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9 Personality Disorders Chapter Objectives After reading this chapter, you should be able to:

• Describe what “personality” means.

• Explain how a personality can be disordered.

• Discuss the causes of personality disor ders.

• Explain how people with personality disor ders can be helped. © Laughing Stock/Corbis get81325_09_c09.indd 237 12/10/13 10:22 AM Section 9.1 Diagnosing Personality Disorders When we describe people who prefer spending a quiet night at home to attending a party as “introverted” or when we call ace fighter pilots “brave,” we are implying that their behav- ior is caused by their personality traits. (Why do fighter pilots take to the sky? Because they are brave.) Such trait-based explanations of behavior have an intuitive a\ ppeal: They fit our beliefs about human nature. Some people are naturally shy; others, gregarious. Some are timid; others are brave. According to the DSM–5, the sum of an individual’s traits con - stitutes his or her personality, a set of “enduring patterns of perceiving, relating to, and thinking about the environment and oneself, which are exhibited in a wide range of impor - tant social and personal contexts” (American Psychiatric Association [APA], 2013, p. 647).

Experience tells us that there is at least some consistency to people’s behavior and that maladaptive personality traits can cause distress. The DSM–5 considers people with these maladaptive personality traits to have a personality disorder: an enduring pattern of inner experience and behavior that deviates markedly from the expectations of an indi - vidual’s culture. Although both the DSM–5 and the International Statistical Classification of Diseases and Related Health Problems ( ICD-9-CM) include a diagnostic category for personality disorders, the idea that a personality can be disordered is steeped in contro - versy (Widiger & Trull, 2007; Sutker, 1994). For example, do career criminals really suffer from a personality disorder, or have they simply made a choice about how they wish to lead their lives? Experts have differing opinions on this issue. They also disagree about which personality traits are debilitating enough to constitute a disorder. Perhaps the fun - damental problem with personality disorders is that they have so little in common. The personality disorders covered in the DSM–5 include excessive shyness, self-absorption, and schizophrenic-like behaviors, and there seems little logical, empirical, or theoretical justification for grouping such disparate “disorders” into a single category.

9.1 Diagnosing Personality Disorders In contrast with clinical disorders such as schizophrenia, personality disorders are sup - posed to arise from enduring character traits. Taken to extremes, practically any personal - ity trait can impair social functioning and create problems. Shy people may lead restricted social lives; those who are extremely aggressive may get into trouble with the law. Because any personality trait, taken to extremes, can produce difficulties in living, some psycholo - gists prefer to conceptualize personality disorders as the unlucky result of falling at the extreme of some personality trait—too shy, too hostile, too self-centered, and so on (Widi- ger & Trull, 2007).

All personality disorders begin to become apparent during adolescence or early on in adulthood, although some do not make their first appearance until adulth\ ood (APA, 2013).

Once these disorders appear, they change little over the years, and they affect behavior in numerous situations.

Some personality disorders— antisocial personality disorder , for example—do not nor- mally cause the individuals who have them personal distress. Instead, other people, especially their victims, feel the anguish. In such cases, diagnosis dep\ ends not on the self-perceptions of the individuals concerned but on the effects of their behavior on oth - ers. This is not unusual in abnormal psychology. get81325_09_c09.indd 238 12/10/13 10:22 AM CHAPTER 9 Section 9.1 Diagnosing Personality Disorders Categories Versus Dimensions Because each of us can be described by noting where we fall on one or more personal- ity traits, or “dimensions,” some psychologists have advocated a dimensional approach to diagnosing personality disorders. Instead of employing the “exclusional” diagnostic categories of the DSM–5—a person either meets the diagnostic criteria for a personality disorder or does not meet them—the dimensional approach to diagnosis describes peo - ple using a standard set of personality dimensions. The DSM-5 includes the dimensional model in Section III, “Emerging Measures and Models.” This section includes proposed diagnostic criteria for this new model. Perhaps this model will replace the current person - ality disorders model in the DSM’s next revision.

The advantage of the dimensional approach is that it avoids pigeonholing people into nar - row categorical boxes, thereby allowing them to be described in richer and more complex ways. Over the years, several attempts have been made to develop dimensi\ onal systems for describing personality (Widiger & Trull, 2007; Cloninger, Bayon, & Przybeck, 1997).

These have not had wide consensus because psychologists have not been ab\ le to agree on which personality dimensions to use for this purpose (Widiger, 1991). One more widely accepted model is the five-factor model. People are rated on the following dimensions, and the combination determines the reasons why we are all so different: extroversion, agree - ableness, conscientiousness, neuroticism, and openness to experience (Goldberg, 1993; Costa & McCrae, 2005).

Case Study: Eric Cooper, Part 1 Excerpt From the Assessment of Eric Cooper by the Court Psychologist MUNICIPAL COURT Psychological Assessment Date: December 4, 2011 Client: Eric Cooper Instruments Minnesota Multiphasic Personality Inventory-2 (MMPI-2) Thematic Apperception Test (TAT) Wechsler Adult Intelligence Scale (WAIS-IV) Psychopathy Checklist-Revised (PCL-R) Clinical interview Psychologist: Dr. Aaron Lusted Referral: Judge Warren Reason for Referral: Judge Warren requested this presentencing report on Eric Cooper, a 30-year-old man who has been previously convicted of several crimes, including robbery and assault.

(continued) get81325_09_c09.indd 239 12/10/13 10:22 AM CHAPTER 9 Section 9.1 Diagnosing Personality Disorders Behavioral Observations: Although the client was cooperative and friendly, he rarely made direct eye contact. Also, despite his general good mood, he would swear out loud and pound the table whenever he missed any questions on the intelligence test. There were no signs of delirium or alcohol intoxication, and the client was able to complete all tests with little prompting. The client reported that he had tried to rob a bank, while drunk, in order to pay his bills. He expressed concern that a guard was hurt during the attempted robbery and said he was pleased that no permanent damage was done. He asked whether there was a cure for his problem but when asked what his problem was, he said, “Bad luck, mostly.” Social History: [See Document 10.3, Social Work Report.] Intellectual Assessment: The client’s scores on the WAIS-IV intelligence test place him in the above-average range of intelligence. His scores on the verbal scales were higher, in general, than his scores on the performance scale. This is not surprising in someone with the client’s educational achievement.

Personality Assessment: The validity scales of the MMPI-2 were all in the average range, indicating that the test profile could be safely interpreted. The main feature of the profile was an elevated score on the psychopathic deviate scale. The client’s responses revealed a self-centered person, whose own feelings always take precedence over those of other people, and a person who lacks empathy for the feelings and rights of others. He also has a strong tendency to act impulsively. . . . The client’s TAT responses reflected a preoccupation with violence—there were numerous references to death, blood, and corpses—but no mention about how the characters in the story might respond or be affected by the violence. It was as if the client could not imagine what might be going through the heads of his own characters. . . . The client’s responses to the Psychopathy Checklist-Revised (which assesses manipu - lative behavior and impulsivity) were those found among people who have been labeled “psycho - paths”—people who lack empathy and are likely to use violence to achieve their goals.

Based on the test results, behavioral observations, and my clinical interview, it appears that the client is a person who has little empathy for or understanding of other people. He thinks mainly of himself, his needs, and his feelings. He is prepared to use violence to further his ends. Because he lacks empa- thy, the client is almost certain to have trouble in personal relationships. In addition, his self-centered attitude as well as his impulsiveness and willingness to use violence are likely to bring him into contin- ued conflict with the law.

Diagnostic Considerations: The client meets the DSM–5 criteria for antisocial personality disorder; he also meets many of the criteria for borderline personality disorder. In addition, he seems to have a pattern of substance abuse. He recently experienced stress from business problems, but his global functioning is only mildly impaired, and he is capable of a high level of psychological functioning.

Alcohol Use Disorder Antisocial personality disorder (possible borderline personality disorder as provisional secondary diagnosis) Case Study (continued) get81325_09_c09.indd 240 12/10/13 10:22 AM CHAPTER 9 Section 9.1 Diagnosing Personality Disorders Types of Personality Disorders The precise number of personality disorders and the names of these disorders have varied from one version of the DSM to the next. Although the DSM–5 has settled on the ten personality disor- ders listed in Table 9.1, it is important to keep in mind that these ten disorders represent only a sample of the total number of potential personal- ity disorders.

Table 9.1: DSM–5 personality disorders Diagnostic term Primary personality characteristics Cluster A Paranoid personality Distrust and suspicion of others, poor social relations Schizoid personality Restricted range of emotions and unstable relationships Schizotypal personality Eccentric behavior, including cognitive distortions Cluster B Antisocial personality Disregard of the rights of other people Borderline personality Unstable relationships, poor self-image, impulsivity Histrionic personality Excessive emotional display and the pursuit of attention Narcissistic personality Grandiose feelings of superiority Cluster C Avoidant personality Socially sensitive, inhibited, feelings of inadequacy Dependent personality Submissive and needing the care of others Obsessive-compulsive personality Preoccupation with order and control Comstock/Thinkstock It is common for clinical disorders and personality disorders to be diagnosed simultaneously. For example, an individual may display signs of depression and avoidant personality disorder, which are two disorders that share the same symptoms. get81325_09_c09.indd 241 12/10/13 10:22 AM CHAPTER 9 Section 9.1 Diagnosing Personality Disorders Diagnostic Reliability Clinicians have difficulty deciding which personality disorder diagnosis is appropriate for which individual. The problem is that the same diagnostic criteria can be applied to supposedly different disorders. Clinicians have no trouble agreeing that a person has poor social relations (one of the diagnostic criteria), but they do not agree about whether a person with poor social relations should be classified as having a borderline, schizoid, or avoidant personality disorder (each of which is marked by the same criterion—poor social relations). Similarly, hostility (another of the diagnostic criteria) is easy to recog- nize, but of little discriminatory value because it is a feature of more than half the person - ality disorders.

Also, given the overlapping diagnostic criteria, it is not surprising th\ at, as mentioned earlier, there is a high co-morbidity among personality disorders (Skodol, 2005). In fact, choosing between two or more personality disorders may be so difficult that clinicians may find it easier to simply give people both diagnoses.

Diagnostic Reliability and Validity The predictive value of the personality and impulse-control disorders is somewhat uncer - tain. Knowing that someone has a personality disorder tells us little about how different personalities develop. Predicting how a person will behave in any situation requires that we understand not only the person’s personality but also the social s\ ituation in which the behavior takes place (Mischel, 1997).

Diagnostic Biases Clinicians must be on the alert for potential biases in themselves when making any diagnosis, but personality disorders lend themselves to diagnostic biases. For example, dependence, submissiveness, and allowing one’s life to be directed by a spouse are all signs of a dependent personality disorder. However, they are also traits encouraged in females by many societies. If females adopt the dependent social role expected by their social group, are we really justified in calling their behavior a personality disorder? And gender biases are not the only ones that clinicians must avoid. Unless clinicians are care - ful, their evaluation of other people may also be biased by their own be\ liefs about or perceptions of social class, ethnicity, age, and education. As shown in the next section, each of these variables can bias clinical judgments about who is suffering from a person - ality disorder. get81325_09_c09.indd 242 12/10/13 10:22 AM CHAPTER 9 Section 9.2 Evolution of a Personality Disorder: From Psychopath to Antisocial Perso\ nality 9.2 Evolution of a Personality Disorder: From Psychopath to Antisocial Personality The idea that criminal behavior is inherited was a subject social reformers who hoped to create a more caring society loathed. What is the point of trying to improve the lot of disadvantaged people if their destiny is genetically predetermined? In the 19th cen- tury, however, social reformers were in the minority. Most professionals followed the psychiatrist Emil Kraepelin, who said that criminal behavior was largely genetic in ori - gin. Kraepelin grouped people who lied, cheated, committed crimes, and harmed oth - ers into a diagnostic category he called “constitutional psy- chopathic inferiority.” “Psy- chopaths” were people who behaved in an antisocial man - ner. The cause of their behavior was genetic (“constitutional”) and probably the result of some failure in evolutionary develop - ment (“inferiority”). Although he admitted that individuals considered to be psychopaths in one culture—terrorists, for example—might be hailed as freedom fighters in another culture, Kraepelin still believed that social causes were second- ary to genetics in the etiology of antisocial behavior.

Over the years, constitutional psychopathic inferiority was shortened (\ by dropping “con - stitutional” and “inferiority”) to psychopath, people who lack empathy, do not fear pun - ishment, and will continue to break the law even if capture and punishment are likely. The first DSM, published in 1952, abandoned the term psychopath entirely. Instead, it referred to a sociopathic personality, which meant that criminals are made, not born. This change in nomenclature signified the dominance of social theories of antisocial behavior: cri\ mi - nals are made, not born.

Moral Insanity Revived The term sociopath never entirely replaced psychopath. Indeed, psychopath was still a widely used diagnostic term when Hervey Cleckley published The Mask of Sanity in 1976.

Cleckley’s psychopaths were antisocial people who appeared “normal,” even to profes - sionals, but whose normality was really only a superficial “mask of sanity.” Beneath the surface, Cleckley argued, psychopaths were deeply disturbed. © Bettmann/CORBIS Commonly, psychopaths can be sociable, yet they often lack empathy. Serial killer Ted Bundy was often characterized as being charismatic and friendly. get81325_09_c09.indd 243 12/10/13 10:22 AM CHAPTER 9 Section 9.2 Evolution of a Personality Disorder: From Psychopath to Antisocial Perso\ nality Because of their mask of sanity, psychopaths initially make a good impression. They can be friendly, intelligent, and show no overt signs of a mental disorder. Yet they lead highly aberrant lives. They have dismal social relationships and disordered work histories, and they are often unreliable. On an impulse, they may give up a successful career to follow some momentary whim. Their projects, both legal and illegal, often turn out badly because, despite their intelligence, they fail to plan ahead. When confronted with evidence of their misbehavior, psychopaths first try to blame others. When this fails, they may admit\ their misdeeds and feign regret, but their remorse and concern for their victims are not genu- ine, and their misbehavior is often repeated. Punishment does not deter them. In fact, psychopathic people engage in antisocial behavior even when they are almost certain to be caught and punished. It is as if they cannot see the future. When they are apprehended, psychopaths remain self-centered. Some have even been known to ask employers for ref - erences after being fired for stealing.

Eric Cooper has many of the characteristics of Cleckley’s psychopaths\ . For examples from Eric’s life, see your e-book for Part 2 of his case study.

Cleckley’s Etiological Hypothesis: An Inability to Feel Emotions For Cleckley, the failure to learn from experience was a central clue to the cause of psy - chopathic behavior. To explain why psychopathic people failed to profit from experience, Cleckley hypothesized that they are unable to experience normal emotions. They pretend to feel regret, affection, and fear, but they are really like actors, who simulate emotions they are not really experiencing. Because they do not feel anxiety about future punish - ment, psychopaths continue to commit antisocial acts for which they have been punished in the past (Zuckerman, 1999; Silverstein, 2007).

DSM–IV Abandons Psychopathy The experimental data collected over the decades are remarkably consistent with Cleck- ley’s clinical observations (Hare, 1996; Hare & Neumann, 2006). People who meet his definition of psychopath act on their immediate instincts and seem not t\ o fear punish- ment. Not surprisingly, they are continuously in trouble. Despite these intriguing, and largely consistent, research findings, the DSM–IV abandoned both the term psycho- path and the term sociopath, replacing them with antisocial personality disorder , which remains in the DSM–5. The DSM–IV deliberately replaced Cleckley’s psychopath— a clearly deviant person—with a diagnostic category that is so genera\ l it can accommo - date practically anyone who behaves in an antisocial manner. Moreover, the new diagnos - tic criteria omit the hallmark of Cleckley’s concept of psychopathy—an inability to feel emotions.

Why the change? The main reason is the DSM–5’s attempt to make its diagnostic criteria as objective as possible. The DSM–5 criteria for antisocial personality focus on observable behaviors (such as impulsivity) and omit those that refer to presumed etiologies (such as a failure to feel emotions). Although the objective criteria strived for in the DSM–5 are an improvement over the subjective diagnostic criteria sometimes used in the past, it is curious that such a consistent body of psychological research has had so little effect on modern diagnostic practice. get81325_09_c09.indd 244 12/10/13 10:22 AM CHAPTER 9 Section 9.2 Evolution of a Personality Disorder: From Psychopath to Antisocial Perso\ nality The hallmark of the DSM–5’s antisocial personal- ity disorder is a flagrant disregard for the rights of other people. People with antisocial personality disorder are often irresponsible, impulsive, and untrustworthy.

Because only three of seven criteria need be met for the diagnosis of antisocial personality disor- der, the DSM–5 criteria can encompass the behav - iors of, among others in no particular order, con artists, thieves, career criminals, charlatans, cor - rupt politicians, even devious used car sales - people. Because the category is so broad, it tells us remarkably little about a person’s behavior.

People with an antisocial personality disorder can have markedly different demeanors. Some can be charming; others may be surly and aggressive.

In other words, despite its status as a disorder of “personality,” the antisocial personality label tells us little about a person’s temperament; it is really just a shorthand way of saying that a per - son engages in a habitual pattern of irresponsible behavior. Often, this behavior brings the person in contact with the law (Skodol, 2005). Nevertheless, it is important to note that an antisocial personal - ity is not the equivalent of criminality. Not all criminals have a psychological disorder and not all people who have antisocial personality disorder are criminals (Silverstein, 2007).

For a diagnosis of antisocial personality disorder, there must be evidence of a conduct disorder in childhood and an adult pattern of antisocial behavior that is evi\ dent by age 15. By insisting on such a lifelong pattern, the DSM–5 seems to have moved back in the direction of Kraepelin’s “constitutional psychopath,” who is eithe\ r born antisocial or who develops such tendencies early in life. In practice, the initial onset o\ f antisocial behavior is difficult to document (Ogloff, 2006). Objective information about a person’s childhood is rarely available, retrospective reports by others are often unreliable, and people sus - pected of being antisocial cannot be trusted to give an accurate history of their own lives.

Despite these uncertainties, the idea that people who are “psychopathic” are different from birth, or at least early childhood, is sometimes used to argue that they cannot help their actions—that they are simply suffering from an illness.

Prevalence and Course of Antisocial Personality Disorder Between 0.2% and 3.3% of the population, mainly men, meet the DSM–5 criteria for anti- social personality disorder (Zimmerman, Favrod, Trieu, & Pomini, 2005; APA, 2013).

Although the preponderance of men diagnosed with antisocial personality disorder may reflect a difference between the sexes, it may also be the result of stereotypical sex roles or of the clinician’s own biases (Morey, Alexander, & Boggs, 2005). In our society, men are expected to be aggressive and to take more risks than women. Men may be socially Adrian Neal/Lifesize/Thinkstock Because most antisocial behaviors occur by age 15, researchers believe a person with antisocial personality disorder is either born with the disorder or develops it early in life. get81325_09_c09.indd 245 12/10/13 10:23 AM CHAPTER 9 Section 9.2 Evolution of a Personality Disorder: From Psychopath to Antisocial Perso\ nality reinforced for behaving in ways consistent with at least some of the diagnostic\ criteria for antisocial personality disorder.

Figure 9.1: Are some cultures more antisocial than others?

In a cross-cultural study, teenagers were asked to write stories describing how imaginary characters would respond to various conflicts. About one-third of the responders from New Zealand, Australia, Northern Ireland, and the United States described violent responses, compared to less than one-fifth of the subjects from Korea, Sweden, and Mexico.

Source: Adapted from Archer and McDonald, 1995, as appears in Corner, R. J. 2007. Abnormal Psychology. 6e. NY: Worth Publishers, Fig. 16.3, p. 473. Reprinted by permission. Percentage with Violence in Stories Country Canada England 05101520 25 30 35 40 45 50 Japan Sw eden Mexico Fr ance Ko rea Northern Ireland United States Australia New Zealand 38.7% 37.8% 32.6% 30.2% 29.0% 28.7% 27.2% 24.2% 19.9% 19.3% 18.6% get81325_09_c09.indd 246 12/10/13 10:23 AM CHAPTER 9 Section 9.2 Evolution of a Personality Disorder: From Psychopath to Antisocial Perso\ nality By the DSM–5’s definition, antisocial personality disorder usually has its origins in adoles- cence, but it may begin even earlier (APA, 2013; Soderstrom, Sjodin, Carlstedt, & Forsman, 2004). In fact, poor impulse control and aggressiveness as a child are important predictors of antisocial personality disorder later in life (Patrick, 2007; Hinshaw & Zupan, 1997). A typical sequence is for an impulsive prepubescent boy to be labeled as a “conduct prob - lem” in school. In adolescence, the same boy is labeled “delinquen\ t,” and in early adult - hood, he is diagnosed as antisocial (Lahey & Loeber, 1997). Girls usually show fewer prob- lems before adolescence (Burnette & Newman, 2005). About 10% of children have conduct disorder; of that group, 75% are male (Nock et al., 2006). Those with conduct disorder are more likely to be diagnosed with antisocial personality disorder in later life (Lahey, Loe- ber, Burke, & Applegate, 2005).

The highest prevalence of antisocial personality disorder is among men aged 25 to 44 years. In middle and old age, the incidence of antisocial personality di\ sorder declines. It is not clear whether this means the disorder diminishes with age or whether people with antisocial personality disorder fail to live past middle age (Hare, McPherson, & Forth, 1998). We do know that many die young from suicide, homicide, accidents, and substance abuse (Plutchik & Van Praag, 1997).

Causes of Antisocial Personality Disorder Many do not believe that there is a gene that makes a person a criminal. The modern view is that genetics and environment both contribute to every type of behavior, including anti- social behavior. In this section, we examine some of the ways in which heredity, biology, and experience interact to produce antisocial behavior.

Genetics Considerable evidence points to a genetic element in antisocial behavior\ , particularly when the antisocial behavior includes aggression (Patrick, 2007). This evidence includes a higher concordance for antisocial traits among identical siblings than among nonidentical siblings (Waldman & Rhee, 2006) and the finding that adopted children grow up to resem - ble their antisocial biological parents more than their non-antisocial adopted parents.

Figure 9.2: Risk factors for antisocial personality disorder Dysfunctional, abusive family environment Genetic tendency towa rd low arousal and sensation seeking Exposure to antisocial models in real life and in the media Antisocial personality Source: From Schwartz, S. 2000. Abnormal Psychology: A Discovery Approach. Mountain View, CA: Mayfield Publishing Company, Fig. 10.3, p. 437. get81325_09_c09.indd 247 12/10/13 10:23 AM CHAPTER 9 Section 9.2 Evolution of a Personality Disorder: From Psychopath to Antisocial Perso\ nality All of the simple explanations that have been offered to date (antisocial behavior is the result of an extra male chromosome, for instance) have proved to be blind alleys (Harmon, Bender, Linden, & Robinson, 1998). All researchers agree that the mechanism by which anti- social behavior is inherited is likely to be complicated (van Goozen et al., 2007). One popu - lar theory is that low levels of serotonin possibly contribute to violent antisocial behavior (Patrick, 2007; Lyons-Ruth et al., 2007). A complication for this hypothesis is that some of the variables that affect serotonin levels may, by themselves, cause antisocial behavior.

For example, disadvantaged people, whose diets are poor, may have low serotonin levels.

Their poverty also puts them at high risk of engaging in antisocial beha\ vior. Is it their low serotonin that causes their antisocial behavior, or is it their poverty? Perhaps it is both.

There is a pressing need to clarify the ways in which genes affect antisocial behavior.

Opponents view genetic research as racially motivated, an attempt to redefine social prob - lems in biological terms. They fear that genetic research will be used to stigmatize some minority groups as “born criminals.” Stigmatizing minorities is a danger, of course, but such an outcome can be avoided by properly educating the public about the meaning of genetic findings. Banning research on the genetics of antisocial personality disorder for political reasons would make it impossible for researchers to get a complete picture about how genetics and environment interact to produce antisocial behavior.

Sensation Seeking A hypothesis with a long history in psychology suggests that antisocial p\ ersonality dis - order is the result of low emotional arousal (Patrick, 2007). The idea is that low arousal is an aversive state that people naturally try to escape. They do this by s\ eeking the stimu - lation and excitement that comes from danger - ous, often antisocial, behavior (Patrick, 2007).

Of course, stimulation seeking need not always lead to antisocial behavior. Successful business- people, mountain climbers, and even scientists may also crave stimulation, but their behavior is not antisocial. Clearly, sensation seeking alone is not a sufficient explanation for why some people develop antisocial personality disorder. We must also explain why such people seek stimulation in socially disapproved ways. One likely place to look is in early childhood family experiences. Family Dynamics Psychodynamic theorists attribute antisocial and most other personality disorders to an absence of trust in other people (Sperry, 2003). This loss of trust, which results from a lack of love during infancy, leads to emotional detachment. Children grow up unable to empathize with others; as a result, they become self-absorbed. The evidence for this view is the frequent finding of dysfunc- tional backgrounds in the histories of people with Hemera/Thinkstock Theorists posit that dysfunctional family dynamics may contribute to antisocial disorders. get81325_09_c09.indd 248 12/10/13 10:23 AM CHAPTER 9 Section 9.2 Evolution of a Personality Disorder: From Psychopath to Antisocial Perso\ nality antisocial personality disorder (Martens, 2005). Again, however, there are many people who grow up with abuse who do not develop antisocial personality disorder, so family dynamics, on their own, are not a sufficient etiological explanation.

Modeling and Media Many lifelong habits are first developed in childhood, including antisocial ones. For this reason, a childhood spent with criminal models is an ideal training ground for children to learn antisocial behavior (Paris, 2001). More often, however, exposure to antisocial behav- ior is not direct, but through the media. Children get to see crimes, including violent ones, on television, in the movies, and of course on the Internet; they can ev\ en “perpetrate” a pretend form of violence by playing computer games.

Certainly, there is some evidence that the number of hours spent watching media vio - lence is a predictor of aggression, both in children and later in life (Huesmann, Moise, & Podolski, 1997). But it is only one of many predictors, and not a very strong one at that.

The correlation between aggression among males and the time spent watching violent television programs in the United States is 0.25. In Australia it is 0.13, and in Finland 0.22.

(Correlations can range from 1.0 to –1.0. Numbers such as those here are not significant because they are too weak to have statistical significance; Hussmann et al., 1997). These correlations are too small to explain or predict violence on their own (Barrett, 1997). Per - haps aggressive kids are more likely to watch violent videos and play violent computer games. To make things even more complicated, there are strong counterexamples to the relationship between media violence and actual violence. Japan, for insta\ nce, is famous for its violent pornographic comics and gory cartoons, yet it has a much lower incidence of vio- lent crime than other countries ( http://answers.google.com/ answers/threadview?id=3231 ).

The evidence boils down to this: Violence in the media is not a sufficient explanation for childhood violence. Censorship of media violence may reduce violence among some suscep - tible children (at the risk of vio - lating everyone else’s right to free speech), but it is unlikely to eliminate what is really a com - plicated social problem with multiple causes.

Treatment of Antisocial Personality Disorder Few adults with antisocial behavior seek treatment, and even fewer are motivated to change. In general, treatments tend to be ineffective (Hilarski, 2007). The most common ‘’treatment” for people with antisocial personality disorder is incarceration in a correctional © MIKE BLAKE/Reuters/Corbis Does violence in the media contribute to childhood violence?

Researchers have conducted numerous studies on this topic, but the results have not pinpointed an exact cause. get81325_09_c09.indd 249 12/10/13 10:23 AM CHAPTER 9 Section 9.3 Cluster A: Paranoid, Schizoid, and Schizotypal Personality Disorders facility. But incarceration is notoriously unsuccessful at rehabilitating most individuals, and repeat offenses are common. Psychological treatment does not usually thrive in invol- untary settings such as prisons, yet there have been controlled studies showing the effec- tiveness of behavior therapy and behavioral staff training programs in reducing antisocial behavior, especially violence, by persons in institutions (Harris, & Rice, 2006). Clinicians have also had some success in reducing violence using antipsychotic and antidepressant medications, but more evidence is needed (Markovitz, 2004). Given the difficulties encoun - tered in treating antisocial personality disorder after it is established, some psychologists have emphasized prevention instead (Shaw et al., 2006). Prevention programs are usually aimed at children and adolescents from high-risk backgrounds (abused children, children in single-parent families, and children from marginal neighborhoods). These programs include parent training and school-based counseling programs, among others.

9.3 Cluster A: Paranoid, Schizoid, and Schizotypal Personality Disorders Following the DSM–5, this chapter divides the personality disorders into three clusters.

Cluster A includes the paranoid, schizoid, and schizotypal personality disorders. Indi - viduals who fall into Cluster A appear odd or eccentric. Cluster B includes the antiso- cial, borderline, histrionic, and narcissistic personality disorders. Individuals in Cluster B are dramatic, emotional, and erratic. Cluster C includes the avoidant, dep\ endent, and obsessive-compulsive personality disorders. Individuals in Cluster C are anxious and fearful. It is not uncommon for the same person to be simultaneously diagnosed with per - sonality disorders from more than one cluster (Skodol, 2005; Phillips & Gunderson, 1996).

Cluster A personality disorders are marked by eccentricity, not to the point of losing touch with reality, but enough for the individual to be perceived by others as odd. The disorders included in Cluster A all share at least a superficial similarity with the Axis I disorder of schizophrenia. Indeed, Cluster A personality disorders have sometimes been construed as milder versions or precursors of schizophrenia. There is considerable overlap among the Cluster A personality disorders, making it difficult for clinicians to differentiate them from one another (Livesley & West, 1986).

Paranoid Personality Disorder People with paranoid personality disorder lack trust in others and constantly fear that their friends may be disloyal or unfaithful. As a consequence, people with paranoid per - sonality disorder avoid revealing their thoughts and feelings. Often, others perceive them as being hypersensitive. Those with this disorder may interpret even innocuous events (omission of their name from a roster, for example) as a sign that others are plotting against them. Any offers of assistance are taken as criticisms that the person is unable to cope on his or her own. Because they react to these perceived insults with anger, people with paranoid personality disorder are perceived by others as hostile.

At one time, paranoid personality disorder was viewed as a milder form of paranoid schizophrenia, but there are important differences between the two conditions. In contrast get81325_09_c09.indd 250 12/10/13 10:23 AM CHAPTER 9 Section 9.3 Cluster A: Paranoid, Schizoid, and Schizotypal Personality Disorders to people with paranoid schizophrenia, those with paranoid personality disorder do not have delusions, hallucinations, or other forms of thought disorder (APA, 2013). Instead, they are characterized mainly by their suspicion of other people. Today, most clinicians believe that paranoid personality disorder is at best only a distant member of the schizo- phrenic spectrum of disorders (Skodol, 2005).

Sometimes, several people with paranoid personality disorder band together into groups with others who share their paranoid beliefs. Of course, seemingly “paranoid” people may have real enemies, so this diagnosis should not be lightly applied to politica\ l or eco- nomic refugees or to people whose backgrounds may have actually included conspiracies and prejudice.

Etiology Paranoid personality disorder first becomes apparent in childhood and seems to occur more often in males than females (APA, 2013). It affects between 0.5% and 4.4% of the general population (O’Connor, 2008; APA, 2013). Because both traumatic brain injury and substance abuse may produce paranoid symptoms, care should be taken when making the diagnosis to exclude both of these possibilities (Morgenstern, Langenbucher, Labou - vie, & Miller, 1997). Treatment Few people with paranoid personality disorder seek psychological treatment; they are too sus - picious of the therapist. Those who do find their way into treatment may receive psychodynamic psychotherapy, cognitive-behavioral therapy, and drugs. Unfortunately, none of these approaches to treatment have met with much success (Piper & Joyce, 2001).

Schizoid Personality Disorder Schizoid personality disorder consists mainly of negative rather than positive symptoms. That is, the defining feature of schizoid personality disor - der is not a delusion, obsession, or thought disor - der—it is the lack of social relationships (Skodol, 2005). People with schizoid personality disorder prefer solitary pursuits and spend much of their time alone. They have flat affect (a limited range of emotions) and are indifferent toward the opin - ions of others. Because of their social isolation, people with schizoid personality disorder are socially inept and appear self-absorbed, cold, and aloof (Skodol, 2005). © Matthias Ritzmann/Corbis The most prominent feature of schizoid personality disorder is the lack of social relationships, and people with this disorder often spend time alone. get81325_09_c09.indd 251 12/10/13 10:23 AM CHAPTER 9 Section 9.3 Cluster A: Paranoid, Schizoid, and Schizotypal Personality Disorders Highlight: Veronica’s Sunday Veronica is a 32-year-old woman who works during the week as a security guard at a bank. This excerpt from a letter written by Veronica’s sister, with whom she lives, to their mother, is a descrip- tion of a typical Sunday in the life of this woman with a schizoid personality disorder:

Dear Mom, I hope you are well, and over your cold. I am doing OK, but I’m worried about Veronica. I have been keeping a close eye on her as you suggested, but she seems to be getting even more withdrawn. Let me tell you about Sunday. Veronica got up at 8:30 and switched on the television. She watched for an hour while still in bed. She then had some juice and coffee while watching a news show on television.

At around 10:30, she fed Kat [the cat]. She sat and watched the cat eat for a while and then spent 45 minutes washing and ironing her clothes. She organized her drawers and then had a shower and got dressed. By this time, it was noon. Her next activity was to sit on a chair directly in front of a win- dow and read the newspaper that we get delivered. After about an hour of this, Veronica once again turned on the television. She watched a talk show, and then she went outside for a walk. When she returned home, she ate a tiny dinner and watched television until late, when she fell asleep. She did not utter a word to me, or anyone else, all day . . .. To keep schizophrenia and schizoid personality disorder separate, the DSM–5 rules out schizoid personality disorder in people with schizophrenia (or any other psychotic disorder). It is also important that diagnosti- cians consider a person’s social situation. For example, the diag- nosis of schizoid personality dis - order is inappropriate for people who have recently migrated from one culture to another.

Although immigrants may show the signs of a schizoid personal - ity disorder (immigrants often take a while to settle into their new surroundings), it would be unwise to make a diagnosis until they have had the opportunity to adjust to their new environment. Finally, the diagnosis should be reserved for people in distress, not for people who prefer and adjust well to living as “loners.” Etiology Although the term simple schizophrenia was once used to describe people with schizoid personality disorder, it, like paranoid personality disorder, is probably only a distant (at best) member of the spectrum of schizophrenia-related disorders (Fulton & Winokur, 1993; Maier, Lichtermann, Minges, & Heun, 1994). Schizoid personality disorder is no Visions of America/SuperStock Diagnosticians must evaluate a person’s social environment before making a final diagnosis. Although many immigrants moving from one culture to another exhibit symptoms of a schizoid personality disorder, these individuals may need time to adjust to their new social surroundings. get81325_09_c09.indd 252 12/10/13 10:23 AM CHAPTER 9 Section 9.3 Cluster A: Paranoid, Schizoid, and Schizotypal Personality Disorders more common among the relatives of people with schizophrenia than it is among the rela- tives of people without schizophrenia. Like paranoid personality disorder, it is more likely to be found among the relatives of depressed than schizophrenic people.

Psychodynamic (and most behavioral) theorists blame rejecting and abusive parents for causing their offspring to shun other people (Sperry, 2003). The trouble with this hypoth - esis is that precisely the same etiology is applied to paranoid personality disorder. What psychodynamic theorists do not explain is why some rejected children withdraw and develop a schizoid personality disorder, whereas others react with anger and become paranoid. Based on the restricted range of affect often displayed by people with schizoid personality disorder, cognitive theorists have hypothesized that their symptoms are the result of some deficit in processing emotional information (Smith, 2006).

Treatment People with schizoid personality disorder rarely seek treatment; they are too disengaged from others to care and too threatened by close relationships to get involved in psycho - therapy (Mittal et al., 2007). Those who do find their way into treatment usually suffer from some associated condition, such as substance abuse or depression. For those who are treated, psychoanalytic therapy focuses on working through the trauma produced by early rejection, whereas cognitive-behavioral therapy attempts to teach people the social skills they need to interact with others. There have been case reports of successful psycho - logical treatment of schizoid personality disorder in young people (Herlihy, 1993), but, for most people, psychotherapy has produced only limited success (Belcher et al., 1995), and medications have not proved much better (Koenigsberg et al., 2002).

Schizotypal Personality Disorder Like people with schizoid personality disorder, those with schizotypal personality disor- der are loners who are unable or uninterested in forming relationships with other people.

They prefer solitary activities to those involving others, and, like people wit\ h schizoid personality disorder, they are often perceived as cold and unemotional. There are also similarities between schizotypal personality disorder and paranoid personality disorder.

Both disorders are marked by suspicion of the motives of others and by ideas of reference, the belief that unrelated comments and events pertain to those with the disorder.

Clearly, the schizotypal personality disorder shares symptoms with both the schizoid and the paranoid personality disorders, but it differs in an important respect: Schizotypal personality disorder is related and similar to schizophrenia (Koenigsberg et al., 2005).

People with schizotypal personality disorder have peculiar thoughts, rambling speech, odd appearance, and eccentric behaviors. Put simply, schizotypal personality disorder seems to be a mild form of schizophrenia that occurs in approximately 0.6% to 3.9% of the population (Bollini & Walker, 2007; APA, 2013).

Etiology Because of the similarity between schizotypal disorder and the schizophrenia spectrum of disorders, researchers have tried to apply the diathesis-stress etiological model of schizophrenia to schizotypal personality disorder. Certainly, the diathesis appears to get81325_09_c09.indd 253 12/10/13 10:23 AM CHAPTER 9 Section 9.4 Cluster B: Antisocial, Borderline, Histrionic, and Narcissistic Personality Disorders be similar. Schizotypal personality disorder is most commonly found in families with schizophrenic relatives (Siever & Davis, 2004), and people with schizotypal personali\ ty disorder exhibit attentional deficits similar to those seen in people with sc\ hizophrenia (Bollini & Walker, 2007). And the similarities between the two disorders do not end there. Schizophrenia and schizotypal personality disorder both have also been linked to higher than average levels of dopamine as well as to enlarged brain ventricles (Bollini & Walker, 2007).

Treatment As it is with schizophrenia, psychotherapy is of limited value in schizotypal personality disorder (Ewing, Falk, & Otto, 1996). The most successful treatment approaches mirror those used in schizophrenia—skills training (McKay & Neziroglu, 1996) and antipsychotic medication (Bollini & Walker, 2007). See Table 9.2 for a comparison of Cluster A personal- ity disorders and schizophrenia.

Table 9.2: Comparison of Cluster A personality disorders and schizophrenia on selected characteristics Disorder Characteristics Negative symptoms (e.g., blunt affect) Paranoid ideas Family members with schizophrenia Positive symptoms (e.g., thought disorder) Schizophrenia Ye sYe sYe s Ye s Cluster A personality disorders Paranoid personality disorder Ye s Schizoid personality disorder Ye s Ye s Schizotypal personality disorder Ye s Ye sYe s 9.4 Cluster B: Antisocial, Borderline, Histrionic, and Narcissistic Personality Disorders People with Cluster B personality disorders tend to be self-absorbed. They find it difficult to empathize with others because they spend so much time and energy on themselves. In addition, they exaggerate the importance of everything that happens to t\ hem, usually in a theatrical and overdramatic way. Because of their excessive self-concern and melodramat - ics, people with Cluster B personality disorders find it difficult to establish and maintain interpersonal relationships (APA, 2013). Antisocial personality disorder has already been discussed, so this section focuses on the remaining three Cluster B disorders: borderline, histrionic, and narcissistic personality disorders. get81325_09_c09.indd 254 12/10/13 10:23 AM CHAPTER 9 Section 9.4 Cluster B: Antisocial, Borderline, Histrionic, and Narcissistic Personality Disorders Borderline Personality Disorder Clinicians and researchers who work from different paradigms have used the term border- line in several different ways: (a) to refer to people whose behavior fell at some hypotheti - cal border between “neurotic” mood disorders and psychotic ones, (b) as a general term for the symptoms caused by mild brain damage, and (c) to describe peop\ le whose poor social relations are marked by manipulative suicide attempts (Gunderson, Zanarini, & Kisiel, 1995; Tyrer, 1994).

In an attempt to give systematic meaning to the term borderline, the DSM–5 has chosen to emphasize instability and impulsivity. According to the DSM–5, people with borderline personality disorder are insecure because they have a morbid fear of abandonment. They want to form close relationships, and, initially at least, they succeed. But their need for \ attention and reassurance eventually becomes too overwhelming and their relationships break down. This is a recurring cycle—other people begin as perfect friends and evolve into enemies; there is no in-between. This tendency to categorize people as entirely good or entirely bad is known in psychoanalytic circles as “splitting.” When relationships deteriorate, people with borderline personality disorder may threaten to harm themselves just to keep the connection going. If this does not w\ ork (and it rarely does), they may actually carry out their threats by mutilating or even killing themselves (Sherry & Whilde, 2008). In addition to self-harm, people with borderline personality dis - order may engage in various forms of imprudent behavior—reckless driving, unsafe sex, gambling, and substance abuse (Sherry & Whilde, 2008). Indeed, their m\ oods tend to swing widely depending on the state of their interpersonal relationships. When these are going well, they may be elated, friendly, and good company. When their relationships are going badly, they become depressed, sullen, and aggressive.

Etiology There is considerable overlap between the symptoms of antisocial personality\ and those of borderline personality disorder. There are some differences as well. Although people with both diagnoses are impulsive, reckless, unable to form stable relationships, and often hostile, borderline personality is also associated with a morbid fear of abandonment\ . It is possible that the underlying causes of the two disorders are similar but that women are socialized to be more frightened of being alone and to turn their aggression inward in the form of suicidal gestures rather than outward toward others (Paris, 1997).

Borderline personality disorder occurs in anywhere from 1.6% to 5.9% of the general pop - ulation (Sherry & Whilde, 2008; APA, 2013), with about 75% being female. As we have seen, sex differences in the incidence of a disorder can have many explanations. In the case of borderline personality disorder, social factors, especially sex role expectations, seem to play an important part (Becker, 1997). Through the process of socialization, similar etio - logical factors wind up producing somewhat different disorders. Of course, social roles change from one society to another, so it is important to keep in mind that practically all of the research and clinical reports concerning borderline personality disorder come from developed countries such as the United States. Traditional societies, such as those found in developing countries, have different sex roles. For example, in some societies, women are almost guaranteed supportive relationships through a network of mutual family and get81325_09_c09.indd 255 12/10/13 10:23 AM CHAPTER 9 Section 9.4 Cluster B: Antisocial, Borderline, Histrionic, and Narcissistic Personality Disorders community obligations. Perhaps this is the reason such societies have a low incidence of borderline personality disorder (Paris, 1996).

Borderline personality disorder has been attributed to parental loss or abuse in child- hood (Sansone, Levitt, & Sansone, 2005) or to post-traumatic stress later in life (Zlotnick, 1997). In both cases, psychological trauma is thought to produce a fear of further loss and a subsequent fear of abandonment (Sherry & Whilde, 2008). Although this seems a plausible theory, it is hardly specific to borderline personality disorder. Parental loss and abuse are found in the backgrounds of many psychological disorders. A similar lack of specificity may be found in the various biological explanations offered for borderline personality disorder—genetics, low levels of serotonin (Norra et al., 2003), thyroid dys - function (Klonoff & Landrine, 1997), and brain structures either being unusually small or being overactive or underactive (see for example Donegan et al., 2003)\ ; all occur in other disorders as well.

Treatment There have been many attempts to develop treatments for borderline personality disorder, but none has proved especially successful. Psychoanalytic psychotherapy concentrates on analyzing the transference relationship that develops between patient and therapist.

That is, in psychoanalysis, establishing a patient-analyst relationship where the patient responds to the analyst as though the analyst is or was an important figu\ re (father, etc.) in the patient’s life is essential. The goal of treatment is to use the transference relation - ship as a model to show people the way in which they undermine their int\ erpersonal relationships (Gabbard, Horwitz, Allen, et al., 1994; Horwitz, Gabbard, Allen, et al., 1996).

A strong patient-therapist transference may also help people with borderline personality disorder to learn to trust others. As you can imagine, however, building a transference relationship and analyzing a client’s interpersonal functioning is dif\ ficult with people whose relationships are characteristically turbulent. Following their usual pattern, bor - derline personality disorder patients begin by idealizing the therapist as a potential savior and later, through splitting, turn this completely around so that the therapist becomes a money-seeking charlatan. In such cases, analyzing the transference relationship takes some time, with many regressions along the way (Bender & Oldham, 2005).

Although cognitive-behavioral therapy may assist people with borderline personality dis - order to lead more effective lives (Waldo & Harman, 1998), people with this disorder may find it difficult to complete a course of therapy. They may drop out of treatment at the first sign (real or imagined) that the therapist is neglecting them. To help such clients follow through with treatment, clinicians may first try to increase a client’s emotional stability.

For example, emotional awareness training, in which people with borderline personality disorder are given practice in recognizing their emotions (as well as those being experi - enced by others) and then taught ways to control their emotions, may help clients to cope with the stress of cognitive and behavioral interventions (Oldham, 2006). Therapis\ ts, too, must make certain adjustments. For example, they must learn to deal with\ the manipula - tive behavior of clients who are hypersensitive to criticism and are always imagining that they are being rejected.

Cognitive-behavioral therapists may employ a multimodal treatment strategy known as dialectical behavior therapy. This approach combines group and individual therapy, sup - portive counseling, and a behavioral contract (usually an agreement not to harm oneself) get81325_09_c09.indd 256 12/10/13 10:23 AM CHAPTER 9 Section 9.4 Cluster B: Antisocial, Borderline, Histrionic, and Narcissistic Personality Disorders with skill training aimed at improving and maintaining relationships (Linehan & Dexter- Mazza, 2008). Support may also be given to friends and family members w\ ho need to learn what to expect and how to deal with a person who has a borderline personality disorder (Gunderson, Berkowitz, & Ruiz-Sancho, 1997).

In addition to psychological treatment, the entire spectrum of psychoactive drugs has been used to treat borderline personality disorder, usually in conjunction with some form of psychological therapy (Soloff, 2005). The most effective drugs are antidepressants (espe- cially the SSRIs), which seem to reduce the impulsivity, depression, and rage that destroy relationships (Binks et al., 2006).

Histrionic Personality Disorder This disorder is a direct descendant of the 19th-century concept of hysteria. People with histrionic personality disorder do not have conversion symptoms. They are mainly motivated by the need to be the center of attention (Skodol, 2005). To gain the notice they crave, people with this disorder may act seductively, dress in eccentric clothes, or act in a loud and boisterous fashion.

People with a histrionic person- ality disorder actively seek com- pliments and are easily upset by criticism. Because of their melo - dramatic displays, histrionic people are viewed as shallow and phony. Etiology Histrionic personality disorder appears to have a prevalence of 1.84% to 3% in the general pop - ulation (O’Connor, 2008; APA, 2013) and equally affects men and women (O’Connor, 2008). Treatment Although people with histrionic personality disorder may seek treatment, they make dif - ficult clients. They tend to use the therapeutic environment as another opportunity to play center stage and present exaggerated versions of their problems (Gutheil, 2005). Group treatment is generally not possible for people with histrionic personality\ disorder because of their need to monopolize the therapist’s attention. Nor are histrionic people good can - didates for insight-oriented therapy (self-awareness and understanding of the influence of the past on their present behavior); they find it impossible to accept any but their own interpretations of their behavior. Perhaps the best therapeutic approach is to concentrate on helping people with this disorder to separate important problems from trivial ones, and to teach them how to pay attention to others. There are no specific drug treatments for histrionic personality disorder, although drugs may be used to treat any concurrent Axis I disorders (such as major depressive disorder [MDD]; Grossman, 2004). Digital Vision/Thinkstock People with histrionic personality disorder desire to be the center of attention. get81325_09_c09.indd 257 12/10/13 10:23 AM CHAPTER 9 Section 9.4 Cluster B: Antisocial, Borderline, Histrionic, and Narcissistic Personality Disorders Narcissistic Personality Disorder According to Greek mythology, Narcis- sus was a boy of legendary beauty who fell in love with his own reflection in the waters of a pond. He stared at his reflec- tion until he wasted away to a flower.

From this story, Freud derived the word narcissistic, meaning a person who is con - sumed with self-love. Freud’s use of the term has evolved into the DSM–5’s diag- nosis of narcissistic personality disorder.

People with this disorder are character - ized by their strong sense of superiority.

They consider themselves to be important and demand special treatment. People with this disorder are often rude because they view rules and common courtesy as meant for others (Miller, Campbell, & Pil- konis, 2007). Like people with histrionic personality disorder, narcissistic people crave attention. They dream of achieving positions that will gain them the power and atten - tion they seek. More often, however, narcissistic people exaggerate their own successes and envy the achievements of others. Beneath the surface, narcissistic people are so plagued by self-doubt that, even when they have reached a goal, they remain unsatisfied because suc- cess never brings them the level of adulation they desire.

Etiology In psychodynamic terms, narcissism starts in childhood. We are all narcissistic as children because the world seems to revolve around us. When we are hungry, someone feeds us; when we are cold, someone always caters to our needs. One of the most important ta\ sks facing children during the process of socialization is learning that there are other people in the world, with their own feelings and needs. Learning to empathize with\ others is a skill that develops through childhood and the teenage years, so we must be wary of applying the DSM–5 criteria to young people (APA, 2013). However, by early adulthood, a narcis- sistic personality disorder should become clear. Once such a disorder develops, it tends to be ongoing (Ronningstam, 1998). Narcissistic personality disorder affects about 0% to 6.2% of the general population (APA, 2013), mainly males.

Treatment Both psychodynamic and cognitive-behavioral approaches to the treatment of narcissistic personality disorder focus attention on helping people to become more realistic in their goals and to find satisfaction and fulfillment in the normal events of daily life (Beck, Free - man, Davis, et al., 2004). Training in recognizing and empathizing with the emotions of others is an important adjunct goal of treatment. As in many other personality disorders, drugs may be used for some symptoms or for concurrent Axis I disorders (Joseph, 1997). © Arte & Immagini srl/CORBIS This painting of Narcissus illustrates him looking at his own reflection. Originally coined by Freud, a person who is narcissistic exhibits extreme self-love and seeks attention. get81325_09_c09.indd 258 12/10/13 10:23 AM CHAPTER 9 Section 9.5 Cluster C: Avoidant, Obsessive-Compulsive, and Dependent Personality Disorders 9.5 Cluster C: Avoidant, Obsessive-Compulsive, and Dependent Personality Disorders The disorders in Cluster C share the characteristics of fearfulness and worry (Alpert et al., 1997). In contrast to the anxiety disorders, however, Cluster C personality disorders tend to have an earlier onset, no clear cause, and a stable lifelong course (\ O’Donohue et al., 2007). Cluster C disorders include avoidant personality disorder, obsessive-compulsive personality disorder, and dependent personality disorder.

Avoidant Personality Disorder People with avoidant personality disorder are shy and socially uncomfortable. Unlike people with schizoid personality disorder, people with avoidant personality disorder would prefer to be sociable, but they avoid social contact because they fear emb\ arrass - ment and criticism. In practice, it is difficult to separate avoidant personality disorder from social phobia (Ralevski et al., 2005). When social anxiety is long-\ standing, the diagnoses are probably interchangeable. Because shyness and social reticence are devel - opmentally appropriate for young children (and because some cultural groups encour - age social timidity for one or both sexes), a client’s age and cultu\ re should be taken into account when making this diagnosis (APA, 2013). Avoidant personality disorder occurs in around 2.4% of the population, and it affects men and women in equal num - bers (O’Connor, 2008; APA, 2013). It is often found in conjunction with the diagnosis of unipolar depression (APA, 2000). Cognitive-behavioral treatments aimed at reducing social anxiety can also help people with avoidant personality disorder to lead fuller lives (Emmelkamp et al., 2006).

Obsessive-Compulsive Personality Disorder Oftentimes students confuse obsessive-compulsive disorder (OCD) with obsessive- compulsive personality disorder (OCPD). OCD behaviors fall along a continuum from relatively mild to severe (Stein & Hollander, 1997). Obsessive-compulsive personality disorder behaviors fall at the mild end of the continuum. People who have this d\ isorder do not display true obsessions or even severe compulsions. Instead, they are characterized by a perfectionistic attitude toward daily life (APA, 2013). People with this disorder try to maintain a rigid control over their routines and, when possible, the behavior of other people. They accomplish the latter by insisting on a tight adherence to rules and sched- ules. They feel that their approach to all matters is the only correct one, and they tend to deny that other people might have reasonable alternative views. Not surprisingly, they are viewed by others as moralistic, rigid, and stubborn. The disorder seems to be more common among white, educated, married males and has a prevalence in the community of about 2.1% to 7.9% (Bartz et al., 2007; APA, 2013).

Dependent Personality Disorder People with dependent personality disorder have a strong need to be taken care of by someone else, preferably someone important (Bornstein, 2005; Skodol, 2005). To fulfill this need, they tend to be submissive to the demands of their chosen car\ etaker, acting, get81325_09_c09.indd 259 12/10/13 10:23 AM CHAPTER 9 Section 9.5 Cluster C: Avoidant, Obsessive-Compulsive, and Dependent Personality Disorders at times, as if they were help- less to look after themselves.

Like people with histrionic per- sonality disorder, those with dependent personality disorder have a strong need for approval.

However, dependent people are timid, whereas histrionic people actively seek attention.

Like people with borderline per - sonality disorders, dependent people worry about being aban- doned. Instead of reacting with rage, however, dependent peo - ple become submissive. Finally, both avoidant and dependent personality disorders are char - acterized by feelings of inade- quacy, but avoidant people tend to withdraw, whereas dependent people seek to develop relationships with people who can care for them.

Dependent personality disorder affects anywhere from 0.6% to 2.5% of the population (Grant et al., 2004; APA, 2013). The DSM–5 asserts that the disorder affects both sexes with only a small bias toward females (APA, 2013). This sex difference probably reflects the cultural stereotype of the dependent woman. Because young children are expected to be dependent and because some cultural groups foster dependent behavior among females, caution should be taken in applying this diagnosis to children or to members of some cul - tural groups. Etiology Although the precise causes of dependent personality disorder are not known, it is thought to begin with a fearful temperament (a genetic disposition) that evoke\ s overprotective - ness from parents (Sperry, 2003). Illness in childhood, abandonment, and traumatic loss can produce a similar overprotectiveness. Children may resent this attitude, but may learn to submit rather than challenge their parents.

Treatment Few people seek treatment for dependent personality disorder. However, some may find their way into therapy for an associated anxiety or mood disorder (Skodol, Gallaher, & Oldham, 1996). In psychodynamic treatment, the therapist uses the transference relation - ship first to form a bond with the client and then to teach the person h\ ow to separate.

The idea is that, through the transference experience, the person will learn more effective modes of relating to others (Sperry, 2003). Cognitive therapists try to help their dependent © Yumiko Kinoshita/Anyone/amanaimages/Corbis Individuals with dependent personality disorder display a strong dependence on other people to fulfill their emotional and physical needs. get81325_09_c09.indd 260 12/10/13 10:23 AM CHAPTER 9 Section 9.5 Cluster C: Avoidant, Obsessive-Compulsive, and Dependent Personality Disorders clients to recognize the faulty cognitions that produce their lack of self-confidence (Free- man, 2002). Behavioral therapists use assertiveness training to enhance\ self-esteem by providing dependent clients with a nonsubmissive mode of relating to others. Relaxation training may also be helpful in reducing anxiety. Although people with this disorder usu - ally go along with their therapist’s treatment suggestions (they are submissive people), they are still difficult to treat because of their need for constant reassurance. Long-term treatment is probably not a good idea with dependent people because it may make them overly dependent on their therapist. On the other hand, support and self\ -help groups could be useful places for clients to practice new skills learned in the\ rapy (provided, of course, that clients participate in the group and do not simply let others do all the talk - ing). Drugs may be prescribed for the anxiety and depression often experienced by people with dependent personality disorder (Fava et al., 2002), but care should be taken because clients may use drug overdoses as a way of manipulating other people. Highlight: Personality Disorder Trait Specified (PDTS) The American Psychiatric Association has come up with an alternative dimensional approach to be considered in a possible DSM-5 update (2013). A core component of this approach is the diagnosis of personality disorder trait specified (PDTS). Individuals would get this diagnosis if one or more of their traits significantly impaired their functioning in everyday life. Psychologists and other helping professionals would identify and list the traits that were impaired, as well as rate the severity of the impairment. The five groups of traits are listed and described below: • Negative Affectivity: People who display this have and experience negative emotions frequently and intensely. They will demonstrate at least one of the following traits: Emotional lability (meaning unstable emotions), anxiousness, separation insecurity, submissiveness, hostility, perseveration (repeating certain behaviors in spite of repeated failures from prior attempts), depressivity, suspiciousness, and restricted affectivity (lack of affect). • Detachment: These people often avoid social interactions, often withdrawing from them.

They will demonstrate one of the following traits: Withdrawal, intimacy avoidance, anhedonia (inability to feel pleasure or get pleasure from pleasurable things), depressivity, restricted affec - tivity, and suspiciousness. • Antagonism: These individuals will behave in ways that will put them in confrontation with oth - ers. They will demonstrate one of the following traits: Manipulativeness, deceitfulness, grandi - osity, attention seeking, callousness, and hostility. • Disinhibition: These individuals behave impulsively without reflecting on potential future conse - quences. They will demonstrate one of the following traits: Irresponsibility, impulsivity, distract - ibility, risk taking, and lack of rigid perfectionism. • Psychoticism: These individuals have unusual and bizarre experiences. They will demonstrate one of the following traits: Unusual beliefs and experiences, eccentricity, and cognitive and per - ceptual dysregulation (odd or unusual thought processes or sensory experiences) (APA, 2013).

If an individual has significant impairment in any of these above five groups, or in only one of the traits listed in the above five groups, they would qualify for a PDTS diagnosis. As mentioned, this approach and diagnosis are currently in review for the next revision of the DSM-5. What is your opin- ion about this? get81325_09_c09.indd 261 12/10/13 11:55 AM CHAPTER 9 CHAPTER 9 Chapter Summary Chapter Summary Categories Versus Dimensions • Personality disorders constitute distinct diagnostic categories; a person either meets the criteria for a personality disorder or does not meet them. • Alternatively, people may be described by where they fall on a variety of person - ality dimensions. The dimensional approach provides richer descriptions and avoids pigeonholing people into narrow categories. • Unfortunately, there are many possible personality dimensions, and no one knows which ones are appropriate for describing people. Diagnostic Issues • Clinicians often disagree about personality disorder diagnoses because of over - lapping criteria. • Borderline, schizoid, and avoidant personality disorders are all marked by poor social relations. • To make diagnosis easier, clinicians often simply give people more than one personality-disorder diagnosis. • In some cases, personality-disorder diagnostic criteria reflect cultural and gender stereotypes. Antisocial Personality Disorder • The hallmark of this disorder is a flagrant disregard for the rights of other people. • The disorder is found mainly in males, it affects between 0.2% and 3.3% of the population, and its incidence decreases with age. • Like much human behavior, antisocial personality disorder begins in childhood, especially among children from abusive or discordant families. • Few people with antisocial personality disorder are motivated to seek treatment. Cluster A: Paranoid, Schizoid, and Schizotypal Personality Disorders • Cluster A personality disorders are marked by eccentricity, not to the point of los - ing touch with reality, but sufficient for the individual to be perceived by others as odd. • Psychological treatments for Cluster A disorders mirror those used in schizophre - nia—social skill training and antipsychotic medication. Cluster B: Antisocial, Borderline, Histrionic, and Narcissistic Personality Disorders • People with Cluster B personality disorders are self-absorbed. They find it diffi - cult to empathize with others, and they exaggerate the importance of eve\ rything that happens to them in a theatrical and overdramatic way. • Because of their excessive self-concern and melodramatics, they find it \ difficult to establish and maintain interpersonal relationships. • These disorders are difficult to treat but may sometimes respond to therapy, par - ticularly a mixture of psychodynamic and cognitive-behavioral treatment. • Drugs are also used, but mainly to treat associated conditions or specific symptoms. get81325_09_c09.indd 262 12/10/13 10:23 AM Key Terms Cluster C: Avoidant, Obsessive-Compulsive, and Dependent Personality Disorders • The disorders in Cluster C share many characteristics with the anxiety disorders, such as fearfulness and worry, and they tend to co-occur with depression. • Cluster C personality disorders tend to have no clear cause and a stable lifelong course. Critical Thinking Questions 1. Personality disorders are chronic and difficult to treat. What makes these disor - ders so difficult to treat? 2. Antisocial personality disorder appears to be associated with criminal tenden - cies/behaviors. Discuss the possible connection between the two. 3. Narcissistic personality disorder was under consideration to be removed as a diagnostic category in the DSM–5. Discuss some reasons why this was under consideration. 4. Individuals with a Cluster B disorder often do not come into treatment volun - tarily. Let us assume you had someone with antisocial personality disorder in treatment who hated being there. How would you go about treating him? 5. Imagine that your coworker has a narcissistic personality disorder. What types of issues do you think you might encounter in working with him/her? Key Terms antisocial personality disorder A Clus- ter B disorder; the key characteristic is a flagrant disregard for the rights of other people. People with antisocial personality disorder are often irresponsible, impulsive, and untrustworthy. avoidant personality disorder A Cluster C disorder; people with avoidant personal- ity disorder are shy and socially uncom- fortable. They would prefer to be sociable, but they avoid social contact because they fear embarrassment and criticism. borderline personality disorder A Cluster B disorder; people with borderline person- ality disorder are insecure because they have a morbid fear of abandonment. They tend to be self-injurious and have short- term, intense interpersonal relationships. dependent personality disorder A Clus- ter C disorder; people with this disorder have a strong need to be taken care of by someone else, preferably someone impor - tant. They tend to be submissive to the demands of their chosen caretaker, acting, at times, as if they were helpless to look after themselves. dialectical behavior therapy A treatment approach for borderline personality disor - der that combines group and individual therapy, supportive counseling, and behav- ioral contracting with skill training aimed at improving and maintaining relationships. dimensional approach This system for diagnosing personality disorders describes people using a standard set of personality dimensions. get81325_09_c09.indd 263 12/10/13 10:23 AM CHAPTER 9 Key Terms histrionic personality disorder A Cluster B disorder; these individuals are mainly motivated by the need to be the center of attention. People with this disorder may act seductively, dress in eccentric clothes, or act in a loud and boisterous fashion. narcissistic personality disorder A Clus- ter B disorder; these individuals have a strong sense of superiority. Those with the disorder consider themselves to be impor - tant and demand special treatment, and they are often rude because they view rules and common courtesy as meant for others.

obsessive-compulsive personality disor - der A Cluster C disorder; people who have this disorder are characterized by a per - fectionistic attitude toward daily life. They try to maintain a rigid control over their routines and, when possible, the behavior of other people. paranoid personality disorder A Cluster A disorder; individuals with the disorder avoid revealing their thoughts and feelings and may interpret even innocuous events as a sign that others are plotting against them. personality The sum of an individual’s traits. personality disorder An enduring pattern of inner experience and behavior that devi- ates markedly from the expectations of an individual’s culture. personality disorder trait specified (PDTS) A personality disorder currently under consideration for inclusion in a future DSM-5 revision. Individuals would get this diagnosis if one or more of their traits significantly impaired their function- ing in everyday life. psychopath People who lack empathy, do not fear punishment, and will continue to break the law even if capture and punish- ment are likely. schizoid personality disorder A Cluster A disorder; people with this disorder have negative rather than positive symptoms.

The defining feature of schizoid personal- ity disorder is not a delusion, obsession, or thought disorder—it is the lack of social relationships. schizotypal personality disorder A Clus- ter A disorder; those with this disorder are considered “loners” who are unable or uninterested in forming relationships with other people. They are often perceived as cold and unemotional. transference relationship In psycho- analysis, establishing a patient/analyst relationship where the patient responds to the analyst as though the analyst is or was an important figure (father, etc.) in the patient’s life. get81325_09_c09.indd 264 12/10/13 10:23 AM CHAPTER 9