Lecture 17
Personality Disorders
Lecture Outline
I. Introduction
II. Differentiation between personality disorders and Axis I disorders
A. Anxiety and Mood Disorders
B. Psychotic Disorders
III.DSM-III-R Diagnostic Categories
IV. A note on "Sex Bias"
V. Proposed DSM-III-R Categories
VI. Conclusion
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I. Introduction
Up to this point we have been looking at "Axis I disorders" -
disorders recorded on Axis I of the DSM-III diagnostic system. Most of
the diagnoses are made on this axis. However, DSM-III also has Axis II:
Here are recorded the so-called Personality Disorders.
DSM-III-R definition of "Personality Traits": "Enduring patterns
of perceiving, relating to, and thinking about the environment and
oneself." These patterns or traits "are exhibited in a wide range of
important social and personal contexts" (APA, 1987, p.335).
DSM-III-R definition of "Personality Disorders": When personality
traits "are inflexible and maladaptive and cause either significant
impairment or subjective distress" (APA, 1987, p.335).
In other words, we are talking about deeply ingrained, basic
patterns of relating to the world and oneself; patterns that
characterize the person's long-term functioning. Such personality
disturbances are often seen early in the person's life, and they
continue through adulthood. Individuals with personality disorders
exhibit recurrent maladaptive behaviors in a wide range of areas,
especially in their interpersonal relationships. These people are often
quite dissatisfied with their lives. Not surprisingly, anxiety and
depression are common complications.
II. Differentiation between personality disorders and Axis I disorders
A. Anxiety and Mood Disorders
The symptoms experienced by individuals suffering from anxiety
or mood disorders tend to be "ego-dystonic". That is, the problems
and difficulties they experience are unacceptable, objectionable,
and alien to the self. In contrast, the problems experienced by a
person with a personality disorder are often perceived as "ego-
syntonic": acceptable, unobjectionable, and part of the self.
When they do confront problems in their lives, people with
personality disorders will blame others (Marmar, 1987).
B. Psychotic Disorders
It is true there can be severe social and occupational
impairments associated with the personality disorders, but
persistent psychotic features, delusions and hallucinations do not
occur. There can be transient psychotic states in certain
personality disorders (esp.: borderline) - but these episodes are
short-lived and normally do not require medication or
hospitalization (Marmar, 1987). Individuals with personality
disorders are (usually) in touch with reality.
III. DSM-III-R Diagnostic Categories
The DSM-III-R groups the personality disorders into three clusters:
Cluster A: disorders marked by odd or eccentric behaviors.
paranoid
schizoid
schizotypal
Cluster B: disorders characterized by dramatic, emotional or
erratic behaviors.
antisocial
borderline
histrionic
narcissistic
Cluster C: disorders characterized by anxious or fearful
behaviors.
avoidant
dependent
obsessive compulsive
passive aggressive
A. Paranoid Personality Disorder
[on overhead: DSM-III-R diagnostic criteria]
Case study: see attached
When in a new situation, the person will actively search for
any "confirmation" of his/her paranoid beliefs: a nice self-
fulfilling prophecy.
This is how the person always operates. Individuals with this
disorder thus have significant problems in their relationships.
Indeed, they shun intimacy. They are rigid and uncompromising;
hostile, stubborn, and defensive (Marmar, 1987).
Prevalence: Unknown - these people rarely seek help (which is
to be expected, given the nature of the disorder).
Sex ratio: More common in men
B. Schizoid Personality Disorder
[on overhead: DSM-III-R diagnostic criteria]
Case study: see attached
These are "loners". They are excessively self-absorbed and
detached, both socially and emotionally. They do better at work
(especially when contact with others in not necessary) than they do
in interpersonal relationships. While these patterns typically
begin in childhood, that is not to suggest that all shy children go
on to develop a schizoid personality disorder.
Prevalence: Not yet established (Marmar, 1987), although it
is low in clinical settings (APA, 1987). But again, these people
also rarely seek help.
Sex ratio: Unknown
C. Schizotypal Personality Disorder
[on overhead: DSM-III-R diagnostic criteria]
Case study: see attached
This disorder is apparently related to Schizophrenia, both in
symptomatology and etiology. Symptoms: peculiar and bizarre
thoughts, beliefs, behaviors, emotions, perceptions, etc. However,
these symptoms are much less severe than that found in
schizophrenia. Etiology: Schizotypal Personality Disorder seems to
share a genetic relationship with schizophrenia: relatives of
Schizophrenic persons are more likely to exhibit schizotypal
symptoms than are genetically unrelated persons (Kendler, 1985).
Some researchers even suggest that schizotypal personality disorder
is actually a milder or "borderline" form of schizophrenia
(Kendler, 1985).
Prevalence: about 3% of the population (APA, 1987).
Sex Ratio: unknown
D. Antisocial Personality Disorder
[on overhead: excerpts from DSM-III-R criteria]
Case study: see attached
Unlike the other personality disorders, where the individual
usually harms him/herself more than he/she harms others, the person
with an antisocial personality disorder harms others: chronic
indifference and violation of others' rights (Cadoret, 1986), what
colloquially we call the "psychopath". This personality disorder
is the most widely researched personality disorder, and the most
reliably diagnosed. This is why your text (indeed, most
introductory texts!) emphasize this disorder.
Prevalence and sex ratio: males - 3%
females - less than 1%
E. Borderline Personality Disorder
[on overhead: DSM-III-R diagnostic criteria]
Case study: see attached
Instability is the hallmark here. There is thus often
considerable interference with social and occupational functioning.
We will discuss this disorder in more detail next lecture.
Prevalence: Apparently common, although this may be because
the diagnosis is currently "fashionable". This
disorder also tends to co-occur with many of the
other personality disorders - it has fuzzy
boundaries
Sex ratio: more common in females, with a 2:1 to 9:1 ratio,
depending on the sample.
F. Histrionic Personality Disorder
[on overhead: DSM-III-R diagnostic criteria]
Case study: see attached
People with this disorder are lively and dramatic, always
drawing attention to themselves. While they may be attractive and
appealing initially, relationships with them are superficial. They
are sometimes described as excessively flirtatious.
Prevalence: Apparently common. There is some evidence of
increased familial incidence (Marmar, 1987).
Sex Ratio: much more common in females than males. (Note:
this disorder can be seen as an exaggerated stereotype of women.
Should this concern us? More on this in a moment). One hypothesis
is that HPD and Antisocial PD are closely related - the former is
merely the female expression of the disorder, and the latter the
male expression.
G. Narcissistic Personality Disorder
[on overhead: DSM-III-R diagnostic criteria]
Case study: see attached
Here is the person who is "full of themselves": grandiose,
unempathetic, exploitative... Narcissistic individuals attempt to
sustain an image of perfection and personal invincibility for
themselves and others (Marmar, 1987). Depression and chronic
intense envy are common. While they may run into all sorts of
problems in their relationships and on the job, certain individuals
may be quite successful in occupational spheres as they are driven
to succeed.
Prevalence: Appears to be common, although this has not always
been so. Perhaps the increased rates recently
noted are due more to professional interest than
to actual increases.
Sex Ratio: Unknown.
H. Avoidant Personality Disorder
[on overhead: DSM-III-R diagnostic criteria]
Case study: see attached
Unlike Schizoid Personality Disorder, in Avoidant Personality
Disorder there is a desire for social involvement. The individual
yearns for affection and acceptance, but is immobilized by his/her
timidity and hypersensitivity, especially regarding fear of
rejection. Difference with Social Phobia: Social phobia is
usually of a specific situation, not interpersonal relationships.
Prevalence: Apparently common
Sex ratio: Unknown
I. Dependent Personality Disorder
[on overhead: DSM-III-R diagnostic criteria]
Case study: see attached
The key features are excessive dependent, submissive and
passive behavior patterns. The individual seems incapable of
making his/her own decisions or living independently. The
individual will belittle what skills he/she does have. Being alone
is painful; the individual is frequently depressed and anxious.
Prevalence: Apparently common
Sex ratio: More common in females (Again, stereotypic
behavior patterns..?)
J. Obsessive Compulsive Personality Disorder
[on overhead: DSM-III-R diagnostic criteria]
Case study: see attached
This is different from the anxiety disorder known as obsessive
compulsive disorder. In the anxiety disorder, there are intrusive
and unwanted thoughts and possible accompanying compulsive
behaviors. In Obsessive Compulsive Personality Disorder, there are
no true obsessions or compulsions. Rather, there is the pervasive
general drive for perfectionism and inflexibility. The two
disorders can, however, coexist.
Prevalence: Unknown
Sex ratio: Frequently diagnosed in men (Marmar, 1987)
(another stereotypic bias?)
K. Passive Aggressive Personality Disorder
[on overhead: DSM-III-R diagnostic criteria]
Case study: see attached
An individual with this disorder is thus indirect in his/her
communications and actions. Rather than just saying "no, I don't
want to", he/she engages in all sorts of indirect resistances.
S/he finds ways of not doing what s/he is supposed to, but never
through direct refusal; rather s/he procrastinates, dawdles, makes
mistakes, etc.
The name of this disorder implies that the passive behaviors
are a cover for feelings of resentfulness and hostility. So,
rather than directly expressing the anger, the person passively
expresses it through indirect means.
Prevalence and sex ratio: Unknown
IV. A note on "Sex Bias"
The pattern of "sex bias" that we have noted is a curious one
indeed.
FEMALES MALES
borderline paranoid
histrionic antisocial
dependent obsessive compulsive
When we look at the characteristics of these different disorders, it
looks like they are being defined in terms of stereotypic male/female
behavior patterns. There has been considerable debate from feminist
writers that many of these disorders are based on behavior patterns
which our culture expects from women - so women are overly represented
in these categories because that's how they've been taught to act. In
essence, what the critics argue is that we have turned typical female
behavior patterns into a psychopathology. Similarly, women who attempt
to break out of these patterns by being assertive and independent are
also diagnosed as having other disorder - borderline perhaps. It's a no
win situation. And it's a situation that has little to do with science,
and more to do with politics. The story doesn't stop here, by any
means... as we shall see in the next section.
VI. Proposed DSM-III-R categories
Two new Personality Disorders have been proposed in the DSM-III-R:
Sadistic personality disorder and Self-defeating personality disorder.
These are placed in an appendix, and described as needing more study
before the validity of the disorders is established. It has been argued
that such diagnoses are needed to account for a not uncommon subset of
patients seen in therapy: those who are unusually cruel and violent in
their relationships, and those who seem to go out of their way to engage
in self-defeating behaviors. Some therapists argue that these two
personality types might account for some of the domestic violence that
occurs, and especially for why the violent relationships continue.
[on overhead: the DSM-III-R diagnostic criteria for both disorders]
There is, however, much debate over the scientific validity of
these proposed categories. Some people are arguing that these
categories ignore the social realities that abused women find themselves
in. Critics argue that by diagnosing the woman we focus on the wrong
thing. If we start diagnosing abused women (and their abusers), will
the real economic and social injustices that give rise to this abuse be
obscured and ignored? Such is the concern of the critics. We end up
"blaming" the woman, and obscuring the more important social problems.
Extremely heated debates ensued when the authors of the DSM-III
proposed these new categories for the revised version of the manual. As
a compromise, the categories are in an appendix. Nevertheless, there is
still a lot of controversy over the political nature of the manual.
Indeed, as we noted, some of the other personality disorders also seem
to be merely stereotyped descriptions of male and female sex roles
(Kaplan, 1983). The personality disorders are some of the most
controversial and debated diagnostic categories in the DSM-III. We will
return to other controversies next lecture.
V. Conclusion
We have looked at the various Personality Disorders as defined by
the DSM-III-R. These people are very difficult to relate to on a
personal level. People diagnosed with some of these disorders (esp:
borderline, dependent, narcissistic and passive-aggressive) have even
been described as the "hateful patients" (Groves, 1978) because of the
manipulative and rejecting behaviors common with these people.