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Chapter 1: Description of Personality DisordersPersonality: enduring aspects of individual differences in our usual tendencies to think, feel, react,
and behave in different situations.
Abnormal personality/personality pathology: inability of persons to react flexibly and appropriate to
life’s challenges.
Personality disorder (PD): enduring pattern of inner experiences and specific behaviors that
deviates to a significant extent from the expectations of the individuals culture. It is pervasive and
inflexible, has an onset in adolescence or early adulthood, is relatively stable over time and leads to
distress or impairment. The problems involve personal identify and dissatisfaction and dysfunction in
interpersonal relationships and the self. They are usually considered as ego-syntonic, they experience
it as something belonging to them and being part of them.
Cluster A: odd/eccentric cluster:
- Paranoid PD: profound mistrust and suspiciousness regarding motives of other persons.
They are hypervigilant to hidden meanings and threats, but in a contentious and hostile way.
They tend to be secretive and hypersensitive to insults
- Schizoid PD: tend to lead withdrawn, isolated life. Are quietly distant and prefer to be on their
own, with minimal needs for relatedness. Tend to be low in energy and their emotional life is
rather flat and unexcitable. They tend to have few close interpersonal relationships if any and
they are emotionally detached in social situations. They are indifferent to criticism and praise.
- Schizotypal PD: peculiarity and eccentricity in thought and behavior. They often hold
unusual, sometimes magical, idiosyncratic beliefs.
Cluster B: dramatic cluster:
- Antisocial PD (ASPD): tend to disregard rights of others and are prone to unethical behavior.
Often associated with drug and alcohol problems and criminal behavior. Tend to be
irresponsible, and do not learn from previous mistakes. Can be quite aggressive and
impulsive, but there are also more cunning and manipulative variations. Often remorse and
guilt are absent for the negative consequences their behavior may have for others.
- Borderline PD (BPD): instability across multiple domains, including affect, interpersonal
relationships and self-image. They can be extremely angry at one moment, despondent the
next and these intense mood shifts are hard to predict and often short-lived. Fears of
abandonment. Associated with self-destructive impulsivity. Sense of self is compromised.
- Histrionic PD: lability and shallowness of their affect. They may quickly change from being
very sad to very cheerful, and express both feelings equally dramatically. These feelings may
seem unreal or shallow to others. They seek to be the center of attention and are unhappy
when they are not. They may be overly emotionally expressive or use their appearance. Quite
extroverted and tend to perceive their relationships as more special than others do.
- Narcissistic PD: self-centeredness and preoccupation with success, achievement and
greatness. Demand admiration and often experienced by others as arrogant. They tend to
have little empathy for others in relationships and may be prone to exploitative behavior.
Cluster C: anxious cluster:
- Avoidant PD: sensitivity to criticism, disapproval, and rejection. Tend to avoid interpersonal
contact and to harbor feelings of inferiority about their abilities and appearance, and feel
mistrustful towards and alienated from other people. Their mood is generally anxious.
- Dependent PD: excessive needs for guidance, reassurance and assistance. Tend to feel
incompetent and lack self-confidence when it comes to many everyday choices, chores and
responsibilities. May impress as rather immature. Believe they cannot manage on their own
and fear being alone. They become highly needy and submissive in interpersonal
relationships.
- Obsessive-compulsive PD: behavioral discipline, counterproductive preoccupation with
details and deep-felt obedience to rules and regulations. They tend to be perfectionist and
rigid. High value on being controlled, typically at the expense of openness and flexibility.
Classification of ICD-11: characterized by problems in functioning of aspects of self and/or
interpersonal dysfunction that have persisted over an extended period of time. Disturbance manifests
in patterns of cognition, emotional experience, emotional expression, and behavior that are
maladaptive and is manifest across a range of personal and social situations. The patterns of
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,behavior are not developmentally appropriate and cannot be explained primarily by social or cultural
factors, including socio-political conflict. Disturbance is associated with substantial distress or
significant impairment in important areas of functioning. 6 different prototypes:
1. Negative affectivity in PD or personality difficulty: prominent feature is experiencing a broad
range of negative emotions. linked to avoidant PD
2. Detachment in PD or personality difficulty: prominent feature is to maintain interpersonal
distance and emotional distance. linked to schizotypal PD
3. Dissociality in PD or personality difficulty: disregard for rights and feelings of others, mainly
expressed by self-centeredness and lack of empathy. linked to antisocial PD
4. Disinhibition trait domain: tendency to act rashly based on immediate external or internal
stimuli, without consideration of potential negative consequences. linked to narcissistic PD
5. Anankastic PD or personality difficulty: narrow focus on one’s rigid standard of perfection and
of right and wrong, and on controlling one’s own and others’ behavior and controlling
situations to ensure conformity to these standards. linked to obsessive-compulsive PD
6. Borderline pattern: pervasive pattern of instability of interpersonal relationships, self-image,
affects and marked impulsivity. linked to borderline PD
Chapter 2: Diagnosis and Assessment
Categorical formulations imply that there should be an identifiable, non-arbitrary cut-off point to define
where normal personality ends and abnormal personality begins. Approaches to tackle this issue:
- Taxometrics: used to investigate whether latent structures are categorical (taxonic) or
dimensional. Evidence for dimensional structure of cluster C, paranoid and borderline PDs.
- Define personality pathology by nature and associated domains of impaired functioning. E.g.:
o Three step criterion by Millon: functional inflexibility, self-defeating circles and
tenuous stability under stress.
o Tripartite criterion (Livesly): failure of self-system to establish stable and integrated
representation of self/others, maladaptive functioning in interpersonal relationships,
and failure to develop and maintain prosocial and cooperative relationships.
Categories are easier to define and can be clearly described, they guide clinical decision making and
they can serve as convenient and efficient shorthand communication.
To diagnose PD, the DSM-5 requires a two-step procedure:
1. One has to establish whether patient meets the general criteria for a PD.
2. Clinician has to evaluate each specific criteria for presence or absence, count the presence of
the diagnostic criteria and compare the total number of them to the preset cut-off for each PD.
Discussion about the DSM criteria:
- Polythetic criteria: no single criterion is absolutely required or essential to the disorder, but
they are alternative definers of the disorder, with a certain critical minimum number for the
diagnosis to be present. Easy to work with due to heterogeneity within diagnostic classes and
it gives the possibility to capture a wide range of psychopathology. However, individual criteria
seem to differ in their sensitivity and specificity.
- Symptoms versus traits: PD is a mixture of symptoms, behavioral expressions of traits and
traits themselves. The emphasis differs between PDs. An advantage of operationalized
behavioral criteria is that minimal inference is needed on the part of the diagnostician, which
promotes interrater reliability, but they tend to favor behavioral expressions at expense of
characteristic patterns of inner experience (e.g. motivation of behavior).
- Comorbidity: comorbidity across PD diagnoses and heterogeneity within diagnosis.
To differentiate between disorders it is important to take into account inner motivation for behaviors.
Two step procedure (Widiger and Samuel) for diagnostic process:
1. Self-report instrument erring on side of the false positives is administered to narrow down the
range of potential PDs.
2. This information is used to select relevant parts of a structured interview. The interview then
comprehensively assesses the presence or absence of the selected PDs.
Dimensional models view personality traits as continuously distributed in populations, and personality
psychopathology as extreme variants of these personality traits. Two models:
- Five-Factor model (FFM) or Big Five: Neuroticism, extraversion, openness to experience,
conscientiousness and agreeableness. Hierarchically structured. Some evidence that
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, covariation between dimensions of FFM match pattern of comorbidity among PDs.
Limitations:
o Not all factors are found to be equal.
o Questioned whether it adequately captures more severe manifestations of personality
psychopathology.
- Alternative Model of Personality Disorders (AMPD) of DSM-5: two key concepts are
integrated: level of personality functioning and dimensional model of 25 personality traits
based on five domains (negative affectivity, detachment, antagonism, disinhibited and
psychoticism). It is assumed that PDs are characterized by problems in self-functioning
(consisting of identity and self-direction) and interpersonal functioning (consisting of empathy
and intimacy).
Semi-structured interviews (gold standard for assessing PDs). Provide specific, carefully selected
questions to operationalize each diagnostic criterion. Fixed format ensures comprehensive
assessment and promotes consistency across clinicians, but it also leaves room for the clinician to
decide whether or not the patient’s answers constitute sufficient evidence for criterion in question.
However, they take considerable time and require specialized training in administration, scoring, and
interpretation.
Self-report instruments have some strengths: efficiency, comprehensive domain coverage, availability
of normative data and can detect response sets and biases (if they do contain validity scales to do so)
However, personality pathology is ego-syntonic, and patients with PD may thus be liable to produce
biased self-portrayals.
Personality psychopathology can be defined as impairment in integration of personality. In this
approach there are two relevant aspects: chronic interpersonal problems and an impaired sense of
self or identity.
Kernberg modeled personality psychopathology by identifying the severity of mental illness, he
labeled it by the term personality organizations. Three basic levels of personality functions (severity):
1. Neurotic: healthiest personality organizations
2. Borderline: less healthy personality organizations
3. Psychotic: most severely ill and disordered
To assess the level of personality organization three aspects need to be evaluated: reality testing of
the person, integrated self and maturity level of the person’s defenses (coping).
Chapter 3: Epidemiology and course
Prevalence of Cluster A: 1.1% paranoid, 0.9% schizoid and 0.6% schizotypal
They are more common among individuals who are separated, unemployed and a lower social class.
Prevalence of Cluster B: 1.8% histrionic, 1.2% antisocial, 1.1% borderline and 0.4% narcissistic
More common in younger age groups, in individuals who are separated and of lower social class.
A subgroup of individuals with antisocial behavior are described as psychopaths: manipulative,
impulsive, showing superficial charm, having shallow affect, and showing a lack of remorse or guilt for
their antisocial behavior. Approximately 1% of the general population.
Prevalence of cluster C: 1.5% avoidant, 0.8% dependent and 3.2% obsessive compulsive
Hardly associated with demographic characteristics.
Only a small proportion of individuals with a PD (<10%) have severe PD.
Severe PD: covering many different personality categories and often several clusters of PD, including
at least one disorder from cluster B.
Course of PDs
- Borderline: most severe in patients’ mid-20s, gradually improves over a long time period. In
clinical samples, patients with BPD are more likely to seek treatment than patients with
another PD. Factors associated with poor outcome and suicide are parental emotional and
sexual abuse, adult adversity, a family history of completed suicide and poor social cohesion.
- Antisocial: delinquency in youth predicts antisocial behavior in adulthood, but most individuals
with recurrent antisocial behavior as a child/adolescent do not persist in antisocial behavior as
adults. The strongest predictors of criminal or violent behavior in adulthood are parental
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, education, poor parental supervision, poor child-rearing skills and large family size.
Individuals may mature out of the disorder over a long time period. Factors associated with
good outcome are job stability, no alcohol abuse, and a stable marriage arrangement. Early
substance abuse and more severely antisocial behavior are associated with worse late life
symptoms.
- Cluster-C: anxious cluster of PD becomes more pronounced with increasing age.
PD traits tend to be only moderately stable during adolescence and that from adolescence through
adulthood maturation and socialization may contribute to the gradual development of less and less
problematic patterns of personality.
PD are associated with impairments in occupational, relationship and leisure functioning.
Comorbidity: coexistence of two or more syndrome disorders and PDs in one patient.
- High level of comorbidity among various PDs and considerable within cluster comorbidity.
- Comorbidity with mental disorders. 50% of individuals with a PD has at least one lifetime
mental disorder. 50% of individuals with a lifetime mental disorder also has one or more PD
- Rates of PD are high for patients treated for drug and alcohol abuse. Particular high for
borderline (may be due to shared aetiological factors) and antisocial PD (shared genetic risk
and neurobehavioral disinhibition).
- For problem gambles the prevalence of PD is high.
- Half of the patients with an anxiety or mood disorder have a comorbid PD.
Theoretical models to explain co-occurrence:
- Vulnerability model: PD predisposes to development of syndrome disorders: e.g., cluster-C
for anxiety and mood disorders.
- Continuity model: PD are subclinical manifestations of a slowly developing syndrome
disorder: e.g., borderline pathology may predispose individuals to have a major depression
- Complication model: PD develops as a result of an enduring syndrome disorder: e.g.,
anxiety disorder in childhood enhances risk for a avoidant PD later in life.
- Coeffect or shared risk model: PD and clinical disorders are two separate structures, but
co-occur as a result of a third common factor or causal process: e.g., abuse disorder and
BPD due to hereditary disinhibition problems or physical and sexual abuse, abusive
parenting.
- Attenuation model: both disorders are alternative expressions of the same genetic or
constitutional liability. BPD and mood disorders may occupy different points along a common
affective or depressive spectrum.
Chapter 4: Risk Factors for Personality Disorders
Genetic factors and environmental influence contribute to the determination of human personality
traits. Four factors underly biology of PD:
- Anxious/emotional dysregulation
- Antisocial
- Social withdrawal
- Anankastic/compulsive
Heritability: percentage of the total variation in the phenotype.
Cluster A: there is a genetic contribution, but heritability is slightly less than for cluster B. Schizotypal
PD is genetically linked and is associated with an increased risk for schizophrenia.
Cluster B:
- Antisocial PD: estimated heritability at 41%. Psychopathy is highly heritable with a substantial
nonshared environmental component and antisocial behavior is heritable without hardly any
shared environmental components. No specific genes found.
- Borderline: estimated heritability at 37%. Runs in families. Environmental life events moderate
the genetic and environmental interaction on borderline PD features. No specific genes found.
- Histrionic PD: estimated heritability at 31%
- Narcissistic PD: estimated heritability at 25%
Cluster C: evidence for a genetic basis of behavioral inhibition in childhood, which may be considered
a precursor of social anxiety in adolescence and, in more severe cases, avoidant PD in adulthood.
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