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Cluster A Personality Disorders
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Paranoid Personality Disorder
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Essentials of Diagnosis
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DSM-IV-TR Diagnostic Criteria
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A pervasive distrust and suspiciousness of others 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:
suspects, without sufficient basis, that others are exploiting, harming, or deceiving him or her
is preoccupied with unjustified doubts about the loyalty or trustworthiness of friends or associates
is reluctant to confide in others because of unwarranted fear that the information will be used maliciously against him or her
reads hidden demeaning or threatening meanings into benign remarks or events
persistently bears grudges, i.e., is unforgiving of insults, injuries, or slights
perceives attacks on his or her character or reputation that are not apparent to others and is quick to react angrily or to counterattack
has recurrent suspicions, without justification, regarding fidelity of spouse or sexual partner
Does not occur exclusively during the course of schizophrenia, a mood disorder with psychotic features, or another psychotic disorder and is not due to the direct physiological effects of a general medical condition.
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(Reprinted, with permission, from the Diagnostic and Statistical Manual of Mental Disorders. 4th edn. Text Revision. Washington, DC: American Psychiatric Association, 2000.)
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General Considerations
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The prevalence of paranoid personality disorder has been estimated at 0.5–4.5% of the general population. It is relatively common in clinical settings, particularly among psychiatric inpatients. Individuals with a paranoid personality disorder typically rarely seek treatment on their own. They are usually referred by family members, coworkers or employers. The disorder appears to be slightly more common in women than in men.
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Although the etiology of paranoid personality disorder is uncertain, both genetic and environmental aspects are thought to play an etiologic role. For example, the risk of developing the disorder is somewhat enhanced in families with a history of schizophrenia and delusional disorders. Environmentally, the risk for this disorder appears to be increased if the individual's parents exhibited irrational outbursts of anger, and where the frequent fear the individual experienced as a child is projected onto others later in life.
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Although the finding is not a strong one, paranoid personality disorder patients do have more biological relatives with schizophrenia than with controls. The link between paranoid personality disorder and schizoid personality disorder is quite weak, although measurable.
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There is some evidence that paranoid personality disorder is more common among individuals with a family history of schizophrenia or delusional disorder, persecutory type, compared to controls. However, this is not a particularly strong finding.
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The cardinal feature of paranoid personality disorder is the presence of generalized distrust or suspiciousness. Individuals feel that they have been treated unfairly, are resentful of this mistreatment, and bear long-lasting grudges against those who have slighted them. They place a high premium on autonomy and react in a hostile manner to others who seek to control them and they can be violent. These patients are often unsuccessful in intimate relationships because of their suspiciousness and aloofness.
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When interviewed, patients with a paranoid personality disorder are formal, businesslike, skeptical, and mistrustful, and exhibit poor or fixated eye contact. They consistently project blame for their difficulties onto others, externalizing their own emotions while paying keen attention to the emotions and attitudes of others. Underlying their formal and at times moralistic presentation is considerable hostility and resentment.
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Differential Diagnosis
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There is considerable overlap between patients with paranoid personality disorder, patients with schizoid personality disorder, and those with schizotypal personality disorder. Of those patients with schizoid personality disorder, 47% were also diagnosed as also having a paranoid personality disorder. In addition, the disorder often appears in combination with schizotypal personality disorder, although this in part is because of the shared feature of paranoid ideation. Other common personality disorder comorbidities include the borderline and narcissistic personality disorders. When paranoid personality disorder is comorbid with narcissistic personality disorder, the paranoid features serve to justify the patient's delusions of persecution, with the obstructions of others seen as evidence of the merit of the patient's overvalued ideas. Paranoid personality disorder is similar to several Axis I disorders. These include delusional disorder—persecutory type, schizophrenia, and paranoid type. Paranoid personality disorder is distinguished from the above Axis I disorders by the absence of delusions, hallucinations, and defective reality testing, although differentiation is not always easy.
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Psychopharmacologic Interventions
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There is little available data to suggest that pharmacologic interventions are of significant benefit in paranoid personality afflicted individuals. Although not demonstrated by controlled clinical trials, low-dose antipsychotic medications may decrease the patient's paranoia and anxiety. Under situations of stress, some patients decompensate, and the paranoid ideation reaches delusional proportions. In such cases antipsychotic medication can be of obvious benefit.
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Psychotherapeutic Interventions
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Group/Marital Interventions
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Group therapy can be quite difficult for patients with paranoid personality disorder. Their lack of basic trust and their suspiciousness often prevent them from being integrated fully into groups. Their wariness and suspiciousness may become self-fulfilling, as their hostility makes other members uncomfortable and rejecting. Paranoid personality disorder patients sometimes present for treatment as couples or as a family. Working with them in this context is also difficult, since such patients often feel that the therapist and family members are working against them.
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Individual Psychotherapies
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Patients with paranoid personality disorder represent a unique challenge to the psychotherapist. They lack trust, and thus, rarely enter treatment unless there is another coexisting emotional disorder, such as a mood or anxiety disorder, or coercion from a family member or employee. They have difficulty relinquishing control, and may not tolerate the ambiguity associated with the less directive interventions. Among behavioral techniques used, social skills role playing, particularly involving appropriate expression of assertiveness has been reported. No therapeutic techniques have actually been proven efficacious in treating paranoid personality disorder patients. However, clinical wisdom suggests that cognitive techniques that focus on the patient's overgeneralizations (e.g., “That person didn't talk to me; therefore, he hates me.”) and their propensity to dichotomize the social world into trustworthy and hostile are useful. With psychodynamic and interpersonal approaches, interpretations are used sparingly, and treatment focuses on the gradual recognition of the origins and negative consequences of the patient's mistrust.
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Little is known about the long-term outcome of paranoid personality disorder. Although the disorder is difficult to treat, patients generally appear to have a greater adaptive capacity than do those who have personality disorders associated with severe social detachment. However, under stress, patients with paranoid personality disorder usually withdraw and avoid interpersonal attachments, thus perpetuating their mistrust, and they may become overtly psychotic.
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Schizoid Personality Disorder
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Essentials of Diagnosis
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DSM-IV-TR Diagnostic Criteria
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A pervasive pattern of detachment from social relationships and a restricted range of expression of emotions in interpersonal settings, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following:
neither desires nor enjoys close relationships, including being part of a family
almost always chooses solitary activities
has little, if any, interest in having sexual experiences with another person
takes pleasure in few, if any, activities
lacks close friends or confidants other than first-degree relatives
appears indifferent to the praise or criticism of others
shows emotional coldness, detachment, or flattened affectivity
Does not occur exclusively during the course of schizophrenia, a mood disorder with psychotic features, another psychotic disorder, or a pervasive developmental disorder and is not due to the direct physiological effects of a general medical condition.
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(Reprinted, with permission, from the Diagnostic and Statistical Manual of Mental Disorders. 4th edn. Text Revision. Washington, DC: American Psychiatric Association, 2000.)
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General Considerations
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Estimates of the prevalence of schizoid personality disorder in the general population vary with the criteria used, ranging from 0.5–7% and individuals with this disorder are relatively uncommon in clinical settings. The disorder occurs more often in men than in women and may be more severe in men. The general withdrawal of patients with schizoid personality disorder means that they rarely disturb others, and in part this accounts for their rare appearance in treatment settings.
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The diagnosis of schizoid personality disorder has become restricted to people with a profound defect in the ability to form personal relationships and to respond to others in a meaningful way.
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The causes of schizoid personality disorder are not well understood. Genetic factors are suspected, and some reports suggest that patients with this disorder often come from environments that are deficient in emotional nurturing. There is also evidence that famine may be associated with schizoid personality disorder, as it appears to be with schizophrenia.
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The symptoms of schizoid personality disorder resemble the negative symptoms of schizophrenia. Thus, an increased prevalence of schizoid personality disorder among individuals with a family history of schizophrenia might be expected.
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However, schizoid personality disorder does not appear to have a strong genetic relationship to schizophrenia. Finally, many of the features of Asperger syndrome also resemble schizoid personality disorder, and the possibility of a relationship to autism exists.
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In the case of the schizoid personality, the individual is not necessarily distressed or disturbing of others. Thus, the life history of patients with schizoid personality disorder is typically characterized by a preference for solitary pursuits. These individuals may have none or only a few intimate relationships, and show little apparent interest in people, outside of internal fantasy. Social detachment and restricted emotional expressivity, i.e., affective constriction, make these patients appear aloof, distant, and difficult to engage. Schizoid personality patients are more likely to demonstrate interest when describing abstract pursuits that require no emotional involvement. Although reality testing is generally intact, schizoid personality disorder patients’ lack of social contact precludes the correction of their somewhat idiosyncratic interpretations of social transactions.
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Differential Diagnosis
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Patients with schizoid personality disorder resemble individuals with avoidant personality disorder (to be described later). They can be distinguished from those with avoidant personality disorder by their indifference to others. They also may be confused with patients with schizotypal personality disorder. In contrast to schizotypal personality disorder, the schizoid personality disorder patient is affectively flat and unresponsive, rather than behaviorally eccentric, with odd thoughts, although both disorders often co-occur. Finally, the schizoid personality disorder patient may share a number of symptoms in common with patients with Asperger syndrome.
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Psychopharmacologic Interventions
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Little is known about the effective pharmacologic treatment of schizoid personality disorder. Thus far, effective pharmacotherapy has not been demonstrated for the disorder as such, although associated anxiety and depression when it occurs may be treated with antidepressant and other medications.
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Psychotherapeutic Interventions
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Group/Family Techniques
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Often individuals with schizoid personality disorder come to treatment at the request of family members. In some cases, family-based interventions may be helpful in clarifying for the patient the family's expectations, and perhaps in addressing any intolerance and invasiveness on the part of the family that could be worsening the patient's withdrawal.
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Group therapy can also be helpful as a source of directed feedback from others that would otherwise be missed or ignored. Such a setting can also allow for the modeling and acquisition of needed social skills. However, the initial participation of the schizoid personality disorder patient will invariably be minimal, and the therapist may sometimes need to act to prevent the patient from being the hostile target of other group members. However, as with so many therapies, the above assertions are based on clinical wisdom, and have not been proven experimentally.
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Individual Psychotherapies
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Psychotherapeutic interventions tend to be difficult to accomplish in the patient with schizoid personality disorder. Such patients are often not psychologically minded and typically experience little perceived distress. The tendency of these patients to intellectualize and distance themselves from emotional experience can also restrict the impact of treatment.
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The therapeutic alliance is often impeded by the low value that these individuals place on relationships. However, clinical wisdom suggests that more cognitively based treatment approaches may receive greater initial acceptance. Distorted expectancies and perceptions about the importance and usefulness of relationships with others can be explored.
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Patients with schizoid personality disorder display problems at an earlier age, i.e., in early childhood, than do patients with other personality disorders. Social disinterest tends to self-perpetuate isolation, as does flattened affect. However, relative to patients with other personality disorders, those with schizoid personality disorder are less likely to experience anxiety or depression, particularly if they are not in social, educational, or occupational situations that tax their limited social skills. Also, the number of individuals with schizoid personality disorder who are not in mental health care may be large, and such individuals may be relatively well-adjusted to their lives.
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Schizotypal Personality Disorder
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Essentials of Diagnosis
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DSM-IV-TR Diagnostic Criteria
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A pervasive pattern of social and interpersonal deficits marked by acute discomfort with, and reduced capacity for, close relationships, as well as by cognitive or perceptual distortions and eccentricities of behavior, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:
ideas of reference (excluding delusions of reference)
odd beliefs or magical thinking that influence behavior or is inconsistent with cultural norms (e.g., superstitious, belief in clairvoyance, telepathy, or “sixth sense”; in children and adolescents, bizarre fantasies or preoccupations)
unusual perceptual experiences (including bodily illusions)
odd thinking and speech (e.g., vague, circumstantial, metaphorical, overelaborative, or stereotyped)
suspiciousness or paranoid ideation
inappropriate or constricted affect
behavior or appearance that is odd, eccentric, or peculiar
lack of close friends or confidants other than first-degree relatives
Does not occur exclusively during the course of schizophrenia, a mood disorder with psychotic features, another psychotic disorder, or a pervasive developmental disorder.
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(Reprinted, with permission, from the Diagnostic and Statistical Manual of Mental Disorders. 4th edn. Text Revision. Washington, DC: American Psychiatric Association, 2000.)
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General Considerations
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The prevalence rate of schizotypal personality disorder has been estimated at approximately 3–5% of the general population. Furthermore, up to 30% of general psychiatric outpatients have one or more schizotypal traits, with comorbidity existing with mood, substance-use, and anxiety disorders. Men are slightly more likely to have the disorder.
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Schizotypal personality disorder occurs significantly more frequently among the biological relatives of schizophrenic individuals than in the general population. This finding, together with the results of twin studies, suggests a genetic relationship to schizophrenia. Of all of the personality disorders, schizotypal personality disorder most strongly shows a continuum with schizophrenia. Thus, it is likely that those etiologic factors which induce schizophrenia are similar to those which induce schizotypal personality disorder.
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The concept of schizotypal personality disorder originally developed because of the fact that relatives of schizophrenic patients often had symptoms similar to schizophrenia. There is also evidence that biologic and neuro-cognitive markers of schizophrenia are shared with patients with schizotypal personality disorder. Schizotypal personality disorder is currently thought to be a component of schizophrenia spectrum disorders (which also includes schizoaffective disorder, schizophreniform disorder, and psychotic mood disorders). As such it may not clearly be an actual personality disorder.
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Schizotypal personality disorder is characterized by peculiar behavior, odd thoughts, odd speech, unusual perceptive experiences, and magical beliefs. These patients usually have negative or poor rapport and show social dysfunction, social anxiety, and a lack of motivation. They are frequently underachievers with regard to occupational status.
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The disorder may be manifested during childhood or adolescence as social isolation and peculiar behavior or language. Although the features of the disorder resemble schizophrenia, rates of depression and anxiety are also quite high among such patients. The latter features often constitute the presenting complaint, rather than the ongoing cognitive anomalies.
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Dimensional Considerations
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A dimensional system can be applied to the characterization of schizotypal personality disorder patients precisively and cluster A disorders patient's in general. The components of the cluster A diagnoses, such as aloofness, mistrust, suspiciousness, eccentricity, vulnerability, anxiousness, interpersonal sensitivity, introspection and introversion, negative temperament, perceptual cognitive distortions, restricted expression, and evidence of intimacy avoidance can be considered on a continuum, allowing placement in a given individual between normalcy and psychopathology.
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Alternatively, cluster A disorders can be considered from the perspective of personality traits and temperamental characteristics. Thus, for example, schizotypal personality disorder patients are associated with high levels of neuroticism and low levels of conscientiousness, agreeableness, and extroversion. Furthermore, Cluster A personality disorder patients in general show high levels of introversion, most dramatically in individuals with schizoid personality disorder.
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Differential Diagnosis
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Schizotypal personality disorder is considered by some investigators to be a schizophrenia spectrum disorder. However, the relatives of schizophrenic patients who display schizotypal personality disorder more often tend to exhibit social isolation and poor rapport, rather than psychotic-like symptoms and ideas of reference. Thus, although the schizotypal personality disorder appears with relatively greater than expected frequency in the relatives of schizophrenic patients (i.e., 10%), it is not necessarily merely a milder form of schizophrenia. With respect to other Cluster A disorders, 70% of patients with schizotypal personality disorders have been found to have one or more additional Cluster A personality disorders. Furthermore, comorbidity with Axis I mood, anxiety, and substance-use disorders is also common.
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Psychopharmacologic Interventions
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Low-dose antipsychotic medications are sometimes prescribed to treat the cognitive peculiarities, depression, odd thoughts and speech, anxiety, and impulsivity of patients with schizotypal personality disorder. First and second generation antipsychotics have been demonstrated to have clinical efficacy in placebo-controlled clinical trials. Antipsychotic medications are particularly useful in patients with moderately severe schizotypal symptoms and mild transient psychotic episodes. It is unknown whether antipsychotic medications have a prophylactic benefit for this disorder. In addition, some anecdotal evidence suggests that lithium and mood stabilizers may be helpful in treating selected schizotypal patients.
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Psychotherapeutic Interventions
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Group/Marital Interventions
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Group therapy, especially social skills training, is believed to be helpful to patients with schizotypal personality disorder. This form of therapy addresses the associated social anxiety and awkwardness. However, patients with more severe symptoms may prove disruptive in group therapy, particularly if prominent paranoid ideation is present, and patients with overtly eccentric behavior may inadvertently make other group members uncomfortable.
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Individual Psychotherapies
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Patients with schizotypal personality disorder are generally thought to be poorly suited for nondirective psychotherapies because of a propensity to decompensate under unstructured conditions. Often recommended is a supportive approach, with an emphasis on reality testing and attention to interpersonal boundaries, combined with directive approaches focused on problematic behavior. A cognitive focus also appears useful, with attempts made to help the patient recognize cognitive distortions, such as referential, paranoid, or magical thinking. This can be accomplished through educative interventions that teach patients to corroborate their odd ideas and thoughts with environmental evidence rather than with personal impressions.
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Estimates of the proportion of patients with schizotypal personality disorder who go on to develop overt schizophrenia are variable. The proportion is generally thought to be relatively low, possibly around 10% or less, with some estimates as high as 20–25%. Paranoid ideation, social isolation, magical thinking, and functional decline are the most stable symptoms, and appear to be the most predictive of the eventual development of schizophrenia. These symptoms are also most associated with a poor prognosis and a more chronic outcome.
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Cluster B Personality Disorders
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Antisocial Personality Disorder
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Essentials of Diagnosis
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There is a pervasive pattern of disregard for and violation of the rights of others occurring since age 15 years, as indicated by three (or more) of the following:
failure to conform to social norms with respect to lawful behaviors as indicated by repeatedly performing acts that are grounds for arrest
deceitfulness, as indicated by repeated lying, use of aliases, or conning others for personal profit or pleasure
impulsivity or failure to plan ahead
irritability and aggressiveness, as indicated by repeated physical fights or assaults
reckless disregard for the safety of self or others
consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or honor financial obligations
lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another
The individual is at least age 18 years.
There is evidence of conduct disorder with onset before age 15 years.
The occurrence of antisocial behavior is not exclusively during the course of schizophrenia or a manic episode.
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(Reprinted, with permission, from the Diagnostic and Statistical Manual of Mental Disorders. 4th edn. Text Revision. Washington, DC: American Psychiatric Association, 2000.)
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General Considerations
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Antisocial personality disorder appears to be reasonably common in the general population, with its rate estimated at 2–4% in males and 0.5–1.0% in women. However, since such patients rarely seek treatment voluntarily, and generally come to treatment only when interventions are mandated, these numbers may be underestimated. Finally, there is a strong correlation between having conduct disorder as a child and developing antisocial personality disorder as an adult.
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It appears that both biological and environmental factors are involved as causes of antisocial personality disorder. Individuals are at increased risk for this disorder if they had an antisocial or alcoholic father (even if they were not raised by that person). Other associated variables occurring in childhood include living in a nonintact family, low parental education, hyperkinetic problems, conduct problems, and bullying and adult criminal offenses in the family.
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Family studies of antisocial personality disorder reveal an increased incidence of this disorder in family members. Individuals are at increased risk for this disorder if they had an antisocial or alcoholic father (even if they were not raised by that person). Twin studies also support a genetic component to the etiology of antisocial personality disorder. The primary environmental deficient appears to be the lack of a consistent person to give emotional and loving support as a young child. Surprisingly, merely living in a high crime area does not in and of itself increase the risk of antisocial personality disorder.
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As described in the DSM-IV-TR, antisocial personality disorder consists of a pattern of recurrent antisocial, delinquent, and criminal behavior that begins in childhood or early adolescence and basically pervades all aspects of an individual's life. Negative job performance and marital instability are also hallmarks of the antisocial personality disorder patient.
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A major feature of antisocial personality disorder is a disregard for the rights and feelings of others. This is a characteristic that leads to a variety of unacceptable behaviors, often noted during adolescence or childhood as a conduct disorder. Thus, beginning earlier than 15 years of age, patients have histories of impulsive behavior, aggression toward others, school discipline problems, and breaking the law. Patients with antisocial personality disorders are deficient in meeting social roles and occupational obligations. Relationships are generally superficial and short-lived. Use of illegal substances is common. These individuals tend to be easily bored and impulsive. They seek novelty in their lives and seem unable to avoid behavior that has a high probability of leading to punishment. They may exploit others for personal benefit or at times for no good reason. They often rationalize their antisocial behavior as necessarily defensive, believing others are trying to exploit them.
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Differential Diagnosis
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Substance abuse is comorbid in two thirds of patients with antisocial personality disorder. Other comorbid conditions include the following: other personality disorders, sexual dysfunction, paraphilias, mood disorders, and anxiety disorders. Patients with antisocial personality disorder have high rates of death from natural causes and suicide.
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With respect to personality traits and temperament, antisocial personality disorder patients often score low in harm avoidance, low in reward dependence and high in novelty seeking. These characteristics are associated with risk taking without fear, lack of concern for others, and impulsivity.
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Psychopharmacologic Interventions
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Overall, there is little evidence that the pharmacologic treatment of antisocial personality disorder is effective. However, treatment of associated symptoms may be useful. Psychostimulants may be used to treat associated symptoms of attention deficit disorder. Although efficacy has not been demonstrated by controlled clinical trials, selective serotonin reuptake inhibitors (SSRIs), bupropion, and antipsychotic agents have been used to reduce impulsive aggression.
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Psychotherapeutic Interventions
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Group, Marital, and Community Programs
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There are no specific psychological tests that are used routinely to diagnose antisocial personality disorder. Because of the patients’ lack of insight, treatments have generally been directed to affected individuals with criminal backgrounds.
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Nevertheless, socially based interventions, particularly with others of similar temperaments and problems, are often considered by clinical practitioners to be the treatment of choice for patients with antisocial personality disorder. It is thought that in group contexts, rationalization and evasion can be confronted by others who recognize these patterns. Group membership and associated caring for and from others presumably allows patients with antisocial personality disorder to experience feelings of belonging that many never received from their families. Similarly, family therapy may be useful when the family system is contributing to or perpetuating the antisocial behavior. Also addressed can be issues of maintaining attachment with a spouse, parenting issues, and the impulsive aggressiveness that can lead to abuse.
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Intensive community-based treatment programs may be helpful. A decrease of 20–40% in criminal behavior and recidivism, a probable marker of antisocial personality disorder, occurs with such treatment. Usually such treatments focus on improving social skills, treating substance abuse, managing impulse control, and diminishing antisocial attitudes.
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Individual Psychotherapeutic Interventions
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The literature generally considers the individual psychotherapy of antisocial personality disorder to be ineffective. Also, individual psychotherapists often find patients with antisocial personality disorder to be difficult, untrustworthy, manipulative, and with low frustration tolerance. Dropout rates can be as high as 70%. Traditional psychotherapy is impeded by the antisocial patient's interpersonal indifference, which hinders the formation of a true therapeutic alliance. Also, punishment based techniques have proven typical ineffective as have contingency-based behavioral techniques.
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Cognitive–behavioral psychotherapy has been used with reported success in treating antisocial personality disorder. The patient's distorted cognitive constructs and attitudes toward social groups are analyzed. Specifically, cognitive approaches involve addressing distortions that are typically self-serving or that minimize the future consequences of the individual's behavior.
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Antisocial personality disorder, as it appears in young adults, is thought to be among the most treatment refractory of the Axis II disorders. However, the behavioral problems associated with antisocial personality disorder tend to peak in late adolescence and early adulthood, and 30–40% of these individuals show significant improvement in their antisocial behaviors by the time they reach their mid-thirties and forties.
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During their later years antisocial personality disorder patients are at risk for developing chronic alcoholism and late-onset depression. They often continue to be irresponsible, but without the dramatic aggressiveness of their earlier years. Possibly of significance, the core personality traits of conscientiousness and agreeableness naturally increase with age, and this change has been suggested to be responsible for the “improvement” in antisocial personality disorder patients over time.
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Borderline Personality Disorder
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Essentials of Diagnosis
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DSM-IV-TR Diagnostic Criteria
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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:
frantic efforts to avoid real or imagined abandonment.
(Do not include suicidal or self-mutilating behavior covered in criterion 5).
a pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation
identity disturbance: Markedly and persistently unstable self-image or sense of self
impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating)
Note: Do not include suicidal or self-mutilating behavior covered in criterion 5.
recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior
affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days)
chronic feelings of emptiness
inappropriate and intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights)
transient, stress-related paranoid ideation or severe dissociative symptom
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(Reprinted, with permission, from the Diagnostic and Statistical Manual of Mental Disorders. 4th edn. Text Revision. Washington, DC: American Psychiatric Association, 2000.)
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General Considerations
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The prevalence of borderline personality disorder in the general population is about 1–2%. However, the disorder is particularly common among psychiatric inpatients and on related medical units, such as emergency rooms, where as many as 20–30% of patients meet criteria for the disorder. Borderline personality disorder is identified more commonly in women than in men, although evidence suggests that it may be under-identified in men. The features of the disorder are more common among young adults.
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Borderline personality disorder patients are quite common in psychiatric settings, typically accounting for one third or more of clinical personality disorder diagnoses, and this diagnosis has been receiving considerable attention in the psychiatric and psychological literature. The causes of the disorder are uncertain. Psychoanalytic thinking commonly focuses on disturbances in the normal separation–individuation phase of development between the child and the mother, as well as other aberrant parenting patterns. Such developmental problems are thought to leave the child with problems of separation and self-identity.
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Many patients with borderline personality disorder report childhood sexual, physical, and/or emotional abuse, and it is likely that such abuse or its perception has etiologic significance. This purported abuse is thought to lead to dissociation, splitting, repression, mood lability, and identity problems. Other forms of parental failure such as neglect or poor expression of affection, overcriticism, or invalidating communication have been proposed to be of etiologic importance, as has developmental trauma. Alternatively, overindulgence has been thought to lead to immature coping styles, leading to the disorder.
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The possible genetic influences leading to borderline personality disorder are not well understood. However, some investigators have speculated that a genetic factor leads to the enhanced anxiety, emotional lability, and instability that characteristic of borderline personality disorder, and that it is the tendency toward emotional lability that is inherited.
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Borderline personality disorder occurs relatively more often in the families of patients with the disorder and there is also some evidence from family studies that bipolar disorder and/or major depression occurs more often in families with borderline personality disorder. It may be that certain personality traits (i.e., aggression, impulsivity, affective instability) are what are genetically determined in the borderline personality disorder patients and their families, rather than the actual syndrome. Possibly related, new evidence suggests that abnormal frontolimbic circuiting underlies borderline personality disorder.
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Borderline personality disorder as now defined in DSM-IV-TR represents a pervasive pattern of mood instability associated with unstable but intense interpersonal relationships. Commonly impulsivity, inappropriate or intense anger, recurrent suicidal threats and gestures, and self-mutilating behavior occur. There is a persistent identity disturbance, chronic feelings of emptiness or boredom, and an exaggerated attempt to avoid real or perceived abandonment. Transient paranoid ideation or dissociative symptoms may also occur. In addition, primitive defense mechanisms, such as splitting (exaggerated dichotomies of good and evil, worthy and unworthy, etc.) are often present. A general overall deficit in the ability to test reality is also characteristic of the diagnosis
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Borderline personality disorder patients are also characterized by a poorly established self-image that is heavily dependent for validation on relationships, in combination with an expectation of mistreatment or exploitation. This combination of features makes those with the disorder extremely concerned about close relationships and highly sensitive to changes in these relationships. Reaction to interpersonal conflicts is characterized by dramatic emotional changes, often associated with impulsive self-destructiveness.
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The borderline personality disorder patient's mood often switches between rage, despair, and anxiety over the course of a single day. Multiple suicidal gestures and self-mutilation and self-injurious behaviors are among the most striking actions of these patients. As described above, such behavior is noted primarily after interpersonal turmoil, often after rejection by an intimate. Suicidal gestures often tend to increase in lethality as they recur, and completed suicide occurs in up to 10% of borderline personality disorder patients.
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Adding to the complexity of borderline personality disorder, self-injurious behavior, often beginning in childhood or adolescence, may not be a sign of suicidal intent as such. Such cutting, burning, and associated attempts to cause pain are often due to attempts to regulate dysphoric affect, guilt, tension, dissociative symptoms, and/or to communicate emotions. These self-injurious behaviors are especially associated with a history of childhood sexual abuse.
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The assessment of borderline personality disorder patients is complicated by the cognitive style that these patients manifest. Although positive comments can be found, patients’ evaluations of themselves and their surroundings often are negative in the extreme. Alternatively, situations and people can be overidealized. The borderline personality patient's tendency to evaluate his or her mental status negatively (i.e., more depressed or anxious) leads to self-reported clinical pictures that are more pathologic than outwardly appear.
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Associated with the borderline personality symptoms as such, the patient may admit to and appear to exaggerate a wide variety of behavioral syndromes, including severe depression and anxiety, psychotic features, paranoid ideation, and somatic concerns.
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Dimensional Perspectives
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Borderline personality disorder can be considered from a dimensional perspective. From this perspective, characteristics of the borderline personality disorder patient are considered on a spectrum between the normal and severely symptomatic. From that perspective, therapy can be directed toward symptom complexes. Borderline personality disorder patients can also be classified with respect to their temperaments and core personality traits. On the five-factor model of personality scale, they often show high neuroticism, low agreeableness, and low conscientiousness, with no special relationship to extraversion reported. Similarly, for the Tridimensional Personality Questionnaire and its derivative, the cluster for borderline personality disorder consists of high novelty seeking (seen primarily in males), fairly high harm avoidance (primarily in females), low reward dependence, and low self-directedness.
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Differential Diagnosis
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Borderline personality disorder is frequently associated with a variety of Axis I disorders, and with almost all other Axis II disorders, especially those in cluster B. Major depression is commonly comorbid with borderline personality disorder. Substance-abuse disorder, alcoholism, posttraumatic stress disorder, and anxiety disorders are frequently diagnosed in patients with borderline personality disorder.
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Psychopharmacologic Intervention
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A number of psychopharmacologic strategies are useful in treating borderline personality disorder. Controlled clinical trials demonstrate the efficacy of lithium carbonate in diminishing anger, irritability, and self-mutilation. A more limited body of evidence indicates that carbamazepine increases behavioral control and diminishes anger and impulsivity. Sodium valproate has been used to treat irritability and aggressiveness in borderline patients. In open label studies, the atypical antipsychotic agent, olanzapine, improves paranoid and other psychotic ideation, impulsive aggression, and depression. Similarly, first-generation antipsychotics and some atypical antipsychotics (clozapine, risperidone, and quetiapine) have a similar therapeutic profile to olanzapine in open label studies. Several SSRI antidepressants (fluoxetine and fluvoxamine) have therapeutic efficacy with regard to mood fluctuations, aggression, and overall adaptive behavior.
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Finally, any medication administered to a borderline disorder patient should be monitored carefully and prescribed cautiously because of the enhanced risks for noncompliance, development of substance abuse, and use in suicide attempts or gestures.
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Psychotherapeutic Intervention
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Group/Family Approaches
++
Group therapy has been reported to be a useful format to address the interpersonal problems of borderline personality disorder patients. In such groups patients can form attachments to the group as such or to individual group members, rather than focusing their positive and negative feelings and transferences on a single therapist. Having peers available to mediate the inevitable conflicts that develop with other group members is also helpful. Similarly, family therapy, used especially to work out dependency issues and issues of dramatic acting out, has been reported to be helpful.
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Individual Psychotherapies
++
Generally, psychotherapy with borderline patients is made difficult by the severity and nature of the borderline personality disorder patients’ behaviors, and by the patient's ability to evoke strong negative reactions before the therapist. However, there are several structured therapies that have proven useful in the treatment of borderline personality disorder patients.
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Dialectical behavior therapy is a very popular and effective form of treatment. In the initial stages of treatment, a supportive approach is used to establish a therapeutic alliance. Over time the therapist focuses on identifying and changing ineffective behaviors. The emphasis of the therapy is on stress tolerance, coping skills development, emotional regulation, self-management, and suppression of secondary gain from acting out behavior.
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With treatment, patients come to recognize the pattern of self-destruction, instability, and projection that have characterized their lives and to understand its origins. Patients also explore their rigid good-versus-bad view of others, recognizing that others’ motivations, like their own, are more complex than they appear, and that their sensitivity to others’ untrustworthiness is often a distortion arising out of experience.
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Dialectical behavioral therapy has been demonstrated to be effective in controlled trials. Treatment results in less self-injurious behavior and anger, and fewer inpatient days. Patients treated with this psychotherapy had less drug and alcohol use, and depressive symptoms were improved.
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Mentalization based psychotherapy is a type of supportive interventions that uses interventions that focus on establishing an alliance. This treatment is structured, has a clear focus, and reaches agreement about the role of the therapist, phone calls, cancellations, and how emergencies are managed. Real-life issues for the patient are a major focus. In controlled clinical trials, individuals receiving mentalization-based therapy showed improvement in anxiety, social adjustment, and organizational skills.
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Patients with borderline personality disorder repeatedly engage in self-destructive behaviors which, as mentioned above, can be lethal. Patients sometimes sabotage treatment when it seems to be going well. In part, their difficult course relates to the extreme negative reactions their demands and behaviors often elicit in their therapists and families. Undoubtedly related, the consistent stable behaviors of many symptoms are affective instability and anger. Their behavior tends to become more dramatic and dangerous as others, such as family, therapists, and significant others, reject them or habituate to their demands and crises. As a result, prognosis can be poor. Over involvement in family relations, antisocial behaviors, chronic anger, and overuse of medical facilities predict a poor outcome. Conversely, impulsive and dangerous behaviors seem to diminish as patients approach middle age. A better outcome is associated with higher intelligence, superior social supports, and increased self-discipline.
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Histrionic Personality Disorder
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Essentials of Diagnosis
++
DSM-IV-TR Diagnostic Criteria
++
A pervasive pattern of excessive emotionality and attention seeking, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:
is uncomfortable in situations in which he or she is not the center of attention
interaction with others is often characterized by inappropriate sexually seductive or provocative behavior
displays rapidly shifting and shallow expression of emotions
consistently uses physical appearance to draw attention to self
has a style of speech that is excessively impressionistic and lacking in detail
shows self-dramatization, is theatric, and has exaggerated expression of emotion
is suggestible, i.e., easily influenced by others or circumstances
considers relationships to be more intimate than they actually are
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(Reprinted, with permission, from the Diagnostic and Statistical Manual of Mental Disorders. 4th edn. Text Revision. Washington, DC: American Psychiatric Association, 2000.)
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General Considerations
++
The frequency of histrionic personality disorder has been estimated to be as high as 12% in females, and the overall prevalence of histrionic personality disorder has been estimated as 1–3% in the general population. Rates of the disorder are much higher in psychiatric and general medical setting, because these patients often actively pursue treatment.
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Histrionic personality disorder tends to be diagnosed more frequently in women, and there is a strong possibility that the disorder may be overlooked in men. For younger adults, males and females have been reported to be equally likely to receive a diagnosis of histrionic personality disorder, whereas in middle age, women predominate. Nevertheless, epidemiologic studies indicate that overall, the gender differences in prevalence may be slight.
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As with most personality disorders, the etiology of histrionic personality disorder is not well understood. Some researchers speculate that problems in parent–child relationships lead to the associated low self-esteem. One possibility is that the patient uses dramatic behavior and other similar means to superficially impress others, due to their low self-concept, thinking that he or she is not worthy of attention without such special behaviors.
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There is considerable evidence that there is a genetic component to histrionic personality disorder. There also appears to be a family association between histrionic and antisocial personality disorders and some have suggested that both of these disorders could be gender-related expressions of the same illness.
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The cardinal feature of histrionic personality disorder is the deliberate use of excessive, superficial emotionality and sexuality to draw attention, evade unpleasant responsibilities, and control others. Histrionic personality disorder patients feel best when they are the center of attention and they become disappointed or petulant should the attention shift. Their emotions are characteristically labile, and they may exhibit temper tantrums, tearful outbursts, or dramatic accusations when upset. These displays are often used to provoke a reaction, such as guilt, sympathy, or acquiescence from those around them.
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Patients with histrionic personality disorder are often quite concerned with their physical appearance and attractiveness, and may dress and carry themselves in a seductive or provocative manner. Interactions may be dominated by flirtatious banter, interspersed with dramatic anecdotes about the patient's life and circumstances.
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Unlike some other personality disorders diagnoses, patients with histrionic personality disorder place a premium on interpersonal relationships, and the quality of these relationships, at least their superficial quality, is quite important to them. However, there is often a pattern of sequential unsuccessful relationships, with a seemingly capricious flight from relationship to relationship occurring. Although descriptions of events may be passionate and colorful, they tend to be imprecise and lack detail, with the information obtained being more impressionistic than specific.
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Also prominent in those with histrionic personality disorder is the repression of anger and other disturbing affects. Anger tends to be expressed either fleetingly or indirectly. More comfortable with the expression of physical rather than psychological symptoms, these patients may present with somatic entities such as somatization disorder or conversion disorder.
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Dimensional Perspectives
++
Considered from the perspective of character traits and temperaments, histrionic personality disorder patients are found to be characterized by high levels of extraversion and marked neuroticism. High scores on novelty seeking and reward dependence and low scores on harm avoidance are also characteristic of these individuals.
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Differential Diagnosis
++
Histrionic personality disorder especially requires differentiation from the cluster B disorders, narcissistic personality disorder, borderline personality disorder, and less so with antisocial personality disorder. The diagnosis also resembles and overlaps with bipolar spectrum disorders, eating disorders, and substance-abuse disorders
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Pharmacologic Interventions
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There is little or no evidence that pharmacologic treatment is effective in altering histrionic personality disorder symptoms as such. However, individuals with this disorder often have major depressive disorder and/or an anxiety disorder. For these patients, conventional antidepressants can be quite effective. Also, in some patients monoamine oxidase inhibitors have been reported to be useful. Because these patients are likely to misuse prescription medications, caution is warranted when prescribing such medications in general, and drugs of abuse specifically.
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Psychotherapeutic Interventions
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Group/Marital Interventions
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It has been suggested that patients with histrionic personality disorder may derive particular benefit from group therapy, especially from groups comprised of similar patients. Such groups provide a mirror of the histrionic patient's own behavior, and can serve to confront emotional displays rather than accepting or ignoring them. Moreover, histrionic personality disorder patients have considerable need for approval from others, and thus, are more likely to accept confrontations in order to avoid being rejected.
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Histrionic personality disorder patients can be challenging to work in couples or marital therapy. Their commitment to the marital relationship is often tenuous, or they may be unwilling to risk relinquishing the degree of control they maintain in the relationship.
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Individual Psychotherapies
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There are no controlled clinical trials that identify the best psychotherapeutic strategies for treating histrionic personality disorder. Clinical consensus indicates that the psychotherapy should be empathic and interactive. Limit setting and identifying acting-out behavior are desirable therapeutic topics.
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Histrionic personality disorder is most commonly treated with psychodynamic psychotherapy, supportive psychotherapy, and cognitive–behavioral therapy. Operationally, regardless of the therapy utilized, the tumultuous relationship history of the patient is likely to repeat itself within the psychotherapeutic relationship. Identification of the patient's true feelings, as engendered in the therapeutic relationship, and the delineation of the self-perpetuating quality of these emotions and their subsequent behaviors is an important part of the therapy. Similarly, a focus on the links between thoughts and feelings increases the patient's capacity for reflection, thereby decreasing the likelihood of impulsive acting out behaviors occurring.
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The prognosis for histrionic personality disorder patients is relatively good. These patients tend to be reasonably effective in social settings. This allows them to be the beneficiaries of social feedback and support. In the face of abandonment, they are vulnerable to depression, but as with many of their other complaints, the dysphoria can be short-lived, and it is highly reactive to external circumstances. The prognosis is more pessimistic if the patient meets criteria for other cluster B personality disorders.
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Over time, histrionic personality disorder patients tend to improve regardless of treatment. Significantly, decreases in extraversion and neuroticism often occur as one ages, and these changes have been suggested as an explanation for the above improvement over time which tends to occur.
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Narcissistic Personality Disorder
+++
Essentials of Diagnosis
++
++
A pervasive 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:
has a grandiose sense of self-importance (e.g., exaggerates achievements and talents, expects to be recognized as superior without commensurate achievements)
is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love
believes that he or she is “special” and unique and can only be understood by, or should associate with, other special or high-status people (or institutions)
requires excessive admiration
has a sense of entitlement, i.e., unreasonable expectations of especially favorable treatment or automatic compliance with his or her expectations
is interpersonally exploitative, i.e., takes advantage of others to achieve his or her own ends
lacks empathy: Is unwilling to recognize or identify with the feelings and needs of others
is often envious of others or believes that others are envious of him or her
shows arrogant, haughty behaviors or attitudes
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(Reprinted, with permission, from the Diagnostic and Statistical Manual of Mental Disorders. 4th edn. Text Revision. Washington, DC: American Psychiatric Association, 2000.)
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General Considerations
++
Narcissistic personality disorder occurs in less than 1% in the general population. It is frequently comorbid in populations of psychiatric patients, being estimated at 2–16%. The disorder is somewhat more common in men than in women.
++
Although the cause of narcissistic personality disorder is unknown, one hypothesis is that there has been a lack of clear parental appreciation of the child's accomplishments. This deficiency, or conversely, excessive attention and overgratification concerning accomplishments, is thought to lead the child, and later the adult to continually seek adoration, and to have difficulties in attaining self-esteem at realistic levels.
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The hallmarks of the narcissistic personality disorder are grandiosity, a notable lack of empathy and of a lack of consideration for others. There also is hypersensitivity to evaluation by others. Narcissistic individuals exaggerate their accomplishments, act egotistical and are manipulative of those around them. They have an exaggerated sense of entitlement, being convinced that they deserve special treatment and admiration. Thus, individuals with narcissistic personality disorder are frequently boastful of their accomplishments and often appear haughty and irritating, although they can be outwardly charming. Usually they have little insight into their narcissism. They are often excessively self-centered and self-absorbed and have problems with commitment. They have an exaggerated sense of uniqueness, and show devaluation, disdain, contempt, and deprecation of others.
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Narcissistic personality disorder patients are prone to attribute and externalize the source of their problems to people who they think do not appreciate, support, or defer to them. Because they are highly vulnerable to criticism, any negative statements about them provokes anger, disdain, counter arguments, and devaluation of the person making the statement. Some narcissistic individuals react to criticism by becoming enraged, sometimes with acute paranoid ideation and marked deterioration in judgment.
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Given the narcissistic personality disorder patient's view on life, these patients are vulnerable to depressive episodes and social withdrawal following injury to their self-image. Linked to this, envy of others is a major feature characteristic of personality disorder patients. Such envy makes it difficult for these patients to appreciate what they actually have acquired or accomplished. Individuals with narcissistic personality disorder are especially prone to dislike growing old, and thus, may become more depressed and demanding during the fourth, fifth, and later decades of life.
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Dimensional Consideration
++
With regard to the core personality or temperamental structure of narcissistic personality disorder patients, such individuals score high on extraversion and low on cooperativeness. They also score high on novelty seeking and low on harm avoidance and reward dependence.
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Differential Diagnosis
++
Patients with narcissistic personality disorder can be easily confused with patients with hypomania because of the grandiosity common to both disorders. Indeed, bipolar manic patients demonstrate most of the identifying criteria of narcissistic personality disorder, but generally only when manic. Although difficult to differentiate, patients with narcissistic personality disorder, rather than being overly involved in a whirl of activities, are usually more selective, participating only in those tasks that they think merit their special talents and unique abilities, and for which they can be recognized.
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Narcissistic personality disorder is also often confused with and commonly associated with a diagnosis of antisocial personality disorder. Some scholars have suggested that the former is merely a less aggressive version of the latter. Both disorders are characterized by interpersonal exploitiveness and a lack of empathy. However, the patient with narcissistic personality disorder is less likely to be thrill seeking and impulsive, and more likely to exaggerate their talents and to be grandiose. It is also difficult to distinguish between patients with narcissistic personality disorder and those with borderline personality disorder. However, the obvious independence and the compulsion to exert interpersonal control in narcissistic personality disorder patients contrasts with the neediness and dependency of many patients with borderline personality disorder. Substance-abuse disorders and hypochondriasis are often comorbid with narcissistic personality disorder.
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Psychopharmacologic Interventions
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There is little evidence to suggest that psychopharmacotherapy is effective in the treatment of narcissistic personality disorder, except when comorbid conditions occur such as depression, anxiety, and suicidality. Under such conditions, appropriate antidepressant or other symptom specific therapies are indicated.
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Psychotherapeutic Interventions
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Group/Marital Interventions
++
Although controlled studies are lacking, there is a large body of clinical experience regarding the psychotherapy of narcissistic personality disorder. With respect to the group therapies, patients with narcissistic personality disorder can be disruptive if criticism by other group members precipitates rage or withdrawal. To this end, the therapist must ensure that some support for the patient is provided in order to render the inevitable confrontations more palatable. However, treatment in a homogeneous group of narcissistic personality disorder patients is thought to help these patients to increase their understanding of themselves through a mirroring of their own maladaptive patterns of behavior.
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Patients with narcissistic personality disorder choose to participate in couples’ therapy with some frequency. Here, the therapist must guard against unilaterally blaming the patient for the disruptions in the relationship, since the maladaptive behavior patterns of the couple are often complementary and self-sustaining. In such cases role-playing and role-reversal techniques have been considered particularly useful.
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Individual Psychotherapeutic Interventions
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As with group and marital treatments, psychotherapy with patients with narcissistic personality disorder is usually challenging. These patients often develop expectations of the therapist that are grandiose or expansive. They may not be able to build a trusting or working alliance. Furthermore, they usually come to treatment only following pressure from others, and thus, unless they are depressed or otherwise symptomatic, they are poorly motivated to receive psychotherapeutic help.
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In treating narcissistic personality disorder patients, certain pitfalls exist. The therapist must avoid the extremes of either joining the patient in his or her self-admiration, or of strongly criticizing the patient. Although confronting the patient is often necessary, it needs to be carefully timed and presented with a tone of support and empathic acceptance.
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Cognitive interventions can be directed at the cognitive distortions of self and others that are typical in these patients. Such distortions often involve a magnification of the differences between the patient and other people whereby the difference favors the patient, and others are viewed with contempt. Conversely, if the difference favors another, the patient feels worthless and humiliated. This situation can be addressed by modifying the patient's standards and goals to an internal frame of reference, rather than a comparison with others.
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Little is known about the long-term prognosis of patients with narcissistic personality disorder. In the absence of treatment, and possibly with treatment, the features of the disorder are unlikely to diminish. Indeed, they tend to worsen during middle age and become more strongly associated with depression and despair.
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The features of the disorder tend to self-perpetuate, with the patient's devaluation of others eventually driving away those who might have provided the expected admiration. The significant depression resulting from such rejections is typically resolved by an increase in defensive self-aggrandizement that repeats the cycle.
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Cluster C Personality Disorders
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Avoidant Personality Disorder
+++
Essentials of Diagnosis
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DSM-IV-TR Diagnostic Criteria
++
A pervasive 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:
avoids occupational activities that involve significant interpersonal contact, because of fears of criticism, disapproval, or rejection
is unwilling to get involved with people unless certain of being liked
shows restraint within intimate relationships because of a fear of being shamed or ridiculed
is preoccupied with being criticized or rejected in social situations
is inhibited in new interpersonal situations because of feelings of inadequacy
views self as socially inept, personally unappealing, or inferior to others
is unusually reluctant to take personal risks or to engage in any new activities because they may prove embarrassing
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(Reprinted, with permission, from the Diagnostic and Statistical Manual of Mental Disorders. 4th edn. Text Revision. Washington, DC: American Psychiatric Association, 2000.)
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General Considerations
++
The prevalence of avoidant personality disorder has been estimated at 0.5–2.4% in the general population, with larger numbers occurring in women than in men.
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As with all other personality disorders, the etiology of avoidant personality disorder is uncertain. Because shyness and fear of strangers is a normal component of certain developmental stages, some theorists have speculated that patients with this disorder may be stagnated in their emotional growth in this regard. Because young people may “outgrow” their social awkwardness, caution is suggested in diagnosing this disorder in children or adolescents.
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Avoidant personality disorder patients possess a persistent behavioral pattern of avoidance, created by anxiety, which leads to a restricted life-style and limited social interactions.
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Individuals with avoidant personality disorder are described as introverted, inhibited, and anxious. They tend to have low self-esteem and they are sensitive to rejection. They tend to be awkward, have social discomfort, and are very afraid of being embarrassed or acting foolish.
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Avoidant personality disorder patients show anxiety and discomfort when discussing their problems. Their excessive concern with evaluation by others is particularly apparent during personal questioning, during which they may interpret innocuous questions as criticism. The social anxiety associated with avoidant personality disorder leads to interpersonal withdrawal and avoidance of unfamiliar or novel social situations, primarily because of fears of rejection rather than because of disinterest in others. In those relationships that are maintained, patients tend to adopt a passive, submissive role, as they are particularly uncomfortable in situations in which there is a great deal of public scrutiny and failures are likely to be widely known.
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Dimensional Perspectives
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Temperamentally, patients with avoidant personality disorder score extremely high on neuroticism and extremely low on extraversion scales, thereby being highly introverted.
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Differential Diagnosis
++
There has been a debate as to whether avoidant personality disorder is in the spectrum of anxiety disorders or is a separate psychopathological entity. Avoidant personality disorder has been shown in familial studies to be related to chronic anxiety.
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Clearly many features of avoidant personality disorder are indistinguishable from those of the Axis I disorder, social phobia. Indeed, the latter two diagnoses may actually be alternative names for the same condition. If there is a difference, the primary distinction lies in the continuing nature of avoidant personality disorder symptoms, with characteristics such as low self-esteem and an intense desire for acceptance reflecting an enduring part of the personality rather than a transient condition. Similarly, avoidant personality disorder and generalized anxiety disorder have symptoms in common, as does avoidant personality disorder and major depression. Comorbidity, therefore, exists with major depressive disorder, dysthymia, social phobia, panic disorders, and related anxiety disorders.
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Psychopharmacologic Interventions
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There is some support in the literature for the use of SSRIs, monoamine oxidase inhibitors and β-blocking agents for controlling the symptoms of social phobia. This suggests that these medications may also be helpful in treating avoidant personality disorder, although controlled studies have not been performed. These medications theoretically may facilitate early efforts at increasing social risk-taking, and thus, allow the patient some successful experiences that can be built upon. Other forms of anxiolytic medication (i.e., buspirone, benzodiazepines) may also be helpful for this purpose, although the risk of addiction with benzodiazepines clearly exists.
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Psychotherapeutic Interventions
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Group & Marital Therapies
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Group therapy, either supportive or cognitive in focus, may be of particular use in helping patients with avoidant personality disorder to have contact with strangers within a generally accepting and supportive environment. This helps the patient to overcome social anxiety and to develop interpersonal trust. In such group encounters, the apprehensions that invariably emerge can assist avoidant personality disorder patients in understanding the effect that their rejection sensitivity has on others. Family or couples therapy may also be of particular benefit for patients who are involved in an environment that perpetuates avoidant behavior by undermining self-esteem.
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Individual Psychotherapeutic Interventions
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Patients with avoidant personality disorder often seek psychotherapy for assistance with their symptoms. However, such patients are usually reluctant to disclose personal information out of fear of rejection and humiliation. Early psychotherapeutic efforts are typically directed at establishing trust through provision of support and reassurance. Subsequent efforts may be directed at encouraging assertive behavior via assertiveness training, social skills training via cognitive therapy, and exploring distorted thoughts and attitudes and overvalued assumptions that maintain social withdrawal. Similarly, behavioral desensitization using gradual exposure to social tasks that have increasing potential for provoking anxiety can lead to positive experiences that enable patients to tolerate social risk-taking.
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Little is known about the natural course and outcome of avoidant personality disorder. The most consistent and continuing symptoms are feelings of inadequacy and social ineptitude. The social anxiety and withdrawal associated with avoidant personality disorder is obviously long-standing and generalized. However, many patients with this disorder manage adapt to their problems and show little impairment, assuming they exist in a favorable interpersonal and occupational environment. The prognosis tends to be worse if other personality disorders are present, or if the patient is in a fixed, unsupportive environment that maintains the avoidance behaviors.
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Dependent Personality Disorder
++
DSM-IV-TR Diagnostic Criteria
++
A pervasive and excessive need to be taken care of that leads to submissive and clinging behavior and fears of separation, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:
has difficulty making everyday decisions without an excessive amount of advice and reassurance from others
needs others to assume responsibility for most major areas of his or her life
has difficulty expressing disagreement with others because of fear of loss of support or approval.
(Do not include realistic fears of retribution.)
has difficulty initiating projects or doing things on his or her own (because of a lack of self-confidence in judgment or abilities rather than a lack of motivation or energy)
goes to excessive lengths to obtain nurturance and support from others, to the point of volunteering to do things that are unpleasant
feels uncomfortable or helpless when alone because of exaggerated fears of being unable to care for himself or herself
urgently seeks another relationship as a source of care and support when a close relationship ends
is unrealistically preoccupied with fears of being left to take care of himself or herself
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(Reprinted, with permission, from the Diagnostic and Statistical Manual of Mental Disorders. 4th edn. Text Revision. Washington, DC: American Psychiatric Association, 2000.)
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General Considerations
++
The prevalence of dependent personality disorder has been estimated at 0.5–3.0% in the general population. Furthermore, this disorder is heavily represented in mental health treatment settings because of the general propensity that such patients have to demonstrate help-seeking behavior. The disorder is more common in women than in men. Individuals with dependent personalities tend to be somewhat older than those with other personality disorders.
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Theories about the cause of dependent personality disorder often suggest a childhood environment existed in which dependent behaviors were directly or indirectly rewarded, and independent activities were discouraged. Increasing evidence from twin studies, also suggests possible, but poorly defined, genetic influences.
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The hallmark of dependent personality disorder is a lifelong interpersonal submissiveness. This submissiveness can be into a particular relationship, but more commonly is a generalized style of relating to others. The dependency arises from poor self-esteem and feelings of inadequacy that drive those afflicted to rely heavily on others to get their needs met. Because abandonment is greatly feared, any expression of displeasure or anger is inhibited so as not to endanger the relationship.
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Dimensional Perspectives
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Not surprisingly, dependent personality disorder patients have been found to combine increased neuroticism with agreeableness.
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Differential Diagnosis
++
Patients with dependent personality disorder often submerge their identity within the context of a dependency relationship, in a way that is similar to borderline personality disorder. However, the dependent personality disorder patient lacks the history of turbulent relationships that characterizes the borderline personality disorder patient. The rage and manipulativeness of the latter disorder contrast with the appeasement that is characteristic of dependent personality disorder cases. However, it is relatively common for patients to meet criteria for both disorders.
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Many individuals who have Axis I disorders, particularly mood and anxiety disorders, as well as those with general medical disorders can appear quite dependent and can present with low self-esteem. For these individuals, the features may be limited to the duration of the primary disorder, and do not reflect a long-standing personality pattern. Dependent personality disorder commonly co-occurs with many Axis I and Axis II disorders, especially panic disorder and agoraphobia.
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Psychopharmacological Interventions
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Patients who have dependent personality disorder often experience fatigue, malaise, and vague anxiety. For these symptoms, SSRI or tricyclic antidepressant therapy can be useful. Anxiolytic medication may also be useful, especially during crises that emerge after efforts at establishing autonomy, since fears of abandonment and separation may be exacerbated at these times. However, as with many other disorders, use of antianxiety medications should be time limited, and focused on specific target symptoms.
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Psychotherapeutic Interventions
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Group/Marital Interventions
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Patients with dependent personality disorder have been reported to derive considerable benefit from group therapy, as it offers an opportunity for the development of supportive peer relations with a low risk for abandonment. Group members can reinforce the patient's efforts at establishing autonomy and provide a protected arena in which to try out new and more constructive interpersonal behaviors.
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Family or couples therapy can also be useful. It may, however, present the challenge of working within a family system in which the patient's dependency may play an important functional role. It is therefore critical to enlist the support of other family members for the patient's efforts at autonomy, lest the patient be undermined or meet with rejection or withdrawal which perpetuates the dependency cycle.
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Individual Psychotherapeutic Interventions
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Patients with dependent personality disorder are generally receptive to psychological treatment as part of a more general pattern of seeking assistance and support from others. The primary goal of such interventions is to make the patient become more autonomous and self-reliant. As with the other personality disorders, a variety of individual treatments of dependent personality disorder are reported useful. Cognitive–behavioral psychotherapy is reported to be very helpful in assisting in developing assertiveness and effective decision making. Negative, cognitive constructs are challenged. Assertiveness training is a typical component of treatment. Role-playing, focusing on communication skills, particularly around negative feelings allows the patient to practice assertive behaviors. In more psychodynamically oriented treatments, exploration of past separations and their impact on current behaviors, as well as exploration of the current long-term effects of dependent behavior can help the patient arrive at a greater understanding of his or her difficulties, with self-discovery reflecting another step toward autonomy.
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The prognosis of dependent personality disorder, in the absence of comorbid diagnoses, is generally good. Individuals with this disorder are likely to have had at least one supportive relationship in the past, and generally have a capacity for empathy and trust exceeding that observed in most of the other personality disorders. The primary obstacles to improvement involve the exacerbation of anxieties as efforts toward establishing autonomy are made, and the emergence of severe depression, should the patient's desperate clinging behaviors or attempts at autonomy ultimately lead to rejection.
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Obsessive–Compulsive Personality Disorder
+++
Essentials of Diagnosis
++
DSM-IV-TR Diagnostic Criteria
++
A pervasive pattern of preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the 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:
is preoccupied with details, rules, lists, order, organization, or schedules to the extent that the major point of the activity is lost
shows perfectionism that interferes with task completion (e.g., is unable to complete a project because his or her own overly strict standards are not met)
is excessively devoted to work and productivity to the exclusion of leisure activities and friendships (not accounted for by obvious economic necessity)
is overconscientious, scrupulous, and inflexible about matters of morality, ethics, or values (not accounted for by cultural or religious identification)
is unable to discard worn-out or worthless objects even when they have no sentimental value
is reluctant to delegate tasks or to work with others unless they submit to exactly his or her way of doing things
adopts a miserly spending style toward both self and others; money is viewed as something to be hoarded for future catastrophes
shows rigidity and stubbornness
++
(Reprinted, with permission, from the Diagnostic and Statistical Manual of Mental Disorders. 4th edn. Text Revision. Washington, DC: American Psychiatric Association, 2000.)
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General Considerations
++
The prevalence of obsessive–compulsive personality disorder has been estimated at roughly 1% in the general population. Although it is more common in clinical settings, it is seen less often there than are many other personality disorders. This is because people with this disorder often view the traits in question as desirable, rather than as a problem. The disorder appears to be more common in men than in women.
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Psychoanalytic theories as to the etiology of obsessive–compulsive personality disorder suggest stagnation in the “anal stages” of development of personality. It is still uncertain whether overly controlling parenting has an influence on this disorder, but this has been proposed.
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Genetic components underlying this disorder are uncertain, and have hardly been explored. However, there is evidence that first-degree relatives of individuals with obsessive–compulsive disorder have relatively higher rates of obsessive–compulsive disorder, which would suggest a genetic relationship.
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Obsessive–compulsive personality disorder is characterized by rigidity and affective constriction, inflexibility, obstinacy, and a penchant for orderliness. Characteristically, there is a strong pattern of perfectionism. The disorder is typically associated with overconscientiousness.
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Patients with obsessive–compulsive personality disorder tend to have difficulty in personal relationships because they do not like to submit to others’ ways of doing things. This can lead to occupational problems, because these individuals often will simply refuse to work with others, or will be annoying to them. In a diagnostic interview, they are usually not interested in the affective quality of relationships and have a formal and somewhat stilted style of relating. They will often describe their life in a solemn, intellectualized way, as though describing a casual acquaintance. Their emotional tone is likely to be muted. They often provide exceptionally detailed responses to questions.
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Differential Diagnosis
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Obsessive–compulsive personality disorder was long considered a prelude to obsessive–compulsive disorder, a relationship that is now considered questionable. Obsessive–compulsive personality disorder differs from Axis I obsessive–compulsive disorder in that the Axis I diagnosis of obsessive–compulsive disorder is typically associated with marked distress concerning the obsessions or compulsions. The patient with obsessive–compulsive personality disorder experiences no such distress, aside from a tendency to worry in general. Indeed, the patient with obsessive–compulsive personality disorder typically views his or her preoccupation with order and perfectionism as a positive characteristic, and one that makes him or her superior to others. As a result, the relationship between the Axis I and Axis II disorders is imperfect at best, and the available evidence suggests that fewer than half of the patients with the Axis I obsessive–compulsive disorder also have an obsessive–compulsive personality disorder. Other personality disorders, such as avoidant and dependent personality are just as common in patients with obsessive–compulsive disorder. Major depressive disorder, dysthymia, and generalized anxiety disorder are often comorbid with obsessive–compulsive personality disorder. Patients with anorexia nervosa and bulimia are sometimes diagnosed with obsessive–compulsive personality disorder.
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Psychopharmacologic Interventions
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Pharmacotherapy has not been demonstrated to be effective in the treatment of obsessive–compulsive personality disorder. serotonergic drugs, such as clomipramine and other SSRIs have not been shown to have the degree of usefulness seen with the treatment of Axis I obsessive–compulsive disorder. However, these drugs are thought by some to helpful in decreasing the perfectionism and the ritualizing that can occur in those with obsessive–compulsive personality disorder. Also these drugs may be useful during crises in which anxiety and depression are prominent.
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Psychotherapeutic Interventions
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Group/Marital Interventions
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Group therapy is difficult to conduct in patients with obsessive–compulsive personality disorder. These patients typically attempt to ally themselves with the therapist and to treat the other group members, whom they often perceive as having the “real” problems. One advantage of treatment in using the group format is that the intellectualized explanations offered by the patient are interrupted by the other group members. This increases anxiety, but also leaves the obsessive–compulsive patient more open to new experiences.
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In family or couples therapy, a major challenge involves having the patient relinquish control over other family members. This process can be assisted by prescribing homework tasks in which various roles, including decision making, are reassigned within the family. The patient's desire to conform to the authority of the therapist can be used to facilitate the loosening of control over others, as well as over himself or herself.
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Individual Psychotherapeutic Interventions
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Obsessive–compulsive personality disorder patients are often difficult to treat because they rarely come to psychotherapeutic treatment except when urged to do so by others. They have difficulty seeing that their personality features are maladaptive. When they do come to psychotherapy on their own, they usually do so because of their associated depression, anxiety, or somatic complaints.
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The individual with obsessive–compulsive personality disorder desires to perform well as a patient, consistent with his or her general pattern of perfectionism in other life areas. However, the general constriction and distrust of affective expression creates a number of resistances for the therapist to overcome. Patients may be highly critical of themselves or of the therapy, demanding justification for every intervention offered. A central part of the treatment will involve exploring the source and the unreasonable nature of the harsh and rigid standards the patient has set for both self and others.
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Given the rationalizing and intellectualizing nature of obsessive–compulsive personality disorder patient, cognitive interventions are often relatively well received. Such efforts usually focus on the inaccuracy of key assumptions held by the patient (i.e. that one must be perfectly in control of the environment, or that any failure is intolerable). Consequences of such beliefs can be explored and ways to refute the beliefs discussed. In controlled clinical trials, cognitive–behavioral psychotherapy has the most efficacy in treating obsessive–compulsive symptoms.
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Little is known about the prognosis of obsessive–compulsive personality disorder. The most stable characteristics are rigidity and problems in delegating. In the absence of co-occurring disorders, the outlook is probably favorable for such patients. The patient's capacity for self-discipline and order precludes many of the problems typical of other personality disorders. However, not a small number of these patients go on to develop Axis I anxiety disorders, and the self-criticism and barren emotional life of these patients leave them particularly vulnerable to developing depression.