This is an extensive summary for the 2nd year course Personality Disorders (BSc Psychology at TiU) based on the book "The Oxford Handbook of Personality Disorders" by Widiger.
Personality Disorders
Contents
Chapter 3: Diagnosis and DSM-5: Work in Progress (pp. 35- 57) ..................................................... 4
1. Dimensional Versus Categorical Models ......................................................................................... 4
2. Developing a Hybrid Model of Personality Disorders ..................................................................... 5
3. DSM-5 Personality Disorder Model Proposed for Field Testing ...................................................... 6
4. Clinical Application .......................................................................................................................... 8
5. Critiques of Proposed Model......................................................................................................... 10
Chapter 5: An Integration of Normal and Abnormal Personality Structure: The Five-Factor Model
(pp. 82-107) ............................................................................................................................... 11
1. Five-Factor Model.......................................................................................................................... 11
2. Five-Factor Model and Personality Disorders ............................................................................... 13
3. Five-Factor Model Diagnosis of Personality Disorder ................................................................... 14
4. Advantages of a Five-Factor Model of Personality Disorder ......................................................... 14
5. The Five-Factor Model and the DSM ............................................................................................. 15
Chapter 9: Epidemiology (pp. 186-205) ....................................................................................... 17
Chapter 11: Axis II Comorbidity (pp. 219-236) ............................................................................. 17
1. Personality Disorder Comorbidity in Epidemiological Samples .................................................... 17
2. Personality Disorder Comorbidity in Clinical Samples .................................................................. 19
3. Personality Disorder Comorbidity in Special Populations ............................................................. 21
4. Summary of the Personality Disorder Comorbidity Study Results ............................................... 23
5. The Meaning of Comorbidity Among Personality Disorders ......................................................... 23
Chapter 12: The Relationship of Personality Disorders and Axis I Clinical Disorders (pp. 237- 259) 24
1. Schizotypal Personality Disorder ................................................................................................... 24
2. Avoidant Personality Disorder....................................................................................................... 25
3. Antisocial Personality Disorder ..................................................................................................... 25
4. Obsessive-Compulsive Personality Disorder ................................................................................. 26
5. Borderline Personality Disorder .................................................................................................... 26
Chapter 14: Course of Personality Disorder (pp. 275-295) ............................................................ 27
1. Conceptual and Methodological Issues......................................................................................... 27
2. Contemporary Longitudinal Studies of Course in Personality Disorders ...................................... 28
Chapter 15: Neurobiological Contributions (pp. 299-324)............................................................. 31
1. Quantitative Phenotypes of Personality ....................................................................................... 31
2. Heritability of Personality Disorders ............................................................................................. 31
3. Cluster A ........................................................................................................................................ 31
, 4. Cluster B ........................................................................................................................................ 33
5. Cluster C......................................................................................................................................... 35
Chapter 16: Cognitive Contributions to Personality Disorders (pp. 325-344) ................................. 35
1. Schemas ......................................................................................................................................... 35
2. Schema Modes .............................................................................................................................. 38
3. Cognitive Biases ............................................................................................................................. 38
4. Dichotomous Thinking ................................................................................................................... 39
5. Implicit Assessment of Cognitive Concepts ................................................................................... 39
Chapter 18: A Contemporary Interpersonal Model of Personality Pathology and Personality
Disorder (pp. 372-398) ................................................................................................................ 40
1. Interpersonal Psychology and Personality Psychopathology ........................................................ 40
2. Definition and Description of Personality Psychopathology ......................................................... 40
3. Contemporary Assumptions of Interpersonal Theory................................................................... 40
4. Key Concepts of Interpersonal Theory: I. Describing Interpersonal Themes and Dynamics ........ 42
5. Key Concepts of Interpersonal Theory: II. Development, Motivation, and Regulation ............... 46
6. Clinical Applications....................................................................................................................... 47
Chapter 19: Pathology of Personality Disorder: An Integrative Conceptualization (pp. 399-406) ... 49
1. Temperament, Traits, and Personality Disorders.......................................................................... 49
2. Traits, Disorders, and Prevalence .................................................................................................. 50
3. Biological Factors in Personality Disorders ................................................................................... 50
4. Psychological and Social Factors ................................................................................................... 50
5. Social Factors in Personality Disorders .......................................................................................... 50
6. An Integrative and Interactive Model of Personality Disorder ..................................................... 51
Chapter 20: Borderline Personality Disorder (pp. 409-436) .......................................................... 51
1. Clinical Aspects .............................................................................................................................. 51
2. Comorbidity ................................................................................................................................... 52
3. Epidemiology ................................................................................................................................. 53
4. Etiology and Risk Factors ............................................................................................................... 54
5. Psychological and Neurobiological Aspects of Borderline Personality Disorder........................... 56
6. An Integrated Perspective ............................................................................................................. 59
Chapter 21: Schizotypal Personality Disorder (pp. 437-477) ......................................................... 59
1. Historical and Conceptual Roots of Schizotypal Personality Disorder .......................................... 60
2. Diagnostic Classification of Schizotypal Personality Disorder ....................................................... 61
3. Impairment, Epidemiology, Course, and Comorbidity in STPD ..................................................... 61
4. Multidimensionality of Schizotypal Personality Disorder ............................................................. 62
5. Five-Factor Model and Schizotypal Personality Disorder .............................................................. 63
6. Etiology of Schizotypal Personality Disorder ................................................................................. 63
,Chapter 22: Psychopathy (pp. 478-504) ....................................................................................... 67
1. Description and Diagnosis ............................................................................................................. 67
2. Psychopathy and Crime ................................................................................................................. 70
3. Representation of FFM Agreeableness and Conscientiousness Traits in Terms of the Four-Factor
Model of Psychopathy ....................................................................................................................... 71
4. APA Diagnostic Manual ................................................................................................................. 71
5. Etiology .......................................................................................................................................... 71
6. Epidemiology ................................................................................................................................. 72
7. Course ............................................................................................................................................ 72
8. Treatment ...................................................................................................................................... 72
9. Cognitive/ Affective Neuroscience ................................................................................................ 73
Chapter 23: Dependent Personality Disorder (pp. 505-526) ......................................................... 73
1. The Evolution of Dependent Personality Disorder ........................................................................ 73
2. Current Diagnostic Frameworks .................................................................................................... 74
3. DPD Assessment Methods ............................................................................................................ 75
4. Epidemiology, Differential Diagnosis, and Comorbidity................................................................ 76
5. Contemporary Theoretical Perspectives ....................................................................................... 76
6. Treatment Strategies ..................................................................................................................... 78
Chapter 25: Avoidant Personality Disorder, Traits, and Type (pp. 549-565)................................... 81
1. Social Sensitivity and the Historical Roots of Avoidant Personality Disorder ............................... 81
2. The Modern Diagnosis of Avoidant Personality Disorder ............................................................. 81
3. Mechanisms and Theories ............................................................................................................. 83
Chapter 34: Cognitive Therapy for Personality Disorders (pp. 727-750) ........................................ 84
1. Dialectical Behaviour Therapy ....................................................................................................... 84
2. Cognitive Model of Personality Disorders ..................................................................................... 84
3. Schema Therapy ............................................................................................................................ 86
4. Similarities and Differences Between Cognitive and Schema Models .......................................... 89
5. Schema Therapy ............................................................................................................................ 89
6. Treatment Outcomes .................................................................................................................... 90
7. Personality Disorders and the Therapeutic Relationships ............................................................ 92
Chapter 36: Mentalization-Based Treatment of Borderline Personality Disorder (pp. 767-784) ..... 93
Chapter 37: Dialectical Behaviour Therapy of BPD and other PDs (pp. 785-793) ........................... 99
1. Biosocial Theory of BPD and Dramatic-Erratic Disorders ............................................................ 100
2. “Doing DBT” ................................................................................................................................. 100
3. Research Support ........................................................................................................................ 101
4. The Underdeveloped Dialectic .................................................................................................... 102
,Chapter 3: Diagnosis and DSM-5: Work in Progress (pp. 35- 57)
− A new hybrid dimensional-categorical model for personality and personality disorder
assessment was proposed for the DSM-5
▪ Multiple reasons
→ Lack of specificity in the DSM-IV-TR definition of personality disorder
→ Inadequate representation of personality disorder severity and arbitrary
thresholds for diagnosis
→ Excessive comorbidity among personality disorders
→ Limited validity for some existing types
→ Heterogeneity within types
→ Instability of current personality disorder criteria sets
− Question whether mental disorders, including personality disorders, should be represented
by sets of dimensions of psychopathology and other features rather than by multiple
categories
− Personality disorders were supposed to be a test case for the return to a dimensional
approach to the diagnosis of mental disorders in DSM-5
1. Dimensional Versus Categorical Models
− Problems with the current categorical model
▪ Excessive co-occurrence among personality disorders diagnosed with the categorical
model
→ Most patients diagnosed with personality disorders meet criteria for more
than one
▪ Extreme heterogeneity among patients receiving the same diagnosis
▪ No empirical rationales for setting the boundaries between pathological and
“normal” personality functioning
▪ Most frequently used personality disorder diagnosis is personality disorder not
otherwise specified (PDNOS)
→ Patient is considered to have a personality disorder but doesn’t meet full
criteria for any one of the types
→ Categorical system may not cover the full domain of personality
psychopathology adequately
− Dimensional models make the co-occurrence of personality disorders and their
heterogeneity more rational
▪ Include multiple dimensions that are continua on all of which people can vary
− Dimensional models are unfamiliar and more difficult to use
▪ 30 dimensions (e.g. five factor model) or more may be necessary to fully describe a
person’s personality
− There’s little empirical information on the treatment or other clinical implications of
dimensional scale elevations and where to set cut points to maximize their utility
− Alternative proposals for dimensional models of personality disorders
▪ Dimensional representations of existing personality disorder constructs
→ Example: convert personality disorder into a 6-point scale ranging from
absent traits to prototypic disorder; significant personality traits and
subthreshold disorders could be noted, in addition to full diagnoses
, → Example: Person-centered dimensional system: protoype matching
approach; patient is compared to a description of prototypic patient with
each disorder
▪ Dimensional reorganizations of diagnostic criteria
→ Assessment model of the Schedule for Nonadaptive and Adaptive Personality
(SNAP); three higher order factors: negative temperament, positive
temperament, and disinhibition; 12 lower order trait scales measuring traits
such as dependency, aggression, and impulsivity
→ Dimensional Assessment of Personality Pathology (DAPP); broad domains of
emotional dysregulation, dissocial behaviour, inhibition, and compulsivity; 28
lower order, primary traits
▪ Integration of Axes II and I via common psychopathological spectra
→ Siever and Davis: fundamental dimensions of cognitive/ perceptual
disturbance, affective instability, impulsivity, and anxiety
→ Another model hypothesizes only two fundamental dimensions:
internalization and externalization
▪ Integration of Axis II with dimensional models of general personality structure
→ Five-Factor Model (FFM)
→ Personality disorders, in general, would be characterized by high neuroticism
→ BPD: low agreeableness, high neuroticism
→ Some research has suggested that it’s easier to distinguish personality
disorders from normality using these models than to distinguish specific
personality disorders from each other
− Attempt to synthesize all models into an overarching dimensional model
▪ E.g. alternative models could be integrated over four levels of specificity
→ Highest level: internalization and externalization
→ Blow: 3-5 broad domains of personality functioning (i.e. extroversion vs.
introversion; antagonism vs. compliance; impulsivity vs. constraint;
emotional dysregulation vs. emotional stability; unconventionality vs. closed
to experience
→ Below: a number of lower order traits, each with behaviourally specific
diagnostic criteria
2. Developing a Hybrid Model of Personality Disorders
− Personality disorders show consistency as syndromes over time but rates of improvement
that are inconsistent with their DSM definitions
▪ Functional impairment is more stable than personality psychopathology itself
▪ Personality traits are more stable than personality disorders
− Personality disorders may be best conceptualized as hybrids of more stable personality traits
and less stable symptomatic behaviors
▪ Defining the core features of personality disorders (distinct from personality traits) is
a high priority
→ E.g. disturbance of self-other representations
→ To meet the criteria for a certain personality disorder, a patient would need
to meet the generic criteria for a personality disorder and to have extreme
levels on a number of prototypic traits
− Recent studies support a hybrid model of personality psychopathology consisting of ratings
of bother disorder and trait constructs
,3. DSM-5 Personality Disorder Model Proposed for Field Testing
− Original hybrid model consisted of four parts
▪ A severity rating of levels of impairment in personality functioning
▪ Narrative prototypes for five personality disorder types
▪ A six-domain/ thirty-seven-facet trait rating system
▪ A revised definition and general criteria for personality disorder
− Has been revised twice
▪ First revision: ratings from the first three assessments were combined to comprise
the essential criteria for a personality disorder
→ A rating of mild impairment or greater on the Levels of Personality
functioning (criterion A), associated with a “good match” or a “very good
match” to a Personality Disorder Type or with a rating of “quite a bit” or
“extremely” descriptive on one or more Personality Trait Domains (criterion
B)
▪ Second revision: diagnostic criteria for six specific personality disorder types to
replace the narrative prototypes
→ Category of personality disorder trait specified, consisting of core
impairments in personality functioning and pathological personality traits
− Levels of personality functioning are based on the severity of disturbances in self and
interpersonal functioning
▪ Disturbances in thinking about the self: identity and self-directedness
▪ Interpersonal disturbances: empathy and intimacy
3.1. Rationales for Proposed Changes
− Lack of specificity in the DSM definition of personality disorder
− Inadequate representation of personality disorder severity
− Arbitrary thresholds for diagnosis
− Excessive comorbidity among personality disorders
▪ Reduction in the number of personality disorder types is expected to reduce
comorbidity
− Limited validity for some existing types
− Heterogeneity within types
▪ Addition of traits facilitates the heterogeneity within types
− Instability of current personality disorder criteria sets
▪ Addition of traits is expected to increase diagnostic stability
− The current general criteria for personality disorder aren’t empirically based and aren’t
sufficiently specific to personality pathology
▪ The requirement of core impairments in self and interpersonal functioning helps to
distinguish personality pathology from other disorders
▪ The use of traits in conjunction with core impairments in personality functioning to
diagnose “personality disorder trait-specified” reduces the need for PDNOS
3.2. Severity of Impairment in Personality Functioning
− Generalized severity may be the most important single predictor of concurrent and
prospective dysfunction in assessing personality psychopathology
, ▪ Personality disorders are optimally characterized by a generalized personality
severity continuum
→ Additional specification of stylistic elements, derived from personality
disorder symptom constellations and personality traits
▪ Severity level is essential to any dimensional system for assessing personality
psychopathology
− Personality disorders are associated with distorted thinking about self and others
▪ Maladaptive patterns of mentally representing the self and others serve as
substrates for personality psychopathology
▪ A self-other dimensional perspective has an empirical basis and significant clinical
utility
− Continuum of impairment in self and interpersonal functioning
▪ Greater impairment in personality functioning predict the presence of a personality
disorder, of more severe personality disorder diagnoses and of personality disorder
comorbidity
3.3. Personality Disorder Types
− Six specific personality disorders
▪ Antisocial, borderline, schizotypal, avoidant, obsessive-compulsive, and narcissistic
personality disorder
− PDNOS becomes personality disorder trait-specific (PDTS)
▪ Represented by significant impairment on the Levels of Personality Functioning
continuum, combined with descriptive specification of patients’ unique pathological
personality trait profiles
− Hybrid model of personality psychopathology consisting of both disorder and trait constructs
▪ Personality traits alone, esp. in the absence of clinical context, are too ambiguous for
clinicians to interpret
3.4. Personality Traits
− Five higher order domains
▪ Negative affectivity, detachment, antagonism, disinhibition, and psychoticism
▪ Each is comprised of three to seven (total =25) lower order trait facets
− Trait-based diagnostic system helps to resolve excessive comorbidity
▪ The personality traits that comprise personality disorders overlap across diagnoses
▪ Traits can combine in virtually an infinite number of ways
→ A personality disorder diagnostic system that’s trait based provides a means
to describe the personality (normal or abnormal) of every patient
− DSM criteria are a mix of more stable trait-like criteria and less stable state-like criteria
▪ Personality disorder diagnoses are less stable than their trait components
▪ Basing diagnostic criteria on more stable traits and considering the more state-like
features that occur in individuals with PDs to be associated symptoms would
eliminate the conceptual-empirical gap with regards to temporal stability
3.5. General Criteria for Personality Disorder
− Failure to develop coherent sense of self or identity and chronic interpersonal dysfunction
▪ Integrity of self-concept
→ Differentiation of self-understanding or self-knowledge
, ▪ Identity integration
→ Integration of this information into a coherent identity
▪ Self-directedness
→ The ability to set and attain satisfying and rewarding personal goals that give
direction, meaning, and purpose to life
▪ Empathy/ Intimacy
▪ Cooperativeness
▪ Complex and integrated representations of others
− Criteria were simplified!
4. Clinical Application
− Decide whether a personality-related problem exists and how severe it is
▪ Characterize personality type according to proposed criteria
▪ Identify other important personality characteristics
− The levels of functioning and trait profile steps are informative regardless of whether
patients is believed to have a personality disorder
− Trait assessment is also needed to describe the trait profile of patients who have sufficient
personality psychopathology to receive a personality disorder diagnosis but don’t match one
of the six types
4.1. Assessment of Levels of Personality
Functioning
− Levels of Personality Functioning Scale
▪ 5-point rating scale of functional
impairment in the self and
interpersonal domains
▪ Any rating above zero is significant
and consistent with a personality
disorder
▪ The more severe the level of
impairment, the more likely the
person is to have a personality
disorder, and to receive multiple
diagnoses
4.2. Assessment of Personality Trait Domains and Facets
− Two kinds of trait ratings
▪ Domain ratings
→ Five domains
▪ Facet ratings
− 4-point rating scale
▪ 0 = very little or not at all descriptive
▪ 1= mildly descriptive
▪ 2 = moderately descriptive
, ▪ 3 = extremely descriptive
− A rating of 2 or greater on one or more of the personality trait domains in the presence of
impairment in personality functioning qualifies for a personality disorder diagnosis
▪ Exclusion criteria for the general criteria for personality disorder have to be met
− The most detailed trait profile is derived from the rating of the trait facets
▪ May be found in myriad combinations
▪ Convert a nonspecific PDNOS diagnosis into a specific personality disorder trait-
specified diagnosis
4.3. Assessment of the Criteria for Personality Disorder
− Three reasons for first assessing personality functioning and traits
▪ Even if a patient doesn’t have a personality disorder the descriptive information from
the other parts of the assessment can be clinically useful
▪ The assessment of levels of personality functioning and personality traits are needed
to rate the criteria and must precede them
, ▪ The various exclusion criteria are the most time-consuming and labour-intensive
parts of the assessment and require the most knowledge about patients and their
clinical histories
5. Critiques of Proposed Model
− Confusion about how the model works in practice
▪ Clinical application emphasizes the flexible nature of the assessment, whereby
clinicians can describe a patient’s personality problems with increasing degrees of a
specificity, depending on the need to do so, as well as on available time and
information
− Critiques have almost universally been against the deletion of any of the DSM personality
disorder types
▪ Existing types have clinical utility and treatment relevance
▪ Empirical basis for retaining vs. deleting types has been questioned
→ Limited research doesn’t mean lack of utility
▪ Deletion of types is expected to result in loss of coverage of personality
psychopathology
− Most critiques believe that the originally proposed linking of traits to types is ambiguous and
without an empirical basis
▪ Traits should be rated separately from the types
− Proposed trait system has been criticized as unfamiliar to clinicians and unlikely to be used
because the traits lack an experiential or empirical basis for clinical salience
− Insufficient research base regarding cut points for diagnosis
− Traits are nonspecific
▪ The same trait may apply to many types
▪ Inherently ambiguous, static representations of personality
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