Two roads diverged in a wood, and I --

I took the one less traveled by,

and that has made all the difference.

--Robert Frost

Chapter 11

Personality Disorders

Dale L. Johnson

In the view of many people, the personality disorders are at the heart of abnormal psychology. In that judgment they are thinking of antisocial personality disorder and the strange, unnecessary cruel, violent behavior that is part of this disorder. There is more to the personality disorders, and some aspects of the disorders are virtually unknown to the general public.

There have always been conceptual problems with the personality disorders. They were first defined in terms of psychoanalytic theory, and remnants of that theory remain. However, with the revolution in thinking that resulted in the DSM-III the old theory had to go as it was not based on scientific evidence. The new personality disorders are based on scientific evidence, but for some of the disorders this evidence is scant. In addition, it has been difficult to sort out the key elements of the disorders. For example, Avoidant Personality Disorder is characterized by an avoidance of interpersonal relations. There is a fear of rejection and much anxiety. Perhaps this disorder should be placed with the anxiety disorders instead of the personality disorders.

Another problem is related to the basic form of these disorders. They are assumed to be abnormal extensions of normal behavior. Thus, it is normal to be socially reticent or introverted, but it is schizoid and abnormal to find relations with other people unnecessary at all. The disorders exist on a continuum, a matter of degree of severity, but in the DSM-IV they are treated as though they are categorical entities. One either has a personality disorder or one does not.

There may be a conceptual problem in the Personality Disorders scheme in that people so often are diagnosed as having more than one disorder. This was apparent in the diagnosis of John Hinkley, the man who shot President Reagan. At his trial he was given the following diagnoses by various experts: schizoid, narcissistic, borderline, passive-aggressive (other experts said he had schizophrenia, and the jury believed them).

The continuum idea holds that personality disorders are like traits. That is, they are relatively enduring aspects of personality that are not influenced much by immediate circumstances. The depression that occurs after the loss of a loved one is thought of as a emotional state; something that is linked to a particular circumstance and may occur even in people who are ordinarily happy. Traits persist. They are a feature of a person without regard to the circumstances.

If the dimensional view of personality disorders is taken seriously then one begins with a set of scientifically derived personality characteristics. These characteristics have been identified using a statistical technigue called factor analysis. In this a large number of questionnaire items are presented to a large group of subjects. The responses to these items are then factor analyzed to see which items are similar to each other. These similarities are called factors. Thousands of factor analytic studies have resulted in five factors (See figure below). Each factor is a dimensional structure with one form of the factor at one end, and the opposite at the other end. These factors comprise the main elements of human personality. The factors emerge in studies of human personality everywhere in the world.

If these are basic personality factors, then personality disorders should be based on these, but they are not in the DSM-IV. Perhaps they will be in some future DSM. If you examine the Big Five Factors and compare them with some of the DSM-IV disorders you can see that Antisocial Personality might be negatively linked to the Agreeableness Factor. Schizoid Personality might be negativelyassociated with the Extraversion Factor, and so on. It may be, however, that the Big Five Factors are not the only basic personality characteristics. Perhaps there are more. One candidate is "sensitivity to rejection." Even this raises many problems: rejection by whom? parents? boss? co-workers? children? And rejection about what? quality of work? interpersonal attentiveness?

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BIG FIVE PERSONALITY FACTORS

Extraversion Talkative, Assertive, Active

vs

Silent, Passive, Reserved

Agreeableness Kind, Trusting, Warm

vs

Hostile, Selfish, Mistrustful

Conscientiousness Organized, Thorough, Reliable

vs

Careless, Negligent, Unreliable

Neuroticism Even-Tempered

vs

Nervous, Moody, Temperamental

Openness to Imaginative, Curious, Creative

experience vs

Shallow, Imperceptive

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Personality disorders were once called, "character disorders," and the term had negative connotations as though the people with these disorders were not really ill or disabled and were manipulators. This bias seems to have been set aside for now.

Apparently not all personality disorders are equal. Searches of the literature using PsycInfo from 1988 to the present revealed the following pattern of numbers of publications:

Paranoid 34

Schizoid 53

Schizotypal 212

Antisocial 681

Borderline 1437

Histrionic 103

Narcissistic 142

Avoidant 128

Dependent 58

Obsessive Comulsive 82

Passive Aggressive 21

These differences in numbers of publications reflect differences in interest by researchers and practitioners, but also may indicate the number of people afflicted and the severity of the various disorders. In terms of disability, many other psychiatric disorders, such as schizophrenia and major depression, are more disabling, but the personality disorders are often accompanied by checkered work and marital histories.

Personality Disorder Clusters

The various personality disorders have been arranged into three clusters.

Cluster A: Odd or Eccentric Disorders

Paranoid Personality Disorder (PPD)

People with this disorder are distrustful and suspicious, but not out of contact with reality. This disorder clearly exists on a continuum. It is normal to look into the motives of others and to wonder what they are up to. At the other end of the continuum is the person with paranoid schizophrenia who develops delusions about the motives of others that defy reality. About 0.5% to 2.5% of the population have this disorder. There is substantial co-morbidity with schizotypal personality disorder. People with PPD are not at high risk for psychotic disorders.

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DSM-IV Criteria

A. A pervasive distrust and suspiciousness about othrs such that their motives are interpreted as malevolent, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following.

1. Suspects, without sufficient basis, that others are exploiting, harming, or deceiving him or her.

2. Is preoccupied with unjustified doubts about loyalty or untrustworthiness of friends and associates.

3. Is reluctant to confide in others because of unwarranted fear that the information will be used maliciously against him or her.

4. Reads hidden demeaning or threatening meanings into benign remarks or events.

5. Persistently bears grudges; i.e., is unforgiving of insults, injuries or slights.

6. Perceives attacks on his or her character or reputation that are not apparent to others and is quick to react angrily or to counterattack.

7. Has recurrent suspicions, without justification, regarding fidelity of spouse or sexual partner.

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Cause

The disorder is believed to have a strong genetic basis.

They are often marginalized, that is, they live in society, but do not interact with many people and do not feel that they are really a part of the society.

Treatment

They rarely seek treatment: "It is not me, it is the world that is out to get me."

Cognitive behavior therapy is a likely candidate, but there has been little research.

Schizoid Personality Disorder (SPP)

These are social isolates, and they prefer it that way. They seem not to need people. They do not seek out the company of others. The man called "The Unabomber," Theodore Kaczynski, almost certainly had Schizoid Personality Disorder. This disorder is found in fewer than 1% of the population.

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DSM-IV Criteria

A. A pervasive pattern of detachment from social relationships and a restricted range of expression of emotions in interpersonal settings, beginning in early childhood and present in a variety of contexts, as indicated by four of the following.

1. Neither desires nor enjoys close relationships, including being part of a family.

2. Almost always chooses solitary activities.

3. Has little, if any, interest in having sexual experiences with another person.

4. Takes pleasure in few, if any, activities.

5. Lacks close friends or confidants otehr than first degree relatives.

6. Appears indifferent to praise or criticism from others.

7. Shows emotional coldness, detachment or flattened affectivity.

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Cause

People are born with this disorder, it does not result from inadequate parenting, abusive experiences, or stress.

Treatment

Training in social skills development is emphasized, but there is little evidence of treatment effectiveness. People with this disorder typically do not see a need for treatment.

Schizotypal Personality Disorder (SztPD)

This disorder is characterized by odd beliefs, magical thinking, and social isolation. Many of these people have reported sighting flying saucers. Recent research makes it quite clear that this disorder is related to schizophrenia, with some people with the disorder going on to develop schizophrenia. However, most do not. About 3% to 5% of the population have this disorder.

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DSM-IV Criteria

A. A pervasive pattern of social and interpersonal deficits marked by acute discomfort with and reduced capacity for, close relationships as well as by cogntive or perceptual eccentricities of behavior beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following.

1. Ideas of referenece.

2. Odd beliefs or magical thinking that influences behavior and is inconsistent with cultural norms (e.g., superstitiousness, belief in clairvoyance, telephathy, or "sixth sense."

3. Unusual perceptual experiences, including body illusions.

4. Odd thinking and speech (e.g, vague, circumstantial, metaphorical, overelaborate, or stereotyped).

5. Suspiciousness or paranoid ideation.

6. Inappropriate or constricted affect.

7. Behavior or appearance that is odd, eccentric or peculiar.

8. Lack of close friends or confidants, other than first degree relatives.

9. Excessive social anxiety that does not diminish with familiarity and tends to be associated with paranoid fears other than negative judgments about self.

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Cause

Genetics is almost certainly involved. In addition, to the extent that this disorder is related to schizophrenia there may be similar causes; i.e., birth injury, maternal exposure to flu or other viruses during pregnancy. In one study of cognitive functioning schizotypal disorder patients fell between normals and people with schizophrenia (Cadenhead, 1999, Schizophrenia Research, 37, 123-132. There is some agreement today that SZTPD) is part of a spectrum of schizophrnia disorders.

Treatment

Social skills training is used. Anti-psychotic drugs are sometimes used, typically in small doses. Cognitive behavior therapy should be used.

In general, there has been little research.

New Developments

Schizoptypal personality disorder is being given a closer look because research has shown that some people with this disorder, or this trait, later develop schizophrenia. Attempts to prevent the onset of schizophrenia have led to interventions with people who have schizotypal personality disorder. To date, these attempts have not been very successful, but this is a new research area and more is expected.

Cluster B: Dramatic, Emotional or Erratic Disorders

Antisocial Personality Disorder (ASPD)

People with this disoder are without doubt the stars of abnormal psychology. We spend a great deal of time thinking about them and the media thrives because of their behavior. Many of convicted criminals have ASPD, but it is important to know that not all do.

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DSM-IV Criteria: Antisocial Personality Disorder

A. There is a pervasive pattern of disregard for the rights of others occurring since age 15 years, as indicated by three (or more) of the following:

1. Failure to conform to social norms with respect to lawful behavior as indicated by repeatedly performing acts that are grounds for arrest.

2. Deceitfulness, as indicated by repeated lying, use of aliases, or conning others for personal profit or pleasure.

3. Impulsivity or failure to plan ahead.

4. Irritability and aggressiveness, as indicated by frequent fights or assaults.

5. Reckless disregard for safety of self or others.

6. Consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or honor financial obligations.

7. Lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated or stolen from another.

B. The individual is at least 18 years.

C. There is evidence of Conduct Disorder with onset before age 15 years.

D. The occurrence of antisocial behavior is not exclusively during the course of schizophrenia or manic episode.

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DSM-IV Criteria: Conduct Disorder

A. A repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated, as manifested by the presence of three (or more) of the following criteria (in the past 12 months) with at least one criterion present in the past 6 months.

Aggression to people and animals

1. Often bullies, threatens or intimidates others.

2. Often initiation physical fights.

3. Has used a weapon that can cause serious physical harm to others (e.g., a bat, brick, broken bottle, knife, gun)

4. Has been physically cruel to people.

5. Has been physically cruel to animals.

6. Has stolen while confronting a victim (e.g., mugging, purse snatching, extortion, robbery).

7. Has forced someone into sexual activity.

Destruction of property

8. Has deliberately engaged in fire setting with the intention of causing serious damage.

9. Has deliberately destroyed others' property (other than by fire setting).

Deceitfulness or theft

10. Has broken into someone's house, building or car.

11. Often lies to obtain goods or favors, or to avoid obligations (i.e., cons others).

12. Has stolen items of nontrivial value without confronting a victim (e.g., shoplifting, but without breaking and entering; forgery).

Serious violations of rules

13. Often stays out at night despite parental prohibitions, beginning before age 13.

14. Has run away from home overnight at least twice while living in parental or parental surrogate home (or once without returning for a lengthy period).

15. Is often truant from school, beginning before age 13 years.

B. The disturbance in behavior causes clinically significant impairment in social, academic or occupational functioning.

C. If the individual is 18 years or older, criteria are not met for Antisocial Personality Disorder.

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Famous People

Yes, some famous people could have been diagnosed as antisocial personality disorder. These include

Herman Goering, one of Hitler's confidants.

Charles Manson. He was an illegitimate child and spent 17 of his first 32 years in prison. He hated the rich and African Americans. He used the Book of Revelation to justify his actions. He was a seducer and hypnotist.

Richard Speck. Killed many people. Wrote a note: "Stop me before I kill more."

Son of Sam Berkowitz. Killed 6 people on a spree. He was a mild-mannered postal worker. He said his dog ordered him to kill. He killed the dog, and the people. He appeared paranoid, but psychiatric examination confirmed a diagnosis of antisocial personality disorder.

Prevalence

A study done by the National Institute of Mental Health, the ECA study (Archives of General Psychiatry, 1984) showed the following:

Lifetime Prevalence

Total Males Females

New Haven 2.1 3.9 0.5

Baltimore 2.6 4.9 0.7

St Louis 3.3 4.9 1.2

Thus, data, now nearly twenty years old, suggest a sex ratio of about 4:1. However, Kessler's more recent research found prevalences of 5.8 for males and 1.2 for females indicating a ratio more like 5:1. This is a male disorder, but it is worth noting that the female prevalence is not low; it is about 1% of the adult population.

Terms

This disorder has had a troubled terminological history and the following terms have all been used:

antisocial personality = sociopath = psychopath = character disorder. As may be seen, all are pejorative, but not without cause. People with Antisocial Personality Disorder are often involved in criminal activities. I have known people with APD who were charming, full of tales of adventure, and socially skilled. One such man made a living flying guns into central American and drugs into the USA. He was wanted by police in several countries, but apparently did little to hide his notoriety. He received his basic training as a pilot with the air force in Viet Nam.

Etiology

Role of the Family

McCord, McCord, Zola, & Gudeman (1959) followed-up participants in the Cambridge Somerville studies of the 1930s. They also looked at other research. They concluded:

"Psychopaths have suffered from emotional deprivation, punishment, neglect, ostracism, or some other form of early socialization that severely cripples their ability to identify with other people, empathize with them or learn social values." (p. 165)

The following family features were found:

Maternal neglect or extreme dominance

Severe, inconsistent discipline by fathers

Aggressive fathers

All especially important in the first 5 years

In the Somerville follow-up, counselors predicted that 16 boys would become violent. 15 did.

Parental rejection never has positive effects on children. A common reaction to parental rejection is aggression and guiltless behavior. I have seen men who reported having had miserable, rejecting childhoods and they said they had made a decision to hurt others in retaliation and to be emotionally hard. These accounts were, of course, retrospective.

It should be noted that some rejected children withdrawn and become self-sufficient. It is though they have given up on social relations.

The next study is the Robins (1966) longitudinal study. This was a prospective study of 584 cases, children seen in child guidance clinics. The Houston Child Guidance Clinic was included. 90% of the children were located 30 years later. The conclusions were:

1) No child without frequent or serious antisocial behavior became an antisocial adult.

2) 32% of children with frequent or serious antisocial behavior became sociopathic adults.

3) Later sociopaths showed clear antisocial behaviors by age 10.

4) Psychopathic fathers were common.

Zuckerman (Psychological Bulletin, 1980,88, 187-214.)points to a psychological characteristic, a trait, which he calls "sensation seeking." He developed a test that identifies this feature and finds that people with antisocial personality disorder score high on sensation seeking. Sensation seeking is associated with strength of intitial orienting reflex, augmenting versus reducing the average evoked potential, the enzyme monoamine oxidase, and gonadal hormones (both androgen and estrogens).

Genetic

There have been several twin studies of antisocial disorder.

Identical Fraternal Fraternal,Opposite Sex

MZ DZ DZ

Kranz, 1936 66 54 14

Eysenck, 1978 58 13

Christensen, 1977 69 33

As may be seen, the eveidence is strong for a genetic factor, but the results of the three studies vary greatly. They are in agreement on the identical twins, but not on the fraternal twins. The textbook discusses more recent studies of gene-environment interactions and they seem to come through strongly as having a causal role.

Some men with violent antisocial behavior have a genetic condition that affects monoamine oxidase-a, an enzyme critical for communication between brain cells.

Central Nervous System Activity and Sociopathy

Although the evidence for an environmental cause is strong, there is also strong evidence for brain function involvement, and this may be genetic.

There are two related hypotheses, underarousal and fearlessness. The circus performer, high wire walker, Walender, once replied when asked why he walked the high wire, "Life is on the high wire; the rest is just waiting." His level of fearlessness was extraordinarily high.

Not all fearless people, such as those who jump with parachutes from airplanes, or climb high cliffs, or do bungee jumping off bridges are antisocial personalities. Indeed, very few are. Most are simply normal, but quite a few are depressed, and willing to take unusual risks because they do not care if they live or die.

Underarousal. It is clear from a large number of studies that people with APD have unusually low levels of arousal. To feel "normal" they need stimulation. The Yerke-Dodson Law included a U-curve of arousal. We tend to need a certain optimal level of arousal and do not feel right with too much or too little.

People with ASPD have

--lower skin conductance levels and lower heart rates. This suggests a greater need for stimulation.

--slow pulse rates of children taking an exam at age 11 predicted delinquent acts by age 21 (Wadsworth).

--more low level brain wave activity. They have excessive Theta waves when awake, suggesting impulsivity and immaturity.

--On Lykken's Activity Preference Questionnaire they chose the more frightening option more often.

--results on conditioning experiments that suggest they learn more slowly.

--more difficulty learning to avoid punishment.

Electroencephalogram (EEG) results suggest that there is some kind of abnormality. Slow waves are common and these are associated with dysfunctionof the inhibitory mechanisms. This, in turn, may be related to the APSD person's inability to learn to avoid or escape from punishment.

Schacter found they were less likely to show learning improvement when shocked. They did better when their adrenaline levels were high.

Hare found they "tune out" negative information.

People with ASPD tend to "pass" lie detectors even when known to be lying.

Treatment

Treatment is very difficult and psychotherapy has not demonstrated effectiveness. People with this disorder are not honest clients and they do not seek therapy.

There is some evidence that preventive programs are effective. My Houston Parent-Child Development Program reduced rates of conduct disorder. The same result has been obtained with somewhat different prevention programs by David Weikart in Michigan and David Olds in New York [Term paper topic?].

Reform schools and prisons are poor places for the rehabilitation of the person with ASPD. They are training schools for crime.

Some years ago a sociologist, Cressey, offered principles for the effective treatment of criminals:

1) If criminals are to be changed, they must be assimilated into groups which emphasize values conducive to law-abiding behavior and, concurrently, alienated from groups emphasizing values conducive to criminality. Special groups must be created.

2) The more relevant the common purpose of the group to the reformation of criminals, the greater will beits influence on the criminal members' attitudes and values.

3) The more cohesive the group, the greater the members' readiness to influence otehrs and the more relevant the problem of conformity to group norms. There must be a strong "we feeling."

4) Both reformers and those to be reformed must achieve status within the group by exhibition of "pre-reform" or anti-criminal values and behavior patterns.

5) The most effective mechanism for exerting group pressure on members will be found in groups so organized that criminals will be induced to join with non-criminals for the purpose of changing other criminals.

These principles were applied with success in the Provo, Utah, juvenile delinquency center, but they have been ignored by most state prison/reformation officials. These administrators have been guided more by the belief that the public is more interested in punishing criminals than in their rehabilitation. Thus, prisons and juvenile institutions are allowed to be brutal and dehumanizing, and the result is that we have an enormous number of people in penal institutions. Many who commit violent or drug-related crimes are imprisoned for excessively long periods and others use the revolving door of admission, release and readmission. Rehabilitation would be less expensive.

Perhaps the most effective program for ex-convicts, a group that includes many people with APD, is the Delancey Street Experience. This residential program was begun by psychologist Mimi Silbert, and her friend, John Maher, a recovering addict.

The program has no professionals, or expert advisors. It is run for and by the residents. On guiding principle is that the resident must take responsibility for his or her actions. Each person is supervised by another person, and, in turn, is the supervisor of someone else. Delancey runs businesses--moving vans, furniture refinishing and sales, etc. The organization functions with two groups: Wall Street, which handles business issues, and The Vatican, which handles interpersonal issues. No one leaves Delancey until they have three marketable skills. There are no losers. All work and no one gets a salary. They share all proceeds and get housing, food, clothing and entertainment. There is an emphasis on self-improvement. They work to increase their vocabularies, they read Emerson on self-reliance, they learn how to manage money, and they study anthropology and ecology. Human relation trainng methods are used throughout. They learn to be good citizens and help others.

Although there have been no formal evaluations of the program they have expanded to many places after the first one in San Francisco, and their businesses are thriving. Delancey Street probably works because the cons have no one to con. They judge and are judged by their peers, not by outsiders.

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Borderline Personality Disorder (BPD)

People with this disorder lead stormy, emotional lives with inconsistent interpersonal relations and erratic educational and work histories. They are at high risk for suicide. The term "borderline" was chosen because it was once believed that these people were at the borderline between neurosis and psychosis. In terms of severity of mental disorders it is not such a bad idea.

Two early ideas about BPD have been revised. It was once thought that everyone with BPD had been abused as a young child. We know this is not true. It was also believed that BPD was a disorder of women. Again, not true although more women than men have the disorder. As for abuse, there is a linear relation between severity of abuse as a child and severity of symptoms as an adult.

There is a strong genetic component in the development of BPD and this may be especially important for such aspects as emotional regulation, impulse/action patterns, cognitive organization including planning ability and anxiety. Serotonergic and cholinergic stystems are involved. There is evidence that some children who have received a diagnosis of attention deficit disorder later develop BPD.

An interesting part of the theory of cause is that when women with BPD and their parents are examined about family experiences the daughters report much higher levels of dysfunction than do their parents. It may be that the disorder results in negative distortions of their early experiences. This was the case in a careful study by Lewinsohn with depressed women and their parents. When the women were depressed they reported negative early experiences, but when they were not depressed they said their experiences were good.

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DSM-IV Criteria:: Borderline Personality Disorder

A. A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following.

1. Frantic efforts to avoid real or imagined abandonment.

2. Patterns of unstable and intense interpersonal relationships, characterized by alternating between extremes of idealization and devaluation.

3. Identity disturbance: markedly and persistently unstable self-image or sense of self.

4. Impulsivity in at least two areas that are potentially self-damaging; e.g., spending, sex, substance abuse, reckless driving, binge eating.

5. Recurrent suicidal behavior, gestures or threats, or self-mutilating behavior.

6. Affective instability due to marked reactivity to mood (e.g., intense episodic dysphoria, irritability, or anxiety, usually lasting a few hours, and rarely, a few days.

7. Chronic feelings of emptiness.

8. Inappropriate intense anger or difficulty controlling anger.

9. Transient, stress-related paranoid ideation or severe dissociative symptoms.

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Treatment

Treatment is difficult because they have so much difficulty in forming relationships with people, including therapists. They begin by finding the therapist marvelous, and in a week, the therapist is seen as betraying them, dishonest and incompetent. The textbook describes Linehan's dialectial behavior therapy method. It seems to have been the most accepted form of treatment, but effectiveness has not been established.

Histrionic Personality Disorder (HPD)

Drama is everything: the sweeping entrance, the emotional outpouring over what other people see as trivial, the threats of death if rejected. These are people who need people, if only for an audience. They love applause and praise. To other people they seem shallow. This disorder is found in 2% of the population. Women and men are equally affected. This is the only disorder in the DSM that includes physical attractiveness as a diagnostic element. Actually, women with HPD have been rated as better looking than women in general. Men with HPD are not more attractive. People with HPD seem preoccupied with sex, but report little sexual satisfaction.

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DSM-IV Criteria

A. A pervasive pattern of excessive emotionality and attention-seeking, begining by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following.

1. Is uncomfortable in situations in which he or she is not the center of attention.

2. Interaction with others is often characterized by inappropriate sexually seductive or provocative behavior.

3. Displays rapidly shifting and shallow expressions of emotions.

4. Consistently uses physical appearance to draw attention to self.

5. Has a style of speech that is excessively impressionistic and lacking in detail.

6. Shows self-dramatization, theatricality, and exaggerated expression of concern.

7. Suggestible; i.e., easily influenced by others or by circumstances.

8. Considers relationships to be more intimate than they acually are.

Causes

Is this the classic "hysteric personality?" If so, then perhaps Freud's formulations about them are appropriate.

There is some evidence that they are similar to antisocial personality disorder, but this may be limited to the interpersonal shallowness and dishonesty that characterizes each.

Treatment

First off, what is the problem? There is little evidence of disability? People with this disorder do not seek help. They are a minor pain for most other people, but some find them charming--in the short run. Clinical trials with this disorder are small and not very impressive. Psychodynamic therapy has been regarded as the treatment of choice, and there was some evidence of success in Luborsky's Menninger Institute study, but the study was not scientifically acceptable.(Note how we fall back on Freud if we don't know.)

Narcissistic Personality Disorder (NPD)

Everyone places self first in most interactions or endeavors, and it is natural to do so. We know ourselves best, what we can do, what we look like, and what we are interested in. We have to take care of Number One.

Some people take this to an extreme and are regarded by others as a real pain. They nearly always put themselves first, without even trying to think of the other. They are hard to live with. Some find them impossible to live with. Of course, there degrees of narcissism. Note that the criteria below are repetitious, as though the definers of the criteria were not clear about the disorder and how they wanted to define it. Also note the overlap with Antisocial Personality Disorder. Fewer than 1% of adults have the disorder. They tend to have a variable mood and self-esteem. Many have a sense of self-entitlement that is pervasive. They expect to be treated well by others because they deserve it.

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DSM-IV Criteria: Narcissistic Personality Disorder

A. A persvasive pattern of grandiosity in fantasy or behavior, need for admiration, and lack of empathy, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following.

1. Has a grandiose sense of self-importance (e.g., exaggerates achievements and talents, expects to be recognized as superior without commensurate achievements).

2. Is preoccupied with fantasies of unlimited success, power, brilliance, beauty or ideal love.

3. Believes that he or she is "special" and unique and can only be understoood by, or should associated with, other special or high-status people (or institutions).

4. Requires excessive admiration.

5. Has a sense of entitlement, i.e., unreasonable expectations of especially favorable treatment or automatic compliance with his or her expectations.

6. Is interpersonally exploitive; i.e., takes advantage of others to achieve his or her own ends.

7. Lacks empathy, is unwilling to recognize or identify with the feelings an needs of others.

8. Is often envious of others or believes that others are envious of him or her.

9. Shows arrogant, haughty behaviors or attitudes.

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Cause

The absence of empathy for the other, or the ability to see oneself as others see one, suggests that something biological is involved. It is as though the person lacks something important for being a normal, sociable human.

The psychosocial studies have all been retrospective, and thus do not produce solid scientific evidence.

Treatment

Behvioral methods have had modest success when they have focused on social skills and the aleviation of social anxiety.

Cluster C: Anxious or Fearful Disorders

Avoidant Personality Disorder (APD)

People with this disorder are similar to those with schizoid in that they avoid people, but the person with avoidant disorder acts as though people are important and does not like being a social isolate. They fear rejection and to avoid being rejected avoid becoming socially involved. Note the overlap with Schizoid Personality Disorder and Social Phobia. Fewer than 1% of the population have this disorder.

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DSM-IV Criteria: Avoidant Personality Disorder

A. A persvasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following.

1. Avoids occupational activities that involve significant interpersonal contact because of fears of criticism, disapproval or rejection.

2. Is unwilling to be involved with people unless certain of being liked.

3. Shows restraint with intimate relationships because of the fear of being shamed or ridiculed.

4. Is preoccupied with being criticized or rejected in social situations.

5. Is inhibited in new interpersonal situations because of feelings of inadequacy.

6. Views self as socially inept, personally unappealing, or inferior to others.

7. Is usually reluctant to take personal risks or to engage in any new activities because they might prove embarrassing.

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Cause

The main theory of cause is that the person has experienced considerable social rejection by parents or other poople important in their lives. Research on this matter is very weak. All of it has been based on retrospective reports; none on longitudinal data.

Treatment

Behavioral training has shown some success. Methods used to treat the anxiety associated with the disorder are also successful. It seems likely that Interpersonal Therapy would be natural treatment, but I have seen no reports of its use.

Dependent Personality Disorder (DPD)

The person clings to others. If a decision must be made this person looks to see what others are doing, and follows along. They tend to distrust their own views or abilities. About 2% of the population meet criteria.

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DSM-IV Criteria: Dependent Personality Disorder

A. A persvasive and excesswive need to be taken care of that leads to submissive and clinging behavior and fears of separation, beginning by early childhood and present in a variety of contexts, as indicated by five (or more) of the following.

1. Has difficulty making everyday decisions without an excessive amount of advice and reassurance from others.

2. Needs others to assume responsibility for most major decisions of his or her life.

3. Has difficulty expressing disagreement with others because of fear of loss of support or approval.

4. Has difficulty initiating projects or doing things on his or her own because of lack of self-confidence in judgment or abilities rather than lack of motivation or energy.

5. Goes to excessive lengths to obtain nurturance and support from others to the point of volunteering to do things that are unpleasant.

6. Feels uncomfortable or helpless when alone because of exaggerated fears of being unable to care for self.

7. Urgently seeks another relationship as a source of care when a close relationship ends.

8. Is unrealistically preoccupied with fears of being left to take care of self.

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Causes

Although it seems research is sparse, it is quite possible that there is a genetic component. It is also possible that the disorder is a product of social training.

Treatment

There is very little research on treatment. Some people grow out of being hyper dependent, as circumstances change. For example, a woman who is very dependent on her mother may become less dependent as the mother ages and needs the help of her daughter.

Obsessive-Compusive Personality Disorder (OPCPD)

The person with this disorder is very concerned with doing things the right way and is preoccupied with this concern. About 4% of people have this disorder. There is a diagnostic question as to whether the person has obsessive-compulsive personality disorder or the more severe obsessive-compulsive disorder. People with obsessive-compulsive personality disorder tend not to be very obsessive, but are rigid, and perfectionistic. If diagnosticians used a dimensional system instead of a categorical system it is unlikely that this disorder would be separate from Axis I Obsessive Compulsive Disorder.

The role of people with this disorder in the workplace is problematic. On the one hand they tend to do excellent work. On the other, they do not get things in on time. Consider a person who is in a managerial position in a research project. She has high aspirations and has a thorough knowledge of the subject of the research. In preparing reports for research conferences she has every detail at hand and has the research crew working with their assigned tasks. However, the deadline for the reports approaches and she is not finished. She stays up all night working on the report and sleeps through the research meeting. I once worked with such a person and found it extremely difficult. I do not like last-minute preparations and think it is counter-productive to be sleepy during key research conferences. The woman had been in dynamic psychotherapy for years with no perceptible effect on her behavior.

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DSM-IV Criteria: Obsessive-Compusive Personality Disorder

A. A persvasive pattern of preoccupation with orderliness, perfectionism, and mental and interpersonal control, athe expense of flexibility, openness, and efficiency, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following.

1. Is preoccupied with details, rules, lists, order, organization, or schedules to the extent that the major point of the activity is lost.

2. Shows perfectionism that interferes with task completion; e.g., is unable to complete a project because his or her overly strict standards are not met.

3. Is excessively devoted to work and productivity to the exclusion of leisure activities and friendships.

4. Is overconscientious, scrupulous, and inflexible about matters of morality, ethics, or values.

5. Is unable to discard worn-out and worthless objects even when they have no sentimental value.

6. Is reluctant to delegate tasks or to work with others unless they submit to exactly his or her way of doing things.

7. Adopts a miserly spending style toward both self and others; money is viewed as something to be hoarded for future catastrophes.

8. Shows rigidity and stubbornness.

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Causes

There probably is a genetic component, but it does not seem to be strong. Family training almost certainly has a part in this. Personal discovery and rewards also play a role. The person discovers through practice that doing things carefully and getting them right brings rewards.

Treatment

Little is known, in part because this is not a very disabling condition and people do not seek help. There is often co-morbidity with depression, and treatment for depression is appropriate.

Other Types of Personality Disorders

These have been suggested, but have not passed committe scrutiny for inclusion in the DSM.

Sadistic

Self-Defeating

Depressive

Negativistic

Passive-Aggressive

Road Rage

General Treatment

Prozac (fluoxetine) has been used with a wide variety of personality disorders. All showed improvement Improvement was sufficient to move people from a personality diagnosis to normal (Fara, 2002, Psychological Medicine, 32, 1049-1057).