PERSONALITY DISORDERS

I. What are Personality Disorders?

A personality disorder is a classification of mental disorders that are characterized by a pattern of behavior that is inflexible and socially maladaptive across a variety of situations.

II. What are personality disorders like?

People suffering from personality disorders typically have problems in many areas of their lives, including social skills, moods, and emotional states. People with these disorders have difficulty establishing normal, healthy relationships.

· In many of the disorders, sufferers lack the ability to have genuine emotions including empathy for others.

· In some disorders, sufferers have no desire to have social relationships or they want relationships, but are scared to reach out to people.

· Personality disorder symptoms stem from basic personality traits that developed over time. A person does not suddenly "get" a personality disorder.

· Because personality disorder traits are deeply ingrained in the personality of suffers, there is no quick treatment. Treatment is typically based on psychotherapy which evaluates faulty thinking patterns and teaches new thinking and behavior patterns.

· A problem in treating individuals with personality disorders is that many do not believe they have a problem.

There is significant overlap in personality disorders; people often have more than one personality disorder. Personality disorders affect 10 to 15% of the population (Hales & Hales, 1995). Some of the disorders affect certain populations more than others. Antisocial, schizoid, and obsessive-compulsive personality disorders affect men more often than women. Women are more likely to be diagnosed with histrionic and dependent personality disorders.

III. Symptoms for all the Personality Disorders

There are ten different personality disorders, each having specific symptoms, but all of them share some basic characteristics which are listed below:

· The person displays an inflexible, pervasive pattern of inner experience and behavior that markedly deviates from the expectations of the individual ‘s culture. This may occur in more than one of the following areas:

-Cognition: ways in which the person may perceive and/or interpret self, others, or situations.

-Emotion: range, intensity, ability, and appropriateness of emotional responses.

-Social Function

-Impulse control

· Person experiences significant distress or impairment in social, occupational, or other important areas of functioning because of this pattern.

· The pattern can be traced to adolescence or early adulthood and is not the result of another mental illness or due to the effects of a substance such as medication, other drugs or alcohol, or a medical condition.

· These characteristics are paraphrased from the Diagnostic and Statistical Manual of Mental Disorders, Fourth edition (DSM-IV)

IV. Three major classifications;

*Cluster A: Odd or Eccentric

*Paranoid

*Schizoid

* Schizotypal

*Cluster B: Dramatic, Emotional, or Erratic

*Antisocial

*Borderline

*Histrionic

*Narcissistic

*Cluster C: Anxious or Fearful

*Avoidant

*dependant

*Obsessive-Compulsive

V. What causes personality disorders?

A. Biological factors

Many mental health professionals feel that personality disorders are primarily a result of the person’s experiences during childhood and adolescence. However, some data from family, twin, and adoption studies has suggested that biology does play a part in these disorders. Contributing to the biological model, some basic personality traits have been found to be inherited. A strong genetic link has been found for antisocial and borderline personality disorders.

Electroencephalograms (EEG), measurements of brain waves, have shown abnormalities in people with antisocial and borderline personality disorders. Some believe that this is a result of their abnormal thinking patterns, while others believe the people may have developed character abnormalities due to some subtle brain injury or defect. Did the abnormal electrical patterns result in abnormal thinking patterns or did abnormal thinking patterns result in abnormal electrical patterns? The debate continues.

B. Psychosocial model

The term "psychosocial" implies that personality disorders are a result of experiences the person has had, particularly during childhood and adolescence. This idea does not necessarily follow any particular theory of psychology or development. The recently developed object-relations theory emphasizes the influence of the parent-child relationship. For example, a child who has a parent incapable of feeling empathy is vulnerable to developing antisocial personality disorder. An unstable parental relationship may lead to a child developing borderline

personality disorder.

The best documented psychosocial factor is child abuse. Physical, emotional, and especially sexual abuse have all been implicated as a cause of personality disorders. That is not to say that people who are abused as children develop personality disorders or that everyone with a personality disorder was abused. It only means abuse leaves a person vulnerable to developing a personality disorder. There are many other factors involved in the development of personality disorders.

VI. Cluster A: Odd or Eccentric

*Paranoid

*Schizoid

*Schizotypal

A. Paranoid Personality Disorder

1. The main characteristics of paranoid personality disorder are:

· Suspicion

With little basis, people with paranoid personality disorder will fear that others want to harm and exploit them. They may believe that spouses and friends are being unfaithful or betraying them. Some file lawsuit after lawsuit in an attempt to keep people from taking advantage of them.

· Hold grudges

People with this disorder do not forgive insults, slights, or injuries easily. They are known for blaming others for their problems.

· Paranoia

As the disorder ‘s name suggests, they perceive insults and threats from benign statements or events. They may see character and reputation attacks that are not apparent to others and may react with anger and counterattacks.

· Problems with intimacy

People with paranoid personality disorder may have difficulty getting intimate with others because they are apprehensive about trusting people.

This pattern of thinking is typically established by early adulthood. It may affect .5 to 2.5% of the population.

2. Treatment

People with this disorder have deep, embedded problems that require intensive treatment Unfortunately, they usually do not see themselves as having a problem. In fact, they may think people who are not paranoid are suckers and need to better protect themselves. Even those who enter therapy, usually for a different problem, become suspicious of their therapist and stop treatment. However, those who stay in therapy can benefit from a supportive therapeutic relationship. Building a trusting therapist-client relationship is the key to success Once they can trust their therapist, then they can confide in them about deeper thoughts and feelings.

B. Schizoid Personality Disorder

Unlike people with schizotypal personality disorder who may have one or two semi-close relationships, people with schizoid personality disorder are extreme loners and rarely have any close relationships.

1. The major characteristics of schizoid personality disorder are:

· No desire for social relationships

People with schizoid personality disorder have no desire to form close relationships. They may form stable relationships with family members or other people but they lack the ability to form close relationships.

· Little or no sex drive

Individuals with this disorder have little sex drive and rarely date or marry. Men are more likely to remain single than women probably because they lack the social skills to initiate courtships. Women may passively date and many, but will remain emotionally aloof.

· Preference for solitary activities

Some people with schizoid personality disorder are very creative, especially with art in the form of painting, sculpting, drawing, etc. Art may take the place of relationships. They typically remain in low level jobs that require little interpersonal contact.

· Limited range of emotions

They have a restricted range of emotions in social settings. This is often described as coldness, detachment, or flatness. People with this disorder appear to be indifferent to compliments and criticisms. They take little or no joy in activities or in life.

2. Treatment

Individual psychotherapy is the preferred treatment method by most people with this disorder. By getting the individual to share their art and develop the relationship from that base, a therapist may be able to establish rapport. Therapists often encourage the person to share their personal hobbies, like music or art with others. Behavior therapy, such gradual exposure to specific tasks, also called systematic desensitization, can help the person form confidence in a social setting. The therapist would probably recommend the person begin with activities which involve little socialization and advance to activities requiring more and more socialization. Group therapy may help the person build social relationships in a supportive atmosphere. Family therapy may also be helpful since people with this disorder typically remain in the house longer. However, though the person ‘s condition may improve, most still prefer solitary activities over social ones.

C. Schizotypal Personality Disorder

People with schizotypal personality disorder are often described as odd or eccentric. About 3% of the population has schizotypal personality disorder and it may be more common in men. Like all personality disorders, it is typically developed by early adulthood. Individuals with this disorder may be at risk of developing anxiety, depression, and other distressing moods. As many as 40 to 50% also suffer from a depressive disorder, which occasionally may cause the person to develop suicidal tendencies. Only a small number of people with this disorder ever develop full-fledged schizophrenia.

1. The major features of schizotypal personality disorder are:

· Extreme discomfort in social relationships

People with schizotypal personality disorders are extremely uncomfortable in close relationships, even with people who are familiar. They have no interest in forming friendships or sexual relationships. Their discomfort may be shown by the person acting cold and aloof when interacting with others.

· Few close relationships

Individuals with this disorder form few, if any, close relationships.

· Odd appearance and thinking

Their appearance and behavior is often characterized as odd or strange. A person with this disorder might complain of odd symptoms, such as pain in the blood or bones. Many believe they are clairvoyant, telepathic, or have a sixth sense.

· Suspicious or paranoid ideas

People with schizotypal personality disorder are very suspicious and may believe that others are talking about them. They may perceive references to themselves in others ‘conversations.

2. Treatment

People with schizotypal personality disorder rarely seek treatment for the symptoms listed above. They are more likely to seek treatment for a depressive disorder, if they have one. The therapist often reevaluates situations and challenges the person ‘s paranoia and suspicion. People with this disorder may benefit from a cognitive-behavioral approach called behavior modification to help them with peculiar mannerisms. Simple instruction, such as viewing videotapes to help them recognize and modify odd behaviors or visiting a speech therapist to help them speak more clearly and more effective, seems to help. Suicidal or severely socially impaired people may require temporary hospitalization. Hospitalization may help a socially impaired sufferer form new relationships and social contacts within the community. Some individuals improve significantly, while others experience little improvement.

VII. Cluster B: Dramatic, Emotional, or Erratic

*Antisocial

*Borderline

*Histrionic

*Narcissistic

A. Antisocial Personality Disorder

Perhaps, the most widely recognized and most validated personality disorders is antisocial personality disorder. It has received more attention and has been studied more than any other personality disorder. This disorder is characterized by a pattern of disregarding and violating others ‘rights and safety. Common symptoms of antisocial personality disorder are:

1. Common traits:

*Defiant

People with antisocial personality disorder do not feel it necessary to live by the norms and laws for behavior dictated by society. They regularly perform illegal acts that are grounds for arrest.
*Lack of remorse and empathy

Individuals with this disorder have no feelings of remorse for those whom they hurt. In fact, they may blame the victim for making them act in the harmful manner. They may rationalize why they have hurt people.

* Self absorbed

People with antisocial personality disorder are only concerned with their own needs and wants and do not care who they must hurt to achieving their goals. Because people with this disorder are so egocentric and lack empathy, they typically have few friends.

* Irresponsible

They have difficulty in fulfilling responsibilities and commitments such as jobs or financial obligations.
*Deceit

People with this disorder display a pattern of constant lying, use of aliases, and conning people for personal profit or pleasure.

* Irritable and aggressive

Individuals with antisocial personality disorder are frequently involved in physical fights or assaults. They have little concern for the safety of themselves or others.

Mental health professionals who work with this population claim these people have an emptiness and sadness at the heart of their personality. They often begin experimenting with drugs, alcohol, and sex at a very early age. People with this disorder are at risk for substance abuse, alcoholism, vagrancy, suicide, incarceration, criminal activity, and dying a violent death. Those with antisocial personality disorder who are able to avoid incarceration are typically exploitative, irresponsible, and deceptive. As spouses, they tend to be abusive, unfaithful, dishonest, and manipulative. Antisocial personality disorder symptoms tend to decrease as the person enters his/her thirties.

2. Prevalence

About 3% of men and 1% of women in the population have this disorder. There are estimates as high as

70- 80% of the prison population has antisocial personality disorder. In later adulthood, symptoms diminish and the person may not be involved in criminal activity, though some of the basic personality characteristics may remain.

3. Treatment

This is very difficult disorder to treat, especially if the person is forced into therapy by family members or the law. Medications are rarely used. However, in some cases, medications have been prescribed to reduce episodes of rage. Some half-way houses for ex-prisoners offer group

Therapy but the drop-out rate is extremely high. There are some programs for adolescent repeat offenders that include a wilderness setting and a rigorous curriculum. Their effectiveness is still being debated.

B. Borderline Personality Disorder

Borderline personality disorder is the most common personality disorder. It occurs in about 2% of the population. Symptoms usually flare up when a psychological stressor occurs, such as the threat of a break-up. When the stress subsides, the symptoms usually subside as well. People with borderline personality disorder may even experience brief periods in which they separate from reality. This disorder often overlaps with dysthymia (milder, longer lasting form of depression) and psychotic disorders. Nearly 90% of those with borderline personality disorder are also diagnosed with another personality disorder or major mental illness.

1. The major characteristics of borderline personality disorder are:

· Unstable personal relationships

People with borderline personality disorder fear abandonment and make desperate attempts to maintain relationships. However, their perception of relationships is so unstable that a friend can become an enemy over an ordinary disagreement.

· Unstable self-image

This disorder is characterized by marked uncertainty in major life issues, such as life goals, sexual orientation, values, career choices, or types of friends.

· Unstable emotions

Their emotional state can fluctuate dramatically from euphoria to intense anxiety to rage in a matter of hours or days. Typically, these emotional fluctuations are reactions to social interactions.

· Little control over impulses

Reckless impulsivity may cause people with this disorder to act in self-destructive ways such as driving dangerously or bingeing on food, alcohol, or sex.

The diagnosis of BPD received much attention after the release of a film called Fatal Attraction in which a character played by Glenn Close (Alex Forrest) shows some of the above symptoms. Remember that Alex Forrest is fictional character and not an actual patient. Nor was this character based on a true story or an actual patient. The illness can manifest itself in many ways, but rarely is violence taken out on another person or animal as portrayed in the film.

2. Prevalence and Risks

Ten to 20% of psychiatric patients are diagnosed with this disorder. There are about three times as many women than men diagnosed with borderline personality disorder. Nearly 3/4 of borderlines attempt suicide or display self-mutilating behaviors like cutting themselves with

razors or burning themselves. Only about l0~/~ of suicide attempts are successful. Symptoms of borderline personality disorder and risks of suicide are greatest during young adulthood and seem to diminish later in life. Most people with borderline personality disorder achieve some stability in their life as they age.

3. Treatment

The goal of therapy is to reduce the frequency of borderline behaviors and allow the person to be more adaptive to society. The best therapeutic approaches to this disorder are still being debated. It appears that establishing a trusting relationship with a therapist who does not punish borderline symptoms has positive results. The therapist must actively participate in the therapeutic process by giving the client constant assurance and support while emphasizing the harmful effect of drug abuse, promiscuity, or other behaviors. Group therapy is an effective supplement to individual therapy allowing the person to express his or her feelings without fear of repercussions. It also provides social support and the opportunity to develop more meaningful relationships with people in or outside the group.

Medications have only been effective at improving moods and sometimes behavior. Doctors are still exploring the effect of antidepressants, antipsychotic drugs, and anti-anxiety drugs. These drugs appear to reduce symptoms of impulsivity, depression, and cognitive impairment, and perceptual impairment. Hospitalization may be necessary if the person is having suicidal thoughts and behaviors.

C. Histrionic Personality Disorder

The word histrionic means "dramatic or theatrical". Individuals with this disorder attempt to get attention in strange and unusual ways. The basic characteristic to this disorder is a pattern of attention seeking and excessively emotional.

1. Characteristics

· Excessively emotional

People with histrionic personality disorder may have rapid shifts of emotion that may seem artificial. They may overreact emotionally or sexually to situations. They can be very manipulative, using emotional explosions to get their way.

· Attention seeking behavior

Individuals with this disorder have an intense craving for attention and feel uncomfortable when they are not the center of attention. They often dress flamboyantly or wear outrageous hairstyles. They may dress or act very sexually in an attempt to gain attention.

· Impressionable

They are very impressionable. People with this disorder are overly trusting and gullible. They often follow the latest trends in fashion, music, ete. They will also form beliefs with little evidence and defend these beliefs passionately.
Self-absorbed

People with histrionic personality disorder are usually vain and self-absorbed. They have superficial relationships and their speech and emotional expression lack genuine feeling.

· Concerned with presentation

Their personalities may change from situation to situation in an attempt to look more attractive to whomever is present Some people with this disorder function with relatively few problems in society. Other, more severe cases, may have maladaptive behavioral

patterns which cause significant difficulties in their lives. This disorder is present in about 2 to 3% of the general population and is more conunon among women.

2. Treatment

Individual psychotherapy is the main treatment for this disorder. The more severe the disorder, the longer the duration of therapy. Brief therapy can include a supportive, problem-solving approach, cognitive techniques to challenge distorted thinking, and interpersonal therapy to teach the person how to develop meaningful relationships. Brief therapy usually lasts four to twelve weeks. People with this disorder lack good analytical skills and the cognitive techniques that aid in developing them. However, a person with histrionic personality disorder can examine their manipulative behaviors and learn other ways to achieve satisfaction in their lives. Therapists may resort to videotaping to show these maladaptive behaviors. Group therapy also provides a supportive forum for feedback. Medication is typically not used for this disorder. People with this disorder are usually only hospitalized if they are having suicidal thoughts or behaviors.

D. Narcissistic Personality Disorder

As the name suggests, people with narcissistic personality disorder are quite self-absorbed. They display a pattern of grandiosity in fantasy or behavior. Acquaintances often describe them as arrogant and boastful.

Less than 1% of the population suffer from this disorder.

1. Characteristics

* Feelings of grandiosity

Not only do people with this disorder feel superior to others, but they also believe they are exceptionally unique and special. They believe they are entitled to special treatment simply because they are who they are. They may envy others while believing that others are envying them. They may exaggerate their accomplishments and talents.
*Need for admiration

People with this disorder seek constant admiration, adulation, and bolstering from others. They may be ambitious, not for success, but for fame and admiration.
*Lack of empathy

They have good social skills when it comes to initial contact with others. They may be quite charming in an attempt to gain the other person’s awe. However, they are so focused on themselves that they are not capable of empathizing with others.
*Preoccupation with fantasy

People with narcissistic personality disorder often fantasize about wealth and fame.

* Overly high expectations

If they do not achieve the goals they have set for themselves, they feel a strong sense of failure which brings feelings of shame and worthlessness. They often react to criticism with rage.

2. Treatment

In other disorders, brief therapy can result in permanent personality change. Brief therapy has not been shown to do the same for narcissistic personality disorder. Insight-oriented psychotherapy is typically the first treatments sought; both of these therapies take several years.

Insight-oriented psychotherapy, also called psychodynamic therapy, tries to provide the individual with greater insight into problems in the hope that this will change behavior. Insight-oriented psychotherapy analyzes aspects of the individual ‘s personality and tries to relate them to childhood conflicts. As with other personality disorders, the client-therapist relationship is crucial. Therapists try to empathize with clients about their sensitivities and disappointments which encourages the client to develop the same skills.

VIII. Cluster C: Anxious or Fearful

*Avoidant

*dependant

*Obsessive-Compulsive

A. Avoidant Personality Disorder

1. Avoidant personality disorder has three major characteristics:

· Social inhibition

People with this disorder may avoid social settings while at the same time desiring social relationships. Even when able to form relationships, they are clingy and fearful the relationship will end. These people usually become introverts because social situations are so uncomfortable. Because of their social inhibition, they will avoid occupations that involve significant contact with others.

· Feelings of inadequacy

Individuals with avoidant personality disorder view themselves as socially undesirable. They desperately want to be liked but their low self-esteem, oversensitivity, and fear of rejection keeps them from being involved in social relationships until it is clear that they will be accepted.

· Oversensitive to negative evaluation

Because people with this disorder fear embarrassing themselves in social situations, they may avoid occupational activities because they fear criticism, disapproval, or rejection. Those with avoidant personality disorder have a basic mistrust for others and believe that others are always watching and being critical of them.

2. Prevelance

Less than 1% of the general population has this disorder.

3. Treatment

These individuals should begin with supportive therapy techniques where they are able to form a supportive relationship with the therapist. Brief, long-term, and psychoanalytic insight-oriented therapies can all be helpful depending on the person ‘s goals and preferences. When the client is ready, behavioral therapies can be used to change maladaptive behaviors. It may also be used to reduce shyness and social anxiety, and develop assertiveness and social skills. This may even boost their confidence enough for the person to be more willing to take chances in social settings. Cognitive therapy techniques, which challenge incorrect assumptions and self-statements, may also be helpful in raising the person ‘s self-esteem. Sometimes, interpersonal therapy, which works to correct relationship difficulties, is used with the client and their family and friends. Group therapy can provide a supportive forum to help people with this disorder overcome social anxiety and in developing trust and support. Medications are rarely used, although it may be reassuring for the person to have the pills, just in case.

B. Dependant Personality Disorder

People with dependant personality go beyond the normal degree of interdependence to allowing another person to take over major areas in their lives. It is not unusual for people with this disorder to have another personality disorder. They are also at a higher risk for developing major depression, dysthymia, and anxiety disorders. There are no reliable estimates to this disorder ‘s prevalence.

1. The major traits of dependent personality disorder are:

· Need for others to control their lives

They have difficulty in making decisions or initiating new projects on their own. This is because they lack the self-confidence and trust in themselves, not because they lack motivation or energy.

* Submissive and clinging behavior

People with this disorder have problems expressing disagreement with others because they fear the person will not like them or support them afterwards.

· Fears of separati on and abandonment

Individuals with dependant personality disorder have a strong need to be taken care of. They will volunteer to do undesirable tasks to keep another person ‘s affection and support. After a relationship ends, they may feel so incapable, helpless, and alone that they will search for a new partner and enter into a relationship with the first person to come along.

· Lack of confidence in themselves and abilities

People with this disorder often belittle their own abilities and would describe themselves as dumb or stupid, Because they doubt their own ability to make decisions, they feel uncomfortable and helpless when no one is there to take care of them. A person with this disorder will rarely initiate projects or activities because they lack self-confidence in their judgment or abilities.

2. Treatment

Psychotherapy is the primary treatment for dependent personality disorder. Much of the time is spent teaching assertiveness skills, decision-making, and developing independence using behavioral and cognitive techniques. Like many of the personality disorders, a supportive therapeutic relationship is vital. Within this relationship, the person with dependent personality disorder will begin expressing their true feelings, make decisions, and deal with episodes of anxiety. This will help to boost their self-esteem. Group therapy can help them to

develop supportive relationships and provide an atmosphere to try their new social skills. Cognitive-behavioral therapy can help them challenge negative self-thoughts.

C. Obsessive-Compulsive Personality Disorder

This disorder is not like obsessive-compulsive disorder which is characterized by obsessions and compulsions. People with obsessive-compulsive personality disorder do not have obsessions and compulsions. Their preoccupation it is not intense enough to be considered an obsession. The one word that best describes obsessive-compulsive personality is perfectionistic. Individuals with this disorder are prone to depression, especially as they grow old and reflect on their lives. They realize they have not done or been everything they had hoped. This personality disorder occurs in about 1% of the population and twice as many men are diagnosed with it than women.

1. The three predominant traits associated with this disorder are:

· Perfectionism

People with this disorder have inflexible ethical standards that they feel people, including themselves, should follow. They are hesitant to delegate work for fear that it will not be done to their exact specifications. Since, they are unwilling to settle for imperfection, the disorder requires organization and discipline.

· Preoccupation with orderliness

People with this disorder pay excessive attention to details, rules, lists, and schedules to the extent that a larger purpose is lost. They may get so involved in the process of working toward a goal that they never reach the goal.

· Mental and interpersonal control

People with this disorder have difficulty in expressing warm emotions. Expressing these emotions would be a sign of emotional or mental weakness which they despise. Instead, they value emotional and mental control. Many of their thoughts begin with the words, "I should." They think rather than feel. When a person overanalyzes things in an attempt to distance themselves from the attached emotion, it is called intellectualization.

2. Treatment

The best treatment for obsessive-compulsive personality disorder is individual psychotherapy to help them accept themselves and their limitations. This is often accompanied with behavior modification therapy to change inflexible behavior patterns. Cognitive therapy as a technique

for individual therapy has been found to be particularly effective because it directly addresses the person ‘s illogical or rigid beliefs and suits the tendency to intellectualize things. Medications that ease depressive and anxiety symptoms often enhance the results of psychotherapy. Those who have been diagnosed with OCD (obsessive-compulsive disorder) may also benefit from medications which reduce compulsive behavior.

References

Andreasen, N. C. & Black, D. W. Introductory Textbook of Psychiatry . American Psychiatric Press, Inc. 1995.

Hales, D., & Hales, R E. Caring for the Mind. Bantum Books. New York, 1995.

Wilson, G. T., Nathan, P. E., 0 ‘Leary, K. D., & Clark, L. A. Abnormal Psychology: Integrating Perspectives . A. Simon & Schuster Company, 1992.

Cynthia C.Gonzalez, Ph.D. UT Pan American Educational Psychology Department