
performance I had ever seen. His parents turned on me in criteria.” Hare and his colleagues, building on the descriptive work
anger. Ryan paused for a second, then he, too, smiled and of Cleckley, researched the nature of psychopathy (see, for exam-
said, “It was worth a shot!” Ryan’s parents were astounded ple, Hare, 1970; Harpur, Hare, & Hakstian, 1989) and developed
that he had again tricked them into believing him; he hadn’t a 20-item checklist that serves as an assessment tool. Six of the
meant a word of what he had just said. Ryan was eventually criteria that Hare includes in his Revised Psychopathy Checklist
discharged to a drug rehabilitation program. Within 4 weeks, (PCL-R) are as follows:
he had convinced his parents to take him home, and within
2 days he had stolen all their cash and disappeared; he appar- 1. Glibness/superficial charm
ently went back to his friends and to drugs. 2. Grandiose sense of self-worth
When he was in his 20s, after one of his many arrests for 3. Pathological lying
theft, he was diagnosed as having antisocial personality dis- 4. Conning/manipulative
order. His parents never summoned the courage to turn him 5. Lack of remorse or guilt
out or refuse him money, and he continues to con them into 6. Callous/lack of empathy
providing him with a means of buying more drugs. • (Hare et al., 2012; p. 480)
With some training, clinicians are able to gather information from

interviews with a person, along with material from significant oth-
Clinical Description ers or institutional files (for example, prison records), and assign
Individuals with antisocial personality disorder tend to have long the person scores on the checklist, with high scores indicating psy-
histories of violating the rights of others (Hare et al., 2012). They chopathy (Hare & Neumann, 2006).
are often described as being aggressive because they take what The Cleckley/Hare criteria focus primarily on underlying
they want, indifferent to the concerns of other people. Lying and personality traits (for example, being self-centered or manipula-
cheating seem to be second nature to them, and often they appear tive). Earlier versions of the DSM criteria for antisocial personal-
unable to tell the difference between the truth and the lies they ity focused almost entirely on observable behaviors (for example,
make up to further their own goals. They show no remorse or “impulsively and repeatedly changes employment, residence, or
concern over the sometimes devastating effects of their actions. sexual partners”). The framers of the previous DSM criteria felt
Substance abuse is common, occurring in 60% of people with that trying to assess a personality trait—for example, whether
antisocial personality disorder, and appears to be a lifelong pattern someone was manipulative—would be more difficult than deter-
among these individuals (Taylor & Lang, 2006). The long-term mining whether the person engaged in certain behaviors, such
as repeated fighting. The DSM-5, how- example, one of the advertisements read
Abnormal Psychology Inside

Out, Vol. 1. Copyright 1994,
Wadsworth Publishing.
ever, moved closer to the trait-based as follows:
criteria and includes some of the same
Wanted: charming, aggressive, care-
language included in Hare’s PCL-R
free people who are impulsively
(e.g., callousness, manipulativeness, and
irresponsible but are good at han-
deceitfulness). Unfortunately, research
dling people and at looking after
on identifying persons with antisocial
personality disorder suggests that this Antisocial Personality number one.
new definition reduces the reliability of Disorder: George
Widom found that her sample appeared
the diagnosis (Regier et al., 2013). Addi- “I have hatred inside me. I don’t care how to possess many of the same charac-
tional work will be needed to improve the much I be somebody. . . . The more I hear teristics as imprisoned psychopaths;
reliability of this diagnosis while main- somebody, the more anger I get inside me. for example, a large percentage of them
taining the core traits that characterize . . . I used drugs when I was . . . probably received low scores on questionnaire
these individuals. 9 or 10 years old . . . smoked marijuana. . . . measures of empathy and socializa-
First time I drank some alcohol I think I was tion and their parents tended to have
Antisocial Personality Disorder higher rates of psychopathology, includ-
probably about 3 years old. . . . I assaulted
and Criminality a woman. . . . I had so much anger. . . . I ing alcoholism. But many of these indi-
Although Cleckley did not deny that was just like a bomb . . . it’s just ticking . . . viduals had stable occupations and had
many psychopaths are at greatly elevated and the way I’m going, that bomb was going managed to stay out of prison. Widom’s
risk for criminal and antisocial behav- to blow up in me. I wouldn’t be able to get study, although lacking a control group,
iors, he did emphasize that some have away from it . . . going to be a lot of people shows that at least some individuals
few or no legal or interpersonal difficul- hurt. . . . I’m not going out without taking with psychopathic personality traits
ties. In other words, some psychopaths somebody with me.” avoid repeated contact with the legal
are not criminals and some do not dis- system and may even function success-
play outward aggressiveness that was Go to MindTap at fully in society.
included in the DSM-IV-TR criteria for www.cengagebrain.com Identifying psychopaths among the
antisocial personality disorder. What to watch this video. criminal population seems to have
separates many in this group from those important implications for predicting
who get into trouble with the law may be their future criminal behavior (Vitacco,
their intelligence quotient (IQ). In a classic prospective, longitudi- Neumann, & Caldwell, 2010). As you can imagine, having person-
nal study, White, Moffitt, and Silva (1989) followed almost 1,000 ality characteristics such as a lack of remorse and impulsivity can
children, beginning at age 5, to see what predicted antisocial behav- lead to difficulty staying out of trouble with the legal system. In
ior at age 15. They found that, of the 5-year-olds determined to be at general, people who score high on measures of psychopathy com-
high risk for later delinquent behavior, 16% did indeed have run-ins mit crimes at a higher rate than those with lower scores and are
with the law by the age of 15 and 84% did not. What distinguished at greater risk for more violent crimes and recidivism (repeating
these two groups? In general, the at-risk children with lower IQs offenses) (Widiger, 2006).
were the ones who got in trouble. This suggests that having a higher As we review the literature on antisocial personality disorder,
IQ may help protect some people from developing more serious note that the people included in the research may be members
problems, or may at least prevent them from getting caught. of only one of the three groups (those with antisocial person-
Some psychopaths function ality disorder, psychopathy, and criminals) we have described.
quite successfully in certain seg- For example, genetic research is usually conducted with crimi-
ments of society (for example, nals because they and their families are easier to identify
politics, business, and entertain- than members of the other groups. As you now know, the
ment). Because of the difficulty criminal group may include people other than those with anti-
in identifying these people, social personality disorder or psychopathy. Keep this in mind
such “successful” or “subclinical” as you read on.
psychopaths (who meet some
of the criteria for psychopathy) Conduct Disorder
have not been the focus of much It is important to note the developmental nature of antisocial
research. In a clever exception, behavior. DSM-5 provides a separate diagnosis for children who
Courtesy of Robert Hare
Widom (1977; pg. 677) recruited engage in behaviors that violate society’s norms: conduct disorder.
a sample of subclinical psycho- It provides for the designation of two subtypes; childhood-onset
paths through advertisements in type (the onset of at least one criterion characteristic of CD prior
underground newspapers that to age 10 years) or adolescent-onset type (the absence of any criteria
Robert Hare has made exten-
appealed to those with many characteristic of CD prior to age 10 years). An additional subtype,
sive studies of people with of the major personality char- new to the DSM-5, is called “with a callous-unemotional presen-
psychopathic personalities. acteristics of psychopathy. For tation” (Barry, Golmaryami, Rivera-Hudson, & Frick, 2012). This
There is a tremendous amount of interest in studying a group
DSM
5
TABLE 12.4 Diagnostic Criteria for Antisocial that causes a great deal of harm to society. Research has been con-
Personality Disorder ducted for a number of years, and so we know a great deal more
about antisocial personality disorder than about most of the other
A. A pervasive pattern of disregard for and violation of personality disorders.
the rights of others, occurring since age 15 years, as
indicated by three (or more) of the following:
Genetic Influences
1. Failure to conform to social norms with respect
to lawful behaviors, as indicated by repeatedly
Family, twin, and adoption studies all suggest a genetic influence
performing acts that are grounds for arrest. on both antisocial personality disorder and criminality (Ferguson,
2. Deceitfulness, as indicated by repeated lying, use
2010a). For example in a classic study, Crowe (1974) examined
of aliases, or conning others for personal profit or children whose mothers were felons and who were later adopted
pleasure. by other families and compared them with adopted children of
3. Impulsivity or failure to plan ahead. normal mothers. All were separated from their mothers as new-
4. Irritability and aggressiveness, as indicated by
borns, minimizing the possibility that environmental factors from
repeated physical fights or assaults. their biological families were responsible for the results. Crowe
5. Reckless disregard for safety of self or others.
found that the adopted offspring of felons had significantly higher
rates of arrests, conviction, and antisocial personality than did the
6. Consistent irresponsibility, as indicated by repeated
failure to sustain consistent work behavior or honor
adopted offspring of normal mothers, which suggests at least some
financial obligations. genetic influence on criminality and antisocial behavior.
7. Lack of remorse, as indicated by being indifferent
Crowe found something else quite interesting, however: The
to or rationalizing having hurt, mistreated, or stolen adopted children of felons who themselves later became crimi-
from another. nals had spent more time in interim orphanages than either the
B. The individual is at least age 18 years. adopted children of felons who did not become criminals or the
C. There is evidence of conduct disorder with onset before
adopted children of normal mothers. As Crowe points out, this
age 15 years. suggests a gene–environment interaction; in other words, genetic
D. The occurrence of antisocial behavior is not exclusively
factors may be important only in the presence of certain environ-
during the course of schizophrenia or bipolar disorder. mental influences (alternatively, certain environmental influences
are important only in the presence of certain genetic predispo-
From American Psychiatric Association. (2013). Diagnostic and statistical sitions). Genetic factors may present a vulnerability, but actual
manual of mental disorders (5th ed.). Washington, DC. development of criminality may require environmental factors,
such as a deficit in early, high-quality contact with parents or
parent surrogates.
This gene–environment interaction was demonstrated most
designation is an indication that the young person presents in a clearly by Cadoret, Yates, Troughton, Woodworth, and Stewart
way that suggests personality characteristics similar to an adult (1995), who studied adopted children and their likelihood of
with psychopathy. developing conduct problems. If the children’s biological parents
Many children with conduct disorder—most often diag- had a history of antisocial personality disorder and their adoptive
nosed in boys—become juvenile offenders and tend to become families exposed them to chronic stress through marital, legal, or
involved with drugs (Durand, in press). Ryan fits into this psychiatric problems, the children were at greater risk for conduct
category. More important, the lifelong pattern of antisocial problems. Again, research shows that genetic influence does not
behavior is evident because young children who display anti- necessarily mean certain disorders are inevitable. Genetic research
social behavior are likely to continue these behaviors as they on conduct disorder suggests the role of genetic and environ-
grow older (Frick, 2012). Data from long-term follow-up mental influences (such as academic difficulty, peer problems,
research indicate that many adults with antisocial personality dis- low family income, neglect and harsh discipline from parents)
order or psychopathy had conduct disorder as children (Robins, (Beaver, Barnes, May, & Schwartz, 2011; Larsson, Viding, Rijsdijk,
1978; Salekin, 2006); the likelihood of an adult having antisocial & Plomin, 2008).
personality disorder increases if, as a child, he or she had both If you remember back to Chapter 4, we introduced the con-
conduct disorder and attention deficit/hyperactivity disorder cept of an endophenotype—underlying aspects of a disorder that
(Biederman, Mick, Faraone, & Burback, 2001; Moffitt, Caspi, might be more directly influenced by genes. In the case of antiso-
Rutter, & Silva, 2001). In many cases, the types of norm viola- cial personality disorder, gene researchers are looking for genetic
tions that an adult would engage in—irresponsibility regarding differences that may influence factors such as serotonin and dopa-
work or family—appear as younger versions in conduct disor- mine levels or the relative lack of anxiety or fear seen in these indi-
der, such as truancy from school or running away from home. viduals (which we discuss next) (Hare et al., 2012). Although this
Some children with conduct disorder do feel remorseful about research is at its early stages, it is refining the search for genes—not
their behavior, which is why DSM-5 included the qualifier “with for ones that “cause” antisocial personality disorder but for genes
a callous-unemotional presentation” in order to better differen- that create the unusual aspects of an antisocial personality, such
tiate these two groups. as fearlessness, aggressiveness, impulsivity, and lack of remorse.
DSM
5
TABLE 12.5 Diagnostic Criteria for Conduct Disorder
A. A repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or
rules are violated, as manifested by the presence of at least three of the following 15 criteria in the past 12 months from any
of the categories below, with at least one criterion present in the past 6 months:
Aggression to People and Animals
1. Often bullies, threatens, or intimidates others.
2. Often initiates physical fights.
3. Has used a weapon that can cause serious physical harm to others (e.g., a bat, brick, broken bottle, knife, gun).
4. Has been physically cruel to people.
5. Has been physically cruel to animals.
6. Has stolen while confronting a victim (e.g., mugging, purse snatching, extortion, armed robbery).
7. Has forced someone into sexual activity.
Destruction of Property
8. Has deliberately engaged in fire setting with the intention of causing serious damage.
9. Has deliberately destroyed others’ property (other than by fire setting).
Deceitfulness or Theft
10. Has broken into someone else’s house, building, or car.
11. Often lies to obtain goods or favors or to avoid obligations (i.e., “cons” others).
12. Has stolen items of nontrivial value without confronting a victim (e.g., shoplifting, but without breaking and entering;
forgery).
Serious Violations of Rules
13. Often stays out at night despite parental prohibitions, beginning before age 13 years.
14. Has run away from home overnight at least twice while living in the parental or parental surrogate home, or once without
returning for a lengthy period.
15. Is often truant from school, beginning before age 13 years.
B. The disturbance in behavior causes clinically significant impairment in social, academic, or occupational functioning.
C. If the individual is age 18 years or older, criteria are not met for antisocial personality disorder.
Specify whether:
Childhood-onset type: Individuals show at least one symptom characteristic of conduct disorder prior to age 10 years.
Adolescent-onset type: Individuals show no symptom characteristic of conduct disorder prior to age 10 years.
Unspecified onset: Criteria for a diagnosis of conduct disorder are met, but there is not enough information available to
determine whether the onset of the first symptom was before age 10 years.
Specify current severity:
Mild: Few if any conduct problems in excess of those required to make the diagnosis are present, and conduct problems cause
relatively minor harm to others (e.g., lying, truancy, staying out after dark without permission, other rule breaking).
Moderate: The number of conduct problems and the effect on others are intermediate between those specified “mild” and those
in “severe” (e.g., stealing without confronting a victim, vandalism).
Severe: Many conduct problems in excess of those required to make the diagnosis are present, or conduct problems cause
considerable harm to others (e.g., forced sex, physical cruelty, use of a weapon, stealing while confronting a victim, breaking and
entering).
From American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC.
Neurobiological Influences not pick up subtle changes in chemistry or structure that could
A great deal of research has focused on neurobiological influ- affect behavior.
ences that may be specific to antisocial personality disorder. One
thing seems clear: General brain damage does not explain why Arousal Theories
some people become psychopaths or criminals; these individu- The fearlessness, seeming insensitivity to punishment, and thrill-
als appear to score as well on neuropsychological tests as the seeking behaviors characteristic of those with antisocial per-
rest of us (Hart, Forth, & Hare, 1990). Such tests are designed sonality disorder (especially those with psychopathy) sparked
to detect only significant damage in the brain, however, and will interest in what neurobiological processes might contribute to
these unusual reactions. Early theoretical work on people with theorists have applied Jeffrey Gray’s (1987) model of brain func-
antisocial personality disorder emphasized two hypotheses: tioning to this population (Fowles, 1988; Quay, 1993). Accord-
the underarousal hypothesis and the fearlessness hypothesis. ing to Gray, three major brain systems influence learning and
According to the underarousal hypothesis, psychopaths have emotional behavior: the behavioral inhibition system (BIS), the
abnormally low levels of cortical arousal (Sylvers, Ryan, Alden, reward system, and the fight/flight system. Two of these systems,
& Brennan, 2009). There appears to be an inverted U-shaped the BIS and the reward system, have been used to explain the
relation between arousal and performance, the Yerkes-Dodson behavior of people with psychopathy. The BIS is responsible for
curve, which suggests people with either high or low levels of our ability to stop or slow down when we are faced with impend-
arousal tend to experience negative affect and perform poorly in ing punishment, nonreward, or novel situations; activation of this
many situations, whereas individuals with intermediate levels of system leads to anxiety and frustration. The BIS is thought to be
arousal tend to be relatively content and perform satisfactorily in located in the septohippocampal system and involves the norad-
most situations. renergic and serotonergic neurotransmitter systems. The reward
According to the underarousal hypothesis, the abnormally low system is responsible for how we behave—in particular, our
levels of cortical arousal characteristic of psychopaths are the pri- approach to positive rewards—and is associated with hope and
mary cause of their antisocial and risk-taking behaviors; they seek relief. This system probably involves the dopaminergic system
stimulation to boost their chronically low levels of arousal. This in the mesolimbic area of the brain, which we previously noted
means that Ryan lied, took drugs, and dug up graves to achieve as the “pleasure pathway” for its role in substance use and abuse
the same level of arousal we might get from talking on the phone (see Chapter 11).
with a good friend or watching television. Several researchers have If you think about the behavior of psychopaths, the possible
examined childhood and adolescent psychophysiological predic- malfunctioning of these systems is clear. An imbalance between
tors of adult antisocial behavior and criminality. Raine, Venables, the BIS and the reward system may make the fear and anxiety
and Williams (1990), for example, assessed a sample of 15-year- produced by the BIS less apparent and the positive feelings associ-
olds on a variety of autonomic and central nervous system ated with the reward system more prominent (Levenston, Patrick,
variables. They found that future criminals had lower skin con- Bradley, & Lang, 2000; Quay, 1993). Theorists have proposed that
ductance activity, lower heart rate during rest periods, and more this type of neurobiological dysfunction may explain why psy-
slow-frequency brain wave activity, all indicative of low arousal. chopaths aren’t anxious about committing the antisocial acts that
According to the fearlessness hypothesis, psychopaths possess characterize their disorder.
a higher threshold for experiencing fear than most other individu- Researchers continue to explore how differences in neurotrans-
als (Lykken, 1957, 1982). In other words, things that greatly fright- mitter function (for example, serotonin) and neurohormone func-
en the rest of us have little effect on the psychopath (Syngelaki, tion (for example, androgens such as testosterone and the stress
Fairchild, Moore, Savage, & Goozen, 2013). Remember that Ryan neurohormone cortisol) in the brains of these individuals can
was unafraid of going alone to dangerous neighborhoods to buy explain the callousness, superficial charm, lack of remorse, and
drugs. According to proponents of this hypothesis, the fearless- impulsivity that characterize people with psychopathy. Integra-
ness of the psychopath gives rise to all the other major features of tive theories that link these differences to both genetic and envi-
the syndrome. ronmental influences are just now beginning to be outlined (Hare
Theorists have tried to connect what we know about the work- et al., 2012) and may lead to better understanding and treatments
ings of the brain with clinical observations of people with antisocial for this debilitating disorder.
personality disorder, especially those with psychopathy. Several
Psychological and Social Dimensions
What goes on in the mind of a psychopath? In one of several stud-
ies of how psychopaths process reward and punishment, Newman,
Patterson, and Kosson (1987) set up a card-playing task on a com-
puter; they provided five-cent rewards and fines for correct and
incorrect answers to psychopathic and nonpsychopathic criminal
offenders. The game was constructed so that at first players were
rewarded about 90% of the time and fined only about 10% of the
time. Gradually, the odds changed until the probability of getting a
reward was 0%. Despite feedback that reward was no longer forth-
coming, the psychopaths continued to play and lose, while those
without psychopathy stopped playing. As a result of this and other
AP Photo/Stephen Morton
studies, the researchers hypothesized that once psychopaths set

their sights on a reward goal, they are less likely than nonpsycho-
paths to be deterred despite signs the goal is no longer achievable
(Dvorak-Bertscha, Curtin, Rubinstein, & Newman, 2009). Again,
considering the reckless and daring behavior of some psychopaths
Many prisons allow visits between inmates and their children, partly (robbing banks without a mask and getting caught immediately),
to help reduce later psychological problems in those children. failure to abandon an unattainable goal fits the overall picture.
Gerald Patterson’s influential work suggests that aggression Psychopaths
in children with antisocial personality disorder may escalate, Nonpsychopaths
partly as a result of their interactions with their parents (Granic & 100
Patterson, 2006; Patterson, 1982). He found that the parents often
give in to the problem behaviors displayed by their children. For
example, a boy’s parents ask him to make his bed and he refuses. 90
One parent yells at the boy. The boy yells back and becomes abu-
sive. At some point, his interchange becomes so aversive that the
80
Percent in prison
parent stops fighting and walks away, thereby ending the fight but
also letting the son not make his bed. Giving in to these problems
results in short-term gains for both the parent (calm is restored in 70
the house) and the child (he gets what he wants), but it results in
continuing problems. The child has learned to continue fighting
60
and not give up, and the parent learns that the only way to “win” is
to withdraw all demands. This “coercive family process” combines
with other factors, such as genetic influences, parental depres- 50
sion, poor monitoring of their child’s activities, and less parental
involvement, to help maintain the aggressive behaviors (Chronis
et al., 2007; Patterson, DeBaryshe, & Ramsey, 1989). Coercive 40
16–20 21–25 26–30 31–35 36–40 41–45
parenting—along with genetics—appears to be at least modestly Age period
involved with the callous-unemotional traits that seem related to
later psychopathy (Waller et al., in press). ● FIGURE 12.2 Lifetime course of criminal behavior in psychopaths
and nonpsychopaths. (Based on Hare, R. D., McPherson, L. M., & Forth,
Although little is known about which environmental factors
A. E. [1988]. Male psychopaths and their criminal careers. Journal of
play a direct role in causing antisocial personality disorder and psy- Consulting and Clinical Psychology, 56, 710–714.)
chopathy (as opposed to childhood conduct disorders), evidence
from adoption studies strongly suggests that shared environmental
factors—that tend to make family members similar—are impor- other times included people labeled as psychopathic or even
tant to the etiology of criminality and perhaps antisocial personal- criminals. Whatever the label, it appears these people have a
ity disorder. For example, in the adoption study by Sigvardsson, genetic vulnerability to antisocial behaviors and personality traits.
Cloninger, Bohman, and von Knorring (1982), low social status of As you have seen, genetics may lead to differences in neurotrans-
the adoptive parents increased the risk of nonviolent criminality mitter and neurohormone (dopamine and serotonin) function
among females. Like children with conduct disorders, individuals that influences aggressiveness, as well as differences in neuro-
with antisocial personality disorder come from homes with incon- hormone (cortisol) function that affects the way people deal with
sistent parental discipline (see, for example, Robins, 1966). stress; these brain differences may lead to personality traits such
as callousness, impulsivity, and aggressiveness that characterize
people with psychopathy (Hare et al., 2012).
Developmental Influences
One potential gene–environment interaction may be seen in
As children move into adulthood, the forms of antisocial behav- the role of fear conditioning in children. If you remember back to
iors change—from truancy and stealing from friends to extortion, Chapter 1 and Chapter 5, we discussed how we learn to fear things
assaults, armed robbery, or other crimes. Fortunately, clinical that can harm us (for example, a hot stove) through the pairing of
lore, as well as scattered empirical reports (Robins, 1966), suggest an unconditioned stimulus (e.g., heat from burner) and a condi-
that rates of antisocial behavior begin to decline rather markedly tioned stimulus (e.g., parent’s warning to stay away), resulting in
around the age of 40. In their classic study, Hare, McPherson, and avoidance of the conditioned stimulus. But what if this condition-
Forth (1988) provided empirical support for this phenomenon. ing is somehow impaired and you do not learn to avoid things that
They examined the conviction rates of male psychopaths and male can harm you? An important study looked at whether abnormal
nonpsychopaths who had been incarcerated for a variety of crimes. responses to fear conditioning as a young child could be respon-
The researchers found that between the ages of 16 and 45 the con- sible for later antisocial behavior in adults (Gao, Raine, Venables,
viction rates of nonpsychopaths remained relatively constant. In Dawson, & Mednick, 2010). This large 20-year study assessed
contrast, the conviction rates of psychopaths remained relatively fear conditioning in a group of 1,795 children at age 3, and then
constant up until about 40, at which time they decreased markedly looked to see who had a criminal record at age 23. They found that
(see ● Figure 12.2). Why antisocial behavior often declines around offenders showed significantly reduced fear conditioning at age
middle age remains unanswered (Hare et al., 2012). 3 compared with matched comparison participants, with many
of these children showing no fear conditioning at all. Deficits in
An Integrative Model amygdala functioning are thought to make individuals unable to
How can we put all this information together to get a better recognize cues that signal threat, making them relatively fearless,
understanding of people with antisocial personality disorder? which suggests that these children had problems in this area of the
Remember that the research just discussed sometimes involved brain (Sterzer, 2010). These findings may point to a mechanism
people labeled as having antisocial personality disorder but at by which genetic influences (leading to damage in the amygdala)
interact with environmental influences (learning to fear threats) to succeeding in treatment or for dropping out early; these include
produce adults who are relatively fearless and therefore engage in cases with a high degree of family dysfunction, socioeconomic
behaviors that cause harm to themselves and others. disadvantage, high family stress, a parent’s history of antisocial
Biological influences further interact with other environ- behavior, and severe conduct disorder on the part of the child
mental experiences such as early childhood adversity. In a (Kaminski, Valle, Filene, & Boyle, 2008).
family that may already be under stress because of divorce or
substance abuse, there may be an interaction style that encour-
Prevention
ages antisocial behavior on the part of the child (Thomas, 2009).
The child’s antisocial and impulsive behavior—partly caused We have seen a dramatic increase in the amount of research on
by the child’s difficult temperament and impulsivity (Chronis prevention strategies focused on children at risk for later antiso-
et al., 2007; Kochanska, Aksan, & Joy, 2007)—alienates other cial personality disorder. The aggressive behaviors of young chil-
children who might be good role models and attracts others dren are remarkably stable, meaning that children who hit, insult,
who encourage antisocial behavior. These behaviors may also and threaten others are likely to continue these behaviors as they
result in the child’s dropping out of school and a poor occu- grow older. Unfortunately, these behaviors become more serious
pational history in adulthood, which help create increasingly over time and are the early signs of the homicides and assaults
frustrating life circumstances that further incite acts against seen among some adults (Eron & Huesmann, 1990; Singer &
society (Thomas, 2009). Flannery, 2000).
This is, admittedly, an abbreviated version of a complex sce- Approaches to change this aggressive course are being
nario. The important element is that in this integrative model of implemented mainly in school and preschool settings and
antisocial behavior, biological, psychological, and cultural factors emphasize behavioral supports for good behavior and skills
combine in intricate ways to create someone like Ryan. training to improve social competence (Reddy, Newman, De
Thomas, & Chun, 2009). A number of types of these programs
are under evaluation, and the results look promising. For exam-
Treatment ple, research using parent training for young children (toddlers
One of the major problems with treating people in this group is from 1 ½ to 2 ½ years) suggests that early intervention may be
typical of numerous personality disorders: They rarely identify particularly helpful (Shaw, Dishion, Supplee, Gardner, & Arnds,
themselves as needing treatment. Because of this, and because 2006). Aggression can be reduced and social competence (for
they can be manipulative even with their therapists, most clini- example, making friends and sharing) can be improved among
cians are pessimistic about the outcome of treatment for adults young children, and these results generally are maintained over a
who have antisocial personality disorder, and there are few docu- few years (Conduct Problems Prevention Research, 2010; Reddy
mented success stories (National Collaborating Centre for Mental et al., 2009). It is too soon to assess the success of such programs
Health, 2010). In general, therapists agree with incarcerating these in preventing adult antisocial behaviors typically observed
people to deter future antisocial acts. Clinicians encourage iden- among people with this personality disorder (Ingoldsby, Shelleby,
tification of high-risk children so that treatment can be attempted Lane, & Shaw, 2012). Given the ineffectiveness of treatment
before they become adults (National Collaborating Centre for for adults, however, prevention may be the best approach to
Mental Health, 2010; Thomas, 2009). One large study with violent this problem.
offenders found that cognitive behavior therapy
could reduce the likelihood of violence 5 years
after treatment (Olver, Lewis, & Wong, 2013).
Importantly, however, treatment success was
negatively correlated with ratings on the PCL-R
for traits of “selfish, callous and remorseless use
of others.” In other words, the higher the score
on this trait (which have seen is related to psy-
chopathy), the less successful this group was in
refraining from violence after their treatment.
The most common treatment strategy for
children involves parent training (Patterson,
1986; Sanders, 1992). Parents are taught to
© Catherine Ursillo/Photo Researchers, Inc.
recognize behavior problems early and to use

praise and privileges to reduce problem behav-
ior and encourage prosocial behaviors. Treat-
ment studies typically show that these types
of programs can significantly improve the
behaviors of many children who display antiso-
cial behaviors (Conduct Problems Prevention
Research Group, 2010). A number of factors,
however, put families at risk either for not Children with conduct disorder may become adults with antisocial personality disorder.
Borderline Personality Disorder Clinical Description
People with borderline personality disorder lead tumultuous Borderline personality disorder is one of the most common per-
lives. Their moods and relationships are unstable, and usually they sonality disorders observed in clinical settings; it is observed in
have a poor self-image. These people often feel empty and are at every culture and is seen in about 1% to 2% of the general popula-
great risk of dying by their own hands. Consider the case of Claire. tion (Torgersen, 2012). Claire’s life illustrates the instability char-
acteristic of people with borderline personality disorder. They tend
to have turbulent relationships, fearing abandonment but lacking
CLAIRE... A Stranger Among Us control over their emotions (Hooley, Cole, & Gironde, 2012). They
often engage in behaviors that are suicidal, self-mutilative, or both,
I have known Claire for more than 40 years and have cutting, burning, or punching themselves. Claire sometimes used
watched her through the good but mostly bad times of her cigarette to burn her palm or forearm, and she carved her ini-
her often shaky and erratic life as a person with borderline tials in her arm. A significant proportion—about 6%—succeed
personality disorder. Claire and I went to school together from at suicide (McGirr, Paris, Lesage, Renaud, & Turecki, 2009). On
the eighth grade through high school, and we’ve kept in touch the positive side, the long-term outcome for people with border-
periodically. My earliest memory of her is of her hair, which line personality disorder is encouraging, with up to 88% achiev-
was cut short and rather unevenly. She told me that when ing remission more than 10 years after initial treatment (Zanarini
things were not going well she cut her own hair severely, which et al., 2006).
helped to “fill the void.” I later found out that the long sleeves People with this personality disorder are often intense, going
she usually wore hid scars and cuts that she had made herself. from anger to deep depression in a short time. Dysfunction in the
Claire was the first of our friends to smoke. What was area of emotion is sometimes considered one of the core features
unusual about this and her later drug use was not that they of borderline personality disorder (Linehan & Dexter-Mazza,
occurred (this was in the 1960s when “If it feels good, do 2008) and is one of the best predictors of suicide in this group
it” hadn’t been replaced by “Just say no”) or that they began (McGirr et al., 2009). The characteristic of instability (in emotion,
early; it was that she didn’t seem to use them to get atten- interpersonal relationships, self-concept, and behavior) is seen as
tion, like everyone else. Claire was also one of the first whose a core feature with some describing this group as being “stably
parents divorced, and both of them seemed to abandon her unstable” (Hooley et al., 2012).
emotionally. She later told me that her father was an alco- This instability extends to impulsivity, which can be seen in
holic who had regularly beaten her and her mother. She did their drug abuse and self-mutilation. Although not so obvious
poorly in school and had a low opinion of herself. She often as to why, the self-injurious behaviors, such as cutting, some-
said she was stupid and ugly, yet she was neither. times are described as tension-reducing by people who engage
Throughout our school years, Claire left town periodi- in these behaviors (Nock, 2010). Claire’s empty feeling is also
cally, without any explanation. I learned many years later common; these people are sometimes described as chronically
that she was in psychiatric facilities to get help with her bored and have difficulties with their own identities (Linehan
suicidal depression. She often threatened to kill herself, & Dexter-Mazza, 2008). The mood disorders we discussed
although we didn’t guess that she was serious. in Chapter 7 are common among people with borderline per-
In our later teens, we all drifted away from Claire. She sonality disorder, with about 20% having major depression
had become increasingly unpredictable, sometimes berating and about 40% having bipolar disorder (Grant et al., 2008).
us for a perceived slight (“You’re walking too fast. You don’t Eating disorders are also common, particularly bulimia (see
want to be seen with me!”), and at other times desperate to Chapter 8): Almost 25% of people with bulimia also have border-
be around us. We were confused by her behavior. With some line personality disorder (Zanarini, Reichman, Frankenburg,
people, emotional outbursts can bring you closer together. Reich, & Fitzmaurice, 2010). Up to 67% of the people with
Unfortunately for Claire, these incidents and her overall borderline personality disorder are also diagnosed with at least
demeanor made us feel that we didn’t know her. As we all one substance use disorder (Grant et al., 2008). As with anti-
grew older, the “void” she described in herself became over- social personality disorder, people with borderline personality
whelming and eventually shut us all out. disorder tend to improve during their 30s and 40s, although
Claire married twice, and both times had passionate but they may continue to have difficulties into old age (National
stormy relationships interrupted by hospitalizations. She Collaborating Centre for Mental Health, 2009).
tried to stab her first husband during a particularly violent
rage. She tried a number of drugs but mainly used alcohol to Causes
“deaden the pain.” The results from numerous family studies suggest that borderline
Now, in her mid-50s, things have calmed down some, personality disorder is more prevalent in families with the disor-
although she says she is rarely happy. Claire does feel a little der and somehow linked with mood disorders (Distel, Trull, &
better about herself and is doing well as a travel agent. Although Boomsma, 2009). Studies of monozygotic (identical) and dizy-
she is seeing someone, she is reluctant to become involved gotic (fraternal) twins indicated a higher concordance rate among
because of her personal history. Claire was ultimately diagnosed monozygotic twins, further supporting the role of genetics in
with depression and borderline personality disorder. • the expression of borderline personality disorder (for example,
Reichborn-Kjennerud et al., 2009).
The emotional reactivity that is a central aspect of borderline
personality disorder has led researchers to look at this personal-
ity trait for clues about inherited influences (endophenotypes).
Important genetic studies are investigating genes associated with
the neurochemical serotonin because dysfunction in this system
has been linked to the emotional instability, suicidal behaviors,
and impulsivity seen in people with this disorder (Distel et al.,
© Dr. P. Marazzi/SPL/Photo Researchers, Inc.
2009). This research is in its early stages and there are as yet no
solid answers for how genetic differences lead to the symptoms of
borderline personality disorder (Hooley et al., 2012).
Neuroimaging studies, designed to locate areas in the brain
contributing to borderline personality disorder, point to the limbic
network (Nunes et al., 2009). Significantly, this area in the brain is
involved in emotion regulation and dysfunctional serotonin neu-
rotransmission, linking these findings with genetic research. Low
Borderline personality disorder is often accompanied by self-mutilation. serotonergic activity is involved with the regulation of mood and
impulsivity, making it a target for extensive study in this group
(Hooley et al., 2012).
To further “zero in” on the nature of this disorder, it is necessary
to refine the concept of emotional reactivity in borderline person-
DSM ality disorder. When asked about their experiences, people with
5
TABLE 12.6 Diagnostic Criteria for Borderline
this disorder will report greater emotional fluctuations and greater
Personality Disorder emotional intensity, primarily in negative emotions such as
A pervasive pattern of instability of interpersonal
anger and anxiety (Rosenthal et al., 2008). Some research—using
relationships, self-image, and affects, and marked “morphing” technology—is looking at how sensitive these indi-
impulsivity, beginning by early adulthood and present viduals are to the emotions of others. One study tested how people
in a variety of contexts, as indicated by five (or more) of with and without borderline personality disorder could correctly
the following: identify the emotion of a face that was morphing on screen (chang-
1. Frantic efforts to avoid real or imagined abandonment. ing slowly from a neutral expression to an emotional expression
(Note: Do not include suicidal or self-mutilating behavior such as anger) and found those with borderline personality disor-
covered in Criterion 5.) der were more accurate than controls (Fertuck et al., 2009).
2. A pattern of unstable and intense interpersonal relation- In one study, the emotion “shame” was explored in people with
ships characterized by alternating between extremes of this disorder (Rusch et al., 2007). For example, people were given
idealization and devaluation. the following scenario:
3. Identity disturbance: markedly and persistently
unstable self-image or sense of self. You attend your coworker’s housewarming party and you
4. Impulsivity in at least two areas that are potentially
spill red wine on a new cream-colored carpet, but you
self-damaging (e.g., spending, sex, substance abuse, think no one notices.
reckless driving, binge eating). (Note: Do not include Participants are then asked to say which of the follow-
suicidal or self-mutilating behavior covered in ing four reactions they would have:
criterion 5.)
● “You would wish you were anywhere but at the party.”
5. Recurrent suicidal behavior, gestures, or threats, or
self-mutilating behavior.
(indicating shame proneness)
● “You would stay late to help clean up the stain after the
6. Affective instability due to a marked reactivity of mood
(e.g., intense episodic dysphoria, irritability, or anxiety
party.” (guilt proneness)
usually lasting a few hours and only rarely more than a
● “You think your coworker should have expected some
few days). accidents at such a big party.” (detachment)
7. Chronic feelings of emptiness.
● “You would wonder why your coworker chose to serve red
8. Inappropriate, intense anger or difficulty controlling
wine with the new light carpet.” (externalization) (p. 317)
anger (e.g., frequent displays of temper, constant anger,
This study found that women with borderline personality
recurrent physical fights).
disorder (no men were included in this study) were more likely
9. Transient, stress-related paranoid ideation or severe
to report shame than healthy women and women with social
dissociative symptoms.
phobia. Importantly, the researchers also found that this elevated
tendency to experience shame was associated with low self-
manual of mental disorders (5th ed.). Washington, DC. esteem, low quality of life, and high levels of anger and hostility
(Rusch et al., 2007). Shame has also been found to be related
to self-inflicted injury (for example, cutting) in this population Borderline personality disorder has been observed among
(Brown, Linehan, Comtois, Murray, & Chapman, 2009). This people who have gone through rapid cultural changes. The
incorporation of shame in interpreting certain situations has problems of identity, emptiness, fears of abandonment, and low
also been observed in children and youth with characteristics anxiety threshold have been found in child and adult immigrants
of borderline personality disorder (Hawes, Helyer, Herlianto, & (Laxenaire, Ganne-Vevonec, & Streiff, 1982; Skhiri, Annabi, Bi,
Willing, 2013). & Allani, 1982). These observations further support the possibil-
Cognitive factors in borderline personality disorder are just ity that prior trauma may, in some individuals, lead to borderline
beginning to be explored. Here, the questions are, just how do personality disorder.
people with this disorder process information, and does this con- Remember, however, that a history of childhood trauma,
tribute to their difficulties? One study that looked at the thought including sexual and physical abuse, occurs in people with other
processes of these individuals asked people with and without disorders, such as schizoid personality disorder, somatic symptom
borderline personality disorder to look at words projected on a disorder (see Chapter 6), panic disorder (see Chapter 5), and dis-
computer screen and try to remember some of the words and try sociative identity disorder (see Chapter 6). In addition, a portion of
to forget others (Korfine & Hooley, 2000). When the words were individuals with borderline personality disorder have no apparent
not related to the symptoms of borderline personality disorder— history of such abuse (Cloninger & Svakic, 2009). Although child-
for example, “celebrate,” “charming,” and “collect”—both groups hood sexual abuse and physical abuse seems to play an important
performed equally well. However, when they were presented with role in the etiology of borderline personality disorder, neither
words that might be relevant to the disorder—for example, “aban- appears to be necessary or sufficient to produce the syndrome.
don,” “suicidal,” and “emptiness”—individuals with borderline
personality disorder remembered more of these words despite An Integrative Model
being instructed to forget them. This preliminary evidence for a
Although there is no currently accepted integrative model for
memory bias may hold clues to the nature of this disorder and
this disorder, it is tempting to borrow from the work on anxiety
may someday be helpful in designing more effective treatment
disorders to outline a possible view. If you recall from Chapter
(Geraerts & McNally, 2008).
5, we describe the “triple vulnerability” theory (Barlow, 2002;
An important environmental risk factor in a gene–environment
Suárez, Bennett, Goldstein, & Barlow, 2008). The first vulner-
interaction explanation for borderline personality disorder is
ability (or diathesis) is a generalized biological vulnerability.
the possible contribution of early trauma, especially sexual and
We can see the genetic vulnerability to emotional reactivity in
physical abuse. Numerous studies show that people with this
people with borderline personality disorder and how this affects
disorder are more likely to report abuse than are healthy indi-
specific brain function. The second vulnerability is a generalized
viduals or those with other psychiatric conditions (see, for
psychological vulnerability. In the case of people with this per-
example, Bandelow et al., 2005; Goldman, D’Angelo, DeMaso, &
sonality disorder, they tend to view the world as threatening and
Mezzacappa, 1992; Ogata et al., 1990). Unfortunately, these
to react strongly to real and perceived threats. The third vulnera-
types of studies (based on recollection and a correlation between
bility is a specific psychological vulnerability, learned from early
the two phenomena) do not tell us directly whether abuse and
environmental experiences; this is where early trauma, abuse,
neglect cause later borderline personality disorder. In an impor-
or both may advance this sensitivity to threats. When a person
tant study, researchers followed 500 children who had docu-
is stressed, his or her biological tendency to be overly reactive
mented cases of childhood physical and sexual abuse and neglect
interacts with the psychological tendency to feel threatened. This
and compared them in adulthood with a control group (no
may result in the outbursts and suicidal behaviors commonly
history of reported abuse or neglect) (Widom, Czaja, & Paris,
observed in this group. This preliminary model awaits validation
2009). Significantly more abused and neglected children went
and further research.
on to develop borderline personality disorder compared with
controls. This finding is particularly significant for girls and
women because girls are 2 or 3 times more likely to be sexually Treatment
abused than boys (Bebbington et al., 2009). In stark contrast to individuals with antisocial personality
It is clear that a majority of people who receive the diagnosis disorder, who rarely acknowledge requiring help, those with
of borderline personality disorder have suffered terrible abuse borderline personality disorder appear quite distressed and
or neglect from parents, sexual abuse, physical abuse by others, are more likely to seek treatment even than people with
or a combination of these (Ball & Links, 2009). For those who anxiety and mood disorders (Ansell, Sanislow, McGlashan, &
have not reported such histories, some workers are examining Grilo, 2007). Reviews of research on the use of medical treat-
just how they could develop borderline personality disorder. ment for people with this disorder suggest that symptomatic
For example, factors such as temperament (emotional nature, treatment can sometimes be helpful. For disturbances in affect
such as being impulsive, irritable, or hypersensitive) or neu- (e.g., anger, sadness) a class of drugs known as mood stabiliz-
rological impairments (being exposed prenatally to alcohol or ers (e.g., some anticonvulsive and antipsychotic drugs) can be
drugs) and how they interact with parental styles may account effective (Silk & Feurino III, 2012). Efforts to provide successful
for some cases of borderline personality disorder (Graybar & treatment are complicated by problems with drug abuse, com-
Boutilier, 2002). pliance with treatment, and suicide attempts. As a result, many
clinicians are reluctant to work with people who have border-
line personality disorder. PAT... Always Onstage
One of the most thoroughly researched cognitive-behavioral
treatments was developed by Marsha Linehan (Linehan et al.,
2006; Linehan et al., 1999; Linehan & Dexter-Mazza, 2008).
This approach—called dialectical behavior therapy (DBT)—
W hen we first met, Pat seemed to radiate enjoyment of life.
She was single, in her mid-30s, and was going to night
school for her master’s degree. She often dressed flamboy-
involves helping people cope with the stressors that seem to antly. During the day she taught children with disabilities,
trigger suicidal behaviors. Priority in treatment is first given to and when she didn’t have class she was often out late on a
those behaviors that may result in harm (suicidal behaviors), date. When I first spoke with her, she enthusiastically told
then those behaviors that interfere with therapy, and, finally, me how impressed she was with my work in the field of
those that interfere with the patient’s quality of life. Weekly indi- developmental disabilities and that she had been extremely
vidual sessions provide support, and patients are taught how to successful in using some of my techniques with her students.
identify and regulate their emotions. Problem solving is empha- She was clearly overdoing the praise, but who wouldn’t
sized so that patients can handle difficulties more effectively. In appreciate such flattering comments?
addition, they receive treatment similar to that used for people Because some of our research included children in her
with PTSD, in which prior traumatic events are reexperienced classroom, I saw Pat often. Over a period of weeks, however,
to help extinguish the fear associated with them (see Chapter 5). our interactions grew strained. She often complained of vari-
In the final stage of therapy, clients learn to trust their own ous illnesses and injuries (falling in the parking lot, twisting
responses rather than depend on the validation of others, some- her neck looking out a window) that interfered with her work.
times by visualizing themselves not reacting to criticism (Lynch She was disorganized, often leaving to the last minute tasks
& Cuper, 2012). that required considerable planning. Pat made promises to
Results from a number of studies suggest that DBT may help other people that were impossible to keep but seemed to be
reduce suicide attempts, dropouts from treatment, and hospitaliza- aimed at winning their approval; when she broke the promise,
tions (Linehan & Dexter-Mazza, 2008; Stanley & Brodsky, 2009). she usually made up a story designed to elicit sympathy and
A follow-up of 39 women who received either dialectical behav- compassion. For example, she promised the mother of one
ior therapy or general therapeutic support (called “treatment as of her students that she would put on a “massive and unique”
usual”) for 1 year showed that, during the first 6 months of follow- birthday party for her daughter but forgot about it until the
up, the women in the DBT group were less suicidal, less angry, mother showed up with cake and juice. Upon seeing her, Pat
and better adjusted socially (Linehan & Kehrer, 1993). Another flew into a rage and blamed the principal for keeping her late
study examined how treating these individuals with DBT in an after school, although there was no truth to this accusation.
inpatient setting (a psychiatric hospital) for approximately 5 days Pat often interrupted meetings about research to talk
would improve their outcomes (Yen, Johnson, Costello, & Simp- about her latest boyfriend. The boyfriends changed almost
son, 2009). The participants improved in a number of areas, such weekly, but her enthusiasm (“Like no other man I have ever
as with a reduction in depression, hopelessness, anger expression, met!”) and optimism about the future (“He’s the guy I want
and dissociation. A growing body of evidence is now available to to spend the rest of my life with!”) remained high for each of
document the effectiveness of this approach to aid many individu- them. Wedding plans were seriously discussed with almost
als with this debilitating disorder (Lynch & Cuper, 2012). every one, despite their brief acquaintance. Pat was ingratiat-
Probably some of the most intriguing research we describe ing, especially to the male teachers, who often helped her out
in this book involves using the techniques in brain imaging to of trouble she got into because of her disorganization.
see how psychological treatments influence brain function. One When it became clear that she would probably lose her
pilot study examined emotional reactions to upsetting photos (for teaching job because of her poor performance, Pat managed
example, pictures of women being attacked) in controls and in to manipulate several of the male teachers and the assistant
women with borderline personality disorder (Schnell & Herpertz, principal into recommending her for a new job in a nearby
2007). This study found that among the women who benefited school district. A year later, she was still at the new school but
from treatment, arousal (in the amygdala and hippocampus) to had been moved twice to different classrooms. According to
the upsetting photos improved over time as a function of treat- teachers she worked with, Pat still lacked close interpersonal
ment. No changes occurred in controls or in women who did relationships, although she described her current romantic
not have positive treatment experiences. This type of integrative relationship as “deeply involved.” After a rather long period
research holds enormous promise for our understanding of of depression, Pat sought help from a psychologist, who diag-
borderline personality disorder and the mechanisms underlying nosed her as also having histrionic personality disorder. •
successful treatment.
Histrionic Personality Disorder Clinical Description

Individuals with histrionic personality disorder tend to be People with histrionic personality disorder are inclined to express
overly dramatic and often seem almost to be acting, which is why their emotions in an exaggerated fashion, for example, hugging
the term histrionic, which means theatrical in manner, is used. someone they have just met or crying uncontrollably during a sad
Consider the case of Pat. movie (Blashfield, Reynolds, & Stennett, 2012). They also tend to
be vain, self-centered, and uncomfortable when they are not in
DSM
5
the limelight. They are often seductive in appearance and behav- TABLE 12.7 Diagnostic Criteria for Histrionic
ior, and they are typically concerned about their looks. (Pat, for Personality Disorder
example, spent a great deal of money on unusual jewelry and was
sure to point it out to anyone who would listen.) In addition, they A pervasive pattern of excessive emotionality and attention
seek reassurance and approval constantly and may become upset seeking, beginning by early adulthood and present in a
or angry when others do not attend to them or praise them. People variety of contexts, as indicated by five (or more) of the
with histrionic personality disorder also tend to be impulsive and following:
have great difficulty delaying gratification. 1. Is uncomfortable in situations in which he or she is not
The cognitive style associated with histrionic personality dis- the center of attention.
order is impressionistic (Beck, Freeman, & Davis, 2007), charac- 2. Interaction with others is often characterized by inappro-
terized by a tendency to view situations in global, black-and-white priate sexually seductive or provocative behavior.
terms. Speech is often vague, lacking in detail, and characterized 3. Displays rapidly shifting and shallow expression of
by exaggeration (Nestadt et al., 2009). For example, when Pat was emotions.
asked about a date she had had the night before, she might say it 4. Consistently uses physical appearance to draw attention
was “way cool” but fail to provide more detailed information. to self.
The high rate of this diagnosis among women versus men 5. Has a style of speech that is excessively impressionistic
raises questions about the nature of the disorder and its diagnos- and lacking in detail.
tic criteria. As we first discussed in the beginning of this chapter, 6. Shows self-dramatization, theatricality, and exaggerated
there is some thought that the features of histrionic personality expression of emotion.
disorder, such as overdramatization, vanity, seductiveness, and 7. Is suggestible (i.e., easily influenced by others or
overconcern with physical appearance, are characteristic of the circumstances).
Western “stereotypical female” and may lead to an overdiagnosis 8. Considers relationships to be more intimate than they
among women. Sprock (2000) examined this important question actually are.
and found some evidence for a bias among psychologists and psy-
chiatrists to associate the diagnosis with women rather than men. From American Psychiatric Association. (2013). Diagnostic and statistical
Causes
Despite its long history, little research has been done on the causes
or treatment of histrionic personality disorder. The ancient Greek that roughly two-thirds of people with a histrionic personality
philosophers believed that many unexplainable problems of also met criteria for antisocial personality disorder. The evidence
women were caused by the uterus (hysteria) migrating within the for this association has led to the suggestion (see, for example,
body (Abse, 1987). As you have seen, however, histrionic person- Cloninger, 1978; Lilienfeld, 1992) that histrionic personality and
ality disorder also occurs among men. antisocial personality may be sex-typed alternative expressions
One hypothesis involves a possible relationship with antisocial of the same unidentified underlying condition. Females with the
personality disorder. Evidence suggests that histrionic personality underlying condition may be predisposed to exhibit a predomi-
and antisocial personality co-occur more often than chance would nantly histrionic pattern, whereas males with the underlying
account for. Lilienfeld and colleagues (1986), for example, found condition may be predisposed to exhibit a predominantly anti-
social pattern. Whether this association exists remains a con-
troversial issue, however, and further research on this potential
relationship is needed (Dolan & Völlm, 2009; Salekin, Rogers, &
Sewell, 1997).
Treatment
Although a great deal has been written about ways of helping
people with histrionic personality disorder, little of the research
demonstrates success (Cloninger & Svakic, 2009). Some therapists
have tried to modify the attention-getting behavior. Kass, Silvers,
and Abrams (1972) worked with five women, four of whom had
been hospitalized for suicide attempts and all of whom were later
Clarissa Leahy/cultura/Corbis
diagnosed with histrionic personality disorder. The women were

rewarded for appropriate interactions and fined for attention-
getting behavior. The therapists noted improvement after an
18-month follow-up, but they did not collect scientific data to
confirm their observation.
People with histrionic personality disorder tend to be vain, extravagant, A large part of therapy for these individuals usually focuses on
and seductive. the problematic interpersonal relationships. They often manipulate
others through emotional crises, using charm, sex, seductiveness,
or complaining (Beck et al., 2007). People with histrionic person- employers—and that they were at fault. After calming down,
ality disorder often need to be shown how the short-term gains he revealed a previous drinking problem, a history of depres-
derived from this interactional style result in long-term costs, and sion, and multiple family problems, all of which he believed
they need to be taught more appropriate ways of negotiating their contributed to any difficulties he experienced.
wants and needs. The firm recommended he be seen at a university clinic
as a condition of his continued employment, where he was
diagnosed with major depression, as well as narcissistic
Narcissistic Personality Disorder personality disorder. Ultimately, his behavior—including
We all know people who think highly of themselves—perhaps lateness and incomplete work—resulted in his termination.
exaggerating their real abilities. They consider themselves some- In a revealing turn of events, Willie reapplied for another
how different from others and deserving of special treatment. position at the same firm 2 years later. A mix-up in records
In narcissistic personality disorder, this tendency is taken to failed to reveal his previous termination, but he lasted only
its extreme. In Greek mythology, Narcissus was a youth who 3 days—showing up late to work on his second and third
spurned the love of Echo, so enamored was he of his own beauty. days. He was convinced he could be successful, yet he could
He spent his days admiring his own image reflected in a pool not change his behavior to conform to even the minimal
of water. Psychoanalysts, including Freud, used the term nar-
cissistic to describe people who show an exaggerated sense of
standards needed to be successful at work. •
self-importance and are preoccupied with receiving attention
(Ronningstam, 2012). Consider the case of Willie.
People with narcissistic personality disorder have an unreason-
WILLIE... It’s All About Me able sense of self-importance and are so preoccupied with them-
selves that they lack sensitivity and compassion for other people
(Ronningstam, 2012). They aren’t comfortable unless someone
W illie was an office assistant in a small law firm. Now in
his early 30s, Willie had an extremely poor job history.
He never stayed employed at the same place for more than
is admiring them. Their exaggerated feelings and their fantasies
of greatness, called grandiosity, create a number of negative attri-
butes. They require and expect a great deal of special attention—
2 years, and he spent considerable time working through
the best table in the restaurant, the illegal parking space in front
temporary employment agencies. Your first encounter,
of the movie theater. They also tend to use or exploit others for
however, would make you believe that he was extremely
their own interests and show little empathy. When confronted
competent and that he ran the office. If you entered the wait-
with other successful people, they can be extremely envious and
ing room you were greeted by Willie, even though he wasn’t
arrogant. And because they often fail to live up to their own expec-
the receptionist. He would be extremely solicitous, asking
tations, they are often depressed.
how he could be of assistance, offer you coffee, and ask you
to make yourself comfortable in “his” reception area. Willie
Causes and Treatment
liked to talk, and any conversation was quickly redirected in
a way that kept him the center of attention. We start out as infants being self-centered and demanding, which
This type of ingratiating manner was welcomed at first is part of our struggle for survival. Part of the socialization process,
but soon annoyed other staff. This was especially true when however, involves teaching children empathy and altruism. Some
he referred to the other workers in the office as his staff, even writers, including Kohut (1971, 1977), believe that narcissistic
though he was not responsible for supervising any of them. personality disorder arises largely from a profound failure by the
The conversations with visitors and staff often consumed a parents of modeling empathy early in a child’s development. As a
great deal of his time and the time of other staff, and this was consequence, the child remains fixated at a self-centered, grandiose
becoming a problem. stage of development. In addition, the child (and later the adult)
He quickly became controlling in his job—a pattern becomes involved in an essentially endless and fruitless search for
revealed in his other positions as well—eagerly taking charge the ideal person who will meet her unfulfilled empathic needs.
of duties assigned to others. Unfortunately, he did not com- In a sociological view, Christopher Lasch (1978) wrote in
plete these tasks well, and this created a great deal of friction. his popular book The Culture of Narcissism that this personality
When confronted with any of these difficulties, Willie disorder is increasing in prevalence in most Western societies,
would first blame others. Ultimately, however, it would primarily as a consequence of large-scale social changes, includ-
become clear that Willie’s self-centeredness and controlling ing greater emphasis on short-term hedonism, individualism,
nature were at the root of many of the office inefficiencies. competitiveness, and success. According to Lasch, the “me gener-
During a disciplinary meeting with all of the law firm’s ation” (“Baby Boomers” born between 1946 and 1954) produced
partners, an unusual step, Willie became explosively abu- more than its share of individuals with narcissistic personality
sive and blamed them for being out to get him. He insisted disorder. Indeed, reports confirm that narcissistic personality dis-
that his performance was exceptional at all of his previous order is increasing in prevalence (Huang et al., 2009). However,
positions—something contradicted by his previous this apparent rise may be a consequence of increased interest in
and research on the disorder.
DSM
5
TABLE 12.8 Diagnostic Criteria for Narcissistic Personality Disorder
A pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy, beginning by early
adulthood and present in a variety of contexts, as indicated by five (or more) of the following:
1. Has a grandiose sense of self-importance (e.g., exaggerates achievements and talents, expects to be recognized as superior
without commensurate achievements).
2. Is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love.
3. Believes that he or she is “special” and unique and can only be understood by, or should associate with, other special or
high-status people (or institutions).
4. Requests excessive admiration.
5. Has a sense of entitlement (i.e., unreasonable expectations of especially favorable treatment or automatic compliance with his
or her expectations).
6. Is interpersonally exploitative (i.e., takes advantage of others to achieve his or her own ends).
7. Lacks empathy: is unwilling to recognize or identify with the feelings and needs of others.
8. Is often envious of others or believes that others are envious of him or her.
9. Shows arrogant, haughty behaviors or attitudes.
From American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC.
Research on treatment options is extremely limited in both

number of studies and reports of success (Cloninger & Svakic, in the community, and often fights with others. He shows
2009; Dhawan, Kunik, Oldham, & Coverdale, 2010). When ther- no remorse for the people he injures or the grief that he
apy is attempted with these individuals, it often focuses on their causes his ailing parents. ____________
grandiosity, their hypersensitivity to evaluation, and their lack 3. Nancy thinks she is the best at everything. She thinks her
of empathy toward others (Beck et al., 2007). Cognitive therapy performance is always excellent, and is extremely critical
strives to replace their fantasies with a focus on the day-to-day of anyone else’s success. She constantly looks for admira-
pleasurable experiences that are truly attainable. Coping strategies tion and reassurance from others. ____________
such as relaxation training are used to help them face and accept
criticism. Helping them focus on the feelings of others is also a 4. Samantha is known for being overly dramatic. She cries
goal. Because individuals with this disorder are vulnerable to uncontrollably during sad movies and we sometimes
severe depressive episodes, particularly in middle age, treatment think that she is acting. She is vain and self-centered,
is often initiated for the depression. It is impossible to draw any interrupting many of our class conversations to discuss
conclusions, however, about the impact of such treatment on the her personal life.____________
actual narcissistic personality disorder.
Concept Check 12.3 Cluster C Personality Disorders

People diagnosed with the next three personality disorders we
Correctly identify the type of personality disorder described highlight—avoidant, dependent, and obsessive-compulsive—
here. share common features with people who have anxiety disorders.
1. Elaine has low self-esteem and usually feels empty unless These anxious or fearful personality disorders are described next.
she does dangerous and exciting things. She is involved in
drugs and has casual sexual encounters, even with strang- Avoidant Personality Disorder
ers. She threatens to commit suicide if her boyfriend As the name suggests, people with avoidant personality disor-
suggests getting help or if he talks about leaving her. She der are extremely sensitive to the opinions of others and although
alternates between passionately loving and hating him, they desire social relationships, their anxiety leads them to avoid
sometimes going from one extreme to the next in a short such associations. Their extremely low self-esteem—coupled
time. ____________ with a fear of rejection—causes them to be limited in their
2. Lance is 17 and has been in trouble with the law for the friendships and dependent on those they feel comfortable with
past 2 years. He lies to his parents, vandalizes buildings (Sanislow, da Cruz, Gianoli, & Reagan, 2012). Consider the
case of Jane.
C lu st e r C P ers ona l i t y D i s order s 467
JANE... Not Worth Noticing DSM
5
TABLE 12.9 Diagnostic Criteria for Avoidant
Personality Disorder
J ane was raised by an alcoholic mother who had border-
line personality disorder and who abused her verbally
and physically. As a child, she made sense of her mother’s
A pervasive pattern of social inhibition, feelings of inade-
quacy, and hypersensitivity to negative evaluation, beginning
abusive treatment by believing that she (Jane) must be an by early adulthood and present in a variety of contexts, as
intrinsically unworthy person to be treated so badly. As an indicated by four (or more) of the following:
adult in her late 20s, Jane still expected to be rejected when 1. Avoids occupational activities that involve significant
others found out that she was inherently unworthy and bad. interpersonal contact because of fears of criticism,
Jane was highly self-critical and predicted that she would disapproval, or rejection.
not be accepted. She thought that people would not like her, 2. Is unwilling to get involved with people unless certain of
that they would see she was a loser, and that she would not being liked.
have anything to say. She became upset if she perceived that 3. Shows restraint within intimate relationships because of
someone in even the most fleeting encounter was reacting the fear of being shamed or ridiculed.
negatively or neutrally. If a newspaper vendor failed to smile 4. Is preoccupied with being criticized or rejected in social
at her, or a sales clerk was slightly curt, Jane automatically situations.
thought it must be because she (Jane) was somehow unwor- 5. Is inhibited in new interpersonal situations because of
thy or unlikable. She then felt quite sad. Even when she was feelings of inadequacy.
receiving positive feedback from a friend, she discounted it. 6. Views self as socially inept, personally unappealing, or
As a result, Jane had few friends and certainly no close ones. inferior to others.
(Case and excerpt reprinted, with permission, from Beck, 7. Is unusually reluctant to take personal risks or to
A. T., & Freeman, A., 1990. Cognitive therapy of personality engage in any new activities because they may prove
disorders. New York: Guilford Press, ©1990 Guilford Press.) • embarrassing.

Theodore Millon (1981), who initially proposed this diagnosis,
notes that it is important to distinguish between individuals who less affectionate than the control group, suggesting parenting may
are asocial because they are apathetic, affectively flat, and rela- contribute to the development of this disorder. Similarly, Meyer
tively uninterested in interpersonal relationships (comparable to and Carver (2000) found that these individuals were more likely to
what DSM-5 terms schizoid personality disorder) and individu- report childhood experiences of isolation, rejection, and conflict
als who are asocial because they are interpersonally anxious and with others.
fearful of rejection. It is the latter who fit the criteria of avoidant
personality disorder (Millon & Martinez, 1995). These individu- Treatment
als feel chronically rejected by others and are pessimistic about
their future. In contrast to the scarcity of research into most other person-
ality disorders, there are a number of well-controlled studies
on approaches to therapy for people with avoidant personal-
Causes ity disorder (Leahy & McGinn, 2012). Behavioral interven-
Some evidence has found that avoidant personality disorder tion techniques for anxiety and social skills problems have
is related to other subschizophrenia-related disorders, occur- had some success (e.g., Borge et al., 2010; Emmelkamp et al.,
ring more often in relatives of people who have schizophrenia 2006). Because the problems experienced by people with avoid-
(Fogelson et al., 2007). A number of theories have been proposed ant personality disorder resemble those of people with social
that integrate biological and psychosocial influences as the cause phobia, many of the same treatments are used for both groups
of avoidant personality disorder. Millon (1981), for example, sug- (see Chapter 5). Therapeutic alliance—the collaborative con-
gests that these individuals may be born with a difficult tempera- nection between therapist and client—appears to be an impor-
ment or personality characteristics. As a result, their parents may tant predictor for treatment success in this group (Strauss
reject them, or at least not provide them with enough early, uncrit- et al., 2006).
ical love. This rejection, in turn, may result in low self-esteem and
social alienation, conditions that persist into adulthood. Limited
support does exist for psychosocial influences in the cause of Dependent Personality Disorder
avoidant personality disorder. For example, Stravynski, Elie, and We all know what it means to be dependent on another person.
Franche (1989) questioned a group of people with avoidant per- People with dependent personality disorder, however, rely on
sonality disorder and a group of control participants about their others to make ordinary decisions as well as important ones,
early treatment by their parents. Those with the disorder remem- which results in an unreasonable fear of abandonment. Consider
bered their parents as more rejecting, more guilt engendering, and the case of Karen.
up fearing abandonment (Stone, 1993). It also is clear, however,
KAREN... Whatever You Say that genetic influences are important in the development of this
disorder (e.g., Gjerde et al., 2012). What is not yet understood are
K aren was a 45-year-old married woman who was

referred for treatment by her physician for problems
with panic attacks. During the evaluation, she appeared to
the physiological factors underlying this genetic influence and how
they interact with environmental influences (Sanislow et al., 2012).
The treatment literature for this disorder is mostly descrip-
be worried, sensitive, and naive. She was easily overcome tive; little research exists to show whether a particular treatment is
with emotion and cried on and off throughout the session. effective (Borge et al., 2010; Paris, 2008). On the surface, because
She was self-critical at every opportunity throughout the of their attentiveness and eagerness to give responsibility for their
evaluation. For example, when asked how she got along problems to the therapist, people with dependent personality dis-
with other people, she reported that “others think I’m dumb order can appear to be ideal patients. That very submissiveness,
and inadequate,” although she could give no evidence as to however, negates one of the major goals of therapy, which is to
what made her think that. She reported that she didn’t like make the person more independent and personally responsible
school because “I was dumb” and that she always felt that (Leahy & McGinn, 2012). Therapy therefore progresses gradually
she was not good enough. as the patient develops confidence in his ability to make deci-
Karen described staying in her first marriage for 10 years, sions independently (Beck et al., 2007). There is a particular need
even though “it was hell.” Her husband had affairs with for care that the patient does not become overly dependent on
many other women and was verbally abusive. She tried to the therapist.
leave him many times but gave in to his repeated requests
to return. She was finally able to divorce him, and shortly Obsessive-Compulsive Personality Disorder
afterward she met and married her current husband, whom
People who have obsessive-compulsive personality disorder are
she described as kind, sensitive, and supportive. Karen stated
characterized by a fixation on things being done “the right way.”
that she preferred to have others make important decisions
Although many might envy their persistence and dedication, this
and agreed with other people to avoid conflict. She worried
about being left alone without anyone to take care of her
and reported feeling lost without other people’s reassurance.
She also reported that her feelings were easily hurt, so she DSM
•
5
worked hard not to do anything that might lead to criticism. TABLE 12.10 Diagnostic Criteria for Dependent
(Case and excerpt reprinted, with permission, from Beck, A. T., & Freeman, A.
(1990). Cognitive therapy of personality disorders. New York: Guilford Press, A pervasive and excessive need to be taken care of that
© 1990 by Guilford Press.)
leads to submissive and clinging behavior and fears of
separation, beginning by early adulthood and present in
a variety of contexts, as indicated by five (or more) of the
following:
Clinical Description 1. Has difficulty making everyday decisions without an
excessive amount of advice and reassurance from others.
Individuals with dependent personality disorder sometimes agree
2. Needs others to assume responsibility for most major
with other people when their own opinion differs so as not to be areas of his or her life.
rejected (Bornstein, 2012). Their desire to obtain and maintain
3. Has difficulty expressing disagreement with others
supportive and nurturant relationships may lead to their other because of fear of loss of support or approval. (Note:
behavioral characteristics, including submissiveness, timidity, Do not include realistic fears of retribution.)
and passivity. People with this disorder are similar to those with 4. Has difficulty initiating projects or doing things on his or
avoidant personality disorder in their feelings of inadequacy, sen- her own (because of a lack of self-confidence in judgment
sitivity to criticism, and need for reassurance. However, people or abilities rather than a lack of motivation or energy).
with avoidant personality disorder respond to these feelings by 5. Goes to excessive lengths to obtain nurturance and
avoiding relationships, whereas those with dependent personality support from others, to the point of volunteering to do
disorder respond by clinging to relationships (Bornstein, 2012). things that are unpleasant.
It is important to note that in certain cultures (e.g., East Asian 6. Feels uncomfortable or helpless when alone because of
Confucianism) dependence and submission may be viewed as a exaggerated fears of being unable to care of himself or
desired interpersonal state (Chen, Nettles, & Chen, 2009). herself.
7. Urgently seeks another relationship as a source of care
Causes and Treatment and support when a close relationship ends.
8. Is unrealistically preoccupied with fears of being left to
We are all born dependent on other people for food, physical pro-
take care of himself or herself.
tection, and nurturance. Part of the socialization process in most
cultures involves helping us live independently (Bornstein, 1992). From American Psychiatric Association. (2013). Diagnostic and statistical
It was thought that such disruptions as the early death of a parent manual of mental disorders (5th ed.). Washington, DC.
or neglect or rejection by caregivers could cause people to grow
preoccupation with details prevents them from completing much
DSM
5
of anything. Consider the case of Daniel. TABLE 12.11 Diagnostic Criteria for
Obsessive-Compulsive
DANIEL... Getting
Right
It Exactly
A pervasive pattern of preoccupation with orderliness,
perfectionism, and mental and interpersonal control, at the
E
expense of flexibility, openness, and efficiency, beginning
ach day at exactly 8 a.m., Daniel arrived at his office at
by early adulthood and present in a variety of contexts, as
the university where he was a graduate student in psy-
indicated by four (or more) of the following:
chology. On his way, he always stopped at the 7-Eleven for
1. Is preoccupied with details, rules, lists, order, organiza-
coffee and the New York Times. From 8 a.m. to 9:15 a.m., he
tion, or schedules to the extent that the major point of
drank his coffee and read the paper. At 9:15 a.m., he reor- the activity is lost.
ganized the files that held the hundreds of papers related to
2. Shows perfectionism that interferes with task comple-
his doctoral dissertation, now several years overdue. From tion (e.g., is unable to complete a project because his
10 a.m. until noon, he read one of these papers, highlight- or her own overly strict standards are not met).
ing relevant passages. Then he took the paper bag that held 3. Is excessively devoted to work and productivity to
his lunch (always a peanut butter and jelly sandwich and an the exclusion of leisure activities and friendships
apple) and went to the cafeteria to purchase a soda and eat (not accounted for by obvious economic necessity).
by himself. From 1 p.m. until 5 p.m., he held meetings, orga- 4. Is overconscientious, scrupulous, and inflexible about
nized his desk, made lists of things to do, and entered his matters of morality, ethics, or values (not accounted for
references into a new database program on his computer. At by cultural or religious identification).
home, Daniel had dinner with his wife and then worked on 5. Is unable to discard worn-out or worthless objects even
his dissertation until after 11 p.m., although much of the time when they have no sentimental value.
was spent trying out new features of his home computer. 6. Is reluctant to delegate tasks or to work with others unless
Daniel was no closer to completing his dissertation than he they submit to exactly his or her way of doing things.
had been 4.5 years ago. His wife was threatening to leave him 7. Adopts a miserly spending style toward both self and
because he was equally rigid about everything at home and others; money is viewed as something to be hoarded
she didn’t want to remain in this limbo of graduate school for- for future catastrophes.
ever. When Daniel eventually sought help from a therapist for 8. Shows rigidity and stubbornness.
his anxiety over his deteriorating marriage, he was diagnosed
as having obsessive-compulsive personality disorder. • From American Psychiatric Association. (2013). Diagnostic and statistical
Like many with this personality disorder, Daniel is work oriented, illness—such as schizophrenia—but are “masters of control” in
spending little time going to movies or parties or doing anything manipulating their victims. Their need to control all aspects of
that isn’t related to his graduate studies. Because of their general the crime fits the pattern of people with obsessive-compulsive
rigidity, these people tend to have poor interpersonal relationships personality disorder, and some combination of this disorder and
(Samuels & Costa, 2012). unfortunate childhood experiences may lead to this disturbing
This personality disorder seems to be only distantly related behavior pattern. Obsessive-compulsive personality disorder
to obsessive-compulsive disorder, one of the anxiety disorders may also play a role among some sex offenders—in particular,
we described in Chapter 5 (Samuels & Costa, 2012). People like pedophiles. Brain-imaging research on pedophiles suggests that
Daniel tend not to have the obsessive thoughts and the com- brain functioning in these individuals is similar to those with
pulsive behaviors seen in the like-named obsessive-compulsive obsessive-compulsive personality disorder (Schiffer et al., 2007).
disorder. Although people with the anxiety disorder sometimes At the other end of the behavioral spectrum, it is also common
show characteristics of the personality disorder, they show the to find obsessive-compulsive personality disorder among gifted
characteristics of other personality disorders as well (for exam- children, whose quest for perfectionism can be quite debilitating
ple, avoidant, histrionic, or dependent) (Trull, Scheiderer, & (Nugent, 2000).
Tomko, 2012).
An intriguing theory suggests that the psychological profiles Causes and Treatment
of many serial killers point to the role of obsessive-compulsive There seems to be a weak genetic contribution to obsessive-
personality disorder. Ferreira (2000) notes that these individuals compulsive personality disorder (Cloninger & Svakic, 2009).
do not often fit the definition of someone with a severe mental Some people may be predisposed to favor structure in their
cognitive-behavioral therapy—following along the lines of
treatment for obsessive-compulsive disorder (see Chapter 5)—
appears to be effective for people with this personality disorder
(Svartberg et al., 2004).
Concept Check 12.4

Match the following scenarios with the correct personality
©Manchan/Digital Vision/Getty Images
disorder.
1. During a therapy session John gets up for a glass of water.
Ten minutes later John still is not back. He first had to
clean the fountain area and neatly arrange the glasses
before pouring his glass of water. ____________
2. Whitney is self-critical and claims she is unintelligent
People with obsessive-compulsive personality disorder are preoccu- and has no skills. She is also afraid to be alone and seeks
pied with doing things “the right way.”
constant reassurance from her family and friends. She
says and does nothing about her cheating husband
because she thinks that if she shows any resolve or
lives, but to reach the level it did in Daniel may require parental initiative she will be abandoned and will have to take
reinforcement of conformity and neatness. care of herself. ____________
Therapy often attacks the fears that seem to underlie the
need for orderliness. These individuals are often afraid that 3. Mike has no social life because of his great fear of rejec-
what they do will be inadequate, so they procrastinate and tion. He disregards compliments and reacts excessively to
excessively ruminate about important issues and minor details criticism, which only feeds his pervasive feelings of inad-
alike. Therapists help the individual relax or use distraction equacy. Mike takes everything personally. ____________
techniques to redirect the compulsive thoughts. This form of
DSM Controversies: The Battle for the Personality Disorders

Discussion about the person- DSM-5 due to the difficulty in making and significant overlap among the
ality disorders in DSM-5 included pro- a diagnosis (too many permutations) disorders (comorbidity) (Skodol, 2012).
posals for a number of major changes and potential problems in using that In anticipation of this significant change,
to this category. As we have seen, the information to design treatments one set of researchers authored a paper
elimination of the distinction between (Skodol, 2012). with the title “The Death of Histrionic
“Axis I” and “Axis II” disorders elevated However, one of the biggest Personality Disorder” (Blashfield et al.,
the personality disorders into the main
main- changes proposed was to completely 2012) and the personality disorders
stream of problems experienced by indi-indi eliminate four of the personality community of researchers in general
viduals. However, other major changes disorders (paranoid, schizoid, histrionic, was divided over this change (Pull,
that appeared to be ready for inclusion avoidant, and dependent personality 2013). Ultimately, the final draft retained
in DSM-5 never occurred. The goal of disorders). Instead, people previously these disorders and left for a later time
creating dimensions of different diagnosed with these disorders would proposals for dealing with the problems
personality traits along the lines of the be identified as having a general of lack of research and specificity. This
“Big 5” rather than the specific disor
disor- personality disorder with the traits back and forth on how to carve up
bor-
ders outlined in this chapter (e.g., bor specified (e.g., suspiciousness, emotional diagnoses exemplifies the difficulties
derline personality disorder, antisocial liability, hostility, etc.). The rationale that continue to exist for any diagnostic
personality disorder) never materialized. for their removal included a relative system, even after decades of arduous
In part this proposal was not included in lack of research on these disorders and dedicated research.

Abnormal Psychology An Integrative Approach, 7th Ed

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Abnormal Psychology An Integrative Approach, 7th Ed

Uploaded by

Copyright:

Available Formats

Personality Disorders

An Overview of Personality Disorders

An O v e rv i ew of P ers ona l i t y D i s order s 441

442 C ha p ter 12 P ersonalit y D isorder s

Table 12.1 Personality Disorders

Cluster B—Dramatic, Emotional, or Erratic Disorders

Borderline personality disorder A pervasive pattern of instability of interpersonal relationships,

Cluster C—Anxious or Fearful Disorders

Obsessive-compulsive personality disorder A pervasive pattern of preoccupation with orderliness, perfectionism,

An O v e rv i ew of P ers ona l i t y D i s order s 443

444 C ha p ter 12 P ersonalit y D isorder s

matization, vanity, seductiveness, and overcon-

An O v e rv i ew of P ers ona l i t y D i s order s 445

cooperate with requests—attempting to under-

446 C ha p ter 12 P ersonalit y D isorder s

Table 12.5 Main Beliefs Associated with Specific

An O v e rv i ew of P ers ona l i t y D i s order s 447

J ake grew up in a middle-class neighborhood, and although

448 C ha p ter 12 P ersonalit y D isorder s

Schizoid Personality Disorder

C lu st e r A P ers ona l i t y D i s order s 449

450 C ha p ter 12 P ersonalit y D isorder s

C lu st e r A P ers ona l i t y D i s order s 451

452 C ha p ter 12 P ersonalit y D isorder s

C lu st e r B P ers ona l i t y D i s order s 453

With some training, clinicians are able to gather information from

454 C ha p ter 12 P ersonalit y D isorder s

Abnormal Psychology Inside

C lu st e r B P ers ona l i t y D i s order s 455

456 C ha p ter 12 P ersonalit y D isorder s

C lu st e r B P ers ona l i t y D i s order s 457

studies, the researchers hypothesized that once psychopaths set

458 C ha p ter 12 P ersonalit y D isorder s

C lu st e r B P ers ona l i t y D i s order s 459

recognize behavior problems early and to use

460 C ha p ter 12 P ersonalit y D isorder s

C lu st e r B P ers ona l i t y D i s order s 461

462 C ha p ter 12 P ersonalit y D isorder s

C lu st e r B P ers ona l i t y D i s order s 463

Histrionic Personality Disorder Clinical Description

464 C ha p ter 12 P ersonalit y D isorder s

diagnosed with histrionic personality disorder. The women were

C lu st e r B P ers ona l i t y D i s order s 465

466 C ha p ter 12 P ersonalit y D isorder s

Research on treatment options is extremely limited in both

Concept Check 12.3 Cluster C Personality Disorders

C lu st e r C P ers ona l i t y D i s order s 467

From American Psychiatric Association. (2013). Diagnostic and statistical

468 C ha p ter 12 P ersonalit y D isorder s

K aren was a 45-year-old married woman who was

C lu st e r C P ers ona l i t y D i s order s 469

470 C ha p ter 12 P ersonalit y D isorder s

Concept Check 12.4

DSM Controversies: The Battle for the Personality Disorders

C lu st e r C P ers ona l i t y D i s order s 471

You might also like