Etiology Of Personality Disorders

10 personality disorders


learning objectives 10

·  10.1 What are some of the general features of personality disorders?

·  10.2 What are some of the difficulties of doing research on personality disorders?

·  10.3 What characteristics do the Cluster A personality disorders have in common?

·  10.4 What characteristics do the Cluster B personality disorders have in common?

·  10.5 What characteristics do the Cluster C personality disorders have in common?

·  10.6 What are the clinical features of borderline personality disorder and how is this disorder treated?

·  10.7 What are the features of antisocial personality disorder and psychopathy?

A person’s broadly characteristic traits, coping styles, and ways of interacting in the social environment emerge during childhood and normally crystallize into established patterns by the end of adolescence or early adulthood. These patterns constitute the individual’s personality—the set of unique traits and behaviors that characterize the individual. Today there is reasonably broad agreement among personality researchers that about five basic personality trait dimensions can be used to characterize normal personality. This five-factor model of personality traits includes the following five trait dimensions: neuroticism, extraversion/introversion, openness to experience, agreeableness/antagonism, and conscientiousness (e.g., Goldberg,  1990 ; John & Naumann,  2008 ; McCrae & Costa,  2008 ).

Clinical Features of Personality Disorders

For most of us, our adult personality is attuned to the demands of society. In other words, we readily comply with most societal expectations. In contrast, there are certain people who, although they do not necessarily display obvious symptoms of most of the disorders discussed in this book, nevertheless have certain traits that are so inflexible and maladaptive that they are unable to perform adequately at least some of the varied roles expected of them by their society, in which case we may say that they have a  personality disorder  (formerly known as a character disorder). Two of the general features that characterize most personality disorders are chronic interpersonal difficulties and problems with one’s identity or sense of self (Livesley,  2001 ).

In the case below, many of the varied characteristics of someone with a personality disorder are illustrated.

Narcissistic Personality Disorder Bob, age 21, comes to the psychiatrist’s office accompanied by his parents. He begins the interview by announcing he has no problems…. The psychiatrist was able to obtain the following story from Bob and his parents. Bob had apparently spread malicious and false rumors about several of the teachers who had given him poor grades, implying that they were having homosexual affairs with students. This, as well as increasingly erratic attendance at his classes over the past term, following the loss of a girlfriend, prompted the school counselor to suggest to Bob and his parents that help was urgently needed. Bob claimed that his academic problems were exaggerated, his success in theatrical productions was being overlooked, and he was in full control of the situation. He did not deny that he spread the false rumors but showed no remorse or apprehension about possible repercussions for himself.

Bob is a tall, stylishly dressed young man. His manner is distant but charming …. However, he assumes a condescending, cynical, and bemused manner toward the psychiatrist and the evaluation process. He conveys a sense of superiority and control over the evaluation…. His mother … described Bob as having been a beautiful, joyful baby who was gifted and brilliant. The father … noted that Bob had become progressively more resentful with the births of his two siblings. The father laughingly commented that Bob “would have liked to have been the only child.” … In his early school years, Bob seemed to play and interact less with other children than most others do. In fifth grade, after a change in teachers, he became arrogant and withdrawn and refused to participate in class. Nevertheless, he maintained excellent grades…. It became clear that Bob had never been “one of the boys.” … When asked, he professed to take pride in “being different” from his peers…. Though he was well known to classmates, the relationships he had with them were generally under circumstances in which he was looked up to for his intellectual or dramatic talents. Bob conceded that others viewed him as cold or insensitive … but he dismissed this as unimportant. This represented strength to him. He went on to note that when others complained about these qualities in him, it was largely because of their own weakness. In his view, they envied him and longed to have him care about them. He believed they sought to gain by having an association with him.

Source: Adapted with permission from DSM-IV-TR Casebook: A Learning Companion to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (pp. 239–41) (Copyright © 2002), Washington, DC. American Psychiatric Association.

According to general DSM-5 criteria for diagnosing a personality disorder, the person’s enduring pattern of behavior must be pervasive and inflexible, as well as stable and of long duration. It must also cause either clinically significant distress or impairment in functioning and be manifested in at least two of the following areas: cognition, affectivity, interpersonal functioning, or impulse control. From a clinical standpoint, people with personality disorders often cause at least as much difficulty in the lives of others as they do in their own lives. Other people tend to find the behavior of individuals with personality disorders confusing, exasperating, unpredictable, and, to varying degrees, unacceptable. Whatever the particular trait patterns affected individuals have developed (obstinacy, covert hostility, suspiciousness, or fear of rejection, for example), these patterns color their reactions to each new situation and lead to a repetition of the same maladaptive behaviors because they do not learn from previous mistakes or troubles. For example, a dependent person may wear out a relationship with someone such as a spouse by incessant and extraordinary demands such as never being left alone. After that partner leaves, the person may go almost immediately into another equally dependent relationship without choosing the new partner carefully.

Personality disorders typically do not stem from debilitating reactions to stress in the recent past, as do posttraumatic stress disorder (PTSD) or many cases of major depression. Rather, these disorders stem largely from the gradual development of inflexible and distorted personality and behavioral patterns that result in persistently maladaptive ways of perceiving, thinking about, and relating to the world. In many cases, major stressful life events early in life help set the stage for the development of these inflexible and distorted personality patterns.

The category of personality disorders is broad, encompassing behavioral problems that differ greatly in form and severity. In the milder cases we find people who generally function adequately but who would be described by their relatives, friends, or associates as troublesome, eccentric, or hard to get to know. Like Bob, they may have difficulties developing close relationships with others or getting along with those with whom they do have close relationships. One severe form of personality disorder (antisocial personality disorder) results in extreme and often unethical “acting out” against society. Many such individuals are incarcerated in prisons, although some are able to manipulate others and keep from getting caught.

The DSM-5 personality disorders are grouped into three clusters. These were derived on the basis of what were originally thought to be important similarities of features among the disorders within a given cluster.  Table 10.1  on page 333 provides a summary.

·  • Cluster A: Includes paranoid, schizoid, and schizotypal personality disorders.  People with these disorders often seem odd or eccentric, with unusual behavior ranging from distrust and suspiciousness to social detachment.

·  • Cluster B: Includes histrionic, narcissistic, antisocial, and borderline personality disorders. Individuals with these disorders share a tendency to be dramatic, emotional, and erratic.

·  • Cluster C: Includes avoidant, dependent, and obsessive-compulsive personality disorders.  In contrast to the other two clusters, people with these disorders often show anxiety and fearfulness.

Personality disorders first appeared in the DSM in 1980 (in DSM– III). Although the use of clusters has continued since then, research has raised many questions about their validity. As will be discussed later in this chapter (see “Unresolved Issues”), there are substantial limitations to the category and cluster designations. Indeed, several proposals carefully considered by the DSM-5 task force were to remove four personality disorders entirely and abandon the cluster organization. One of the primary issues is that there are simply too many overlapping features across both categories and clusters (Krueger & Eaton,  2010 ; Sheets & Craighead,  2007 ; Widiger & Mullins-Sweatt,  2005 ). Nevertheless, because much of the research literature to date has used these clusters as an organizing rubric in one way or another, we still mention them here.

research CLOSE-UP: Epidemiological Study

Epidemiological studies are designed to establish the prevalence (number of cases) of a particular disorder in a very large sample (usually many thousands) of people living in the community.

There is not as much evidence for the prevalence of personality disorders as there is for most of the other disorders discussed in this book, in part because there has never been a really large  epidemiological study comprehensively examining all the personality disorders the way the two National Comorbidity Surveys examined the other disorders we have discussed (Kessler et al.,  1994 ; Kessler, Berglund, Demler et al.,  2005b ). Nevertheless, a handful of epidemiological studies in recent years have assessed the prevalence of the personality disorders, albeit with differing conclusions (Lenzenweger,  2008 ; Paris,  2010 ). However, prevalence estimates for one or more personality disorders have ranged from 4.4 to 14.8 percent (Grant et al.,  2005 ; Lenzenweger,  2008 ; Paris,  2010 ). Such discrepancies are likely due to problematic diagnostic criteria, which will be discussed later in this chapter. One review averaging across six relatively small epidemiological studies estimated that about 13 percent of the population meets criteria for at least one personality disorder at some point in their lives (Mattia & Zimmerman,  2001 ; see also Weissman,  1993 ). Several studies from Sweden yielded very similar estimates (Ekselius et al.,  2001 ; Torgersen et al.,  2001  2012 ). In addition, a very large subset of people in the NCS-Replication received a modified personality disorders interview that allowed assessment of the prevalence of Cluster A, B, and C personality disorders but only two specific personality disorders (Lenzenweger et al.,  2007 ). This study estimated that about 10 percent of the population exhibits at least one personality disorder, with 5.7 percent in Cluster A, 1.5 percent in Cluster B, and 6 percent in Cluster C. Due to the high comorbidity between clusters, some individuals meet criteria for personality disorders in more than one cluster, so the percent of people in each cluster adds up to more than 10 percent.

Since their entry into the DSM in 1980, the personality disorders have been coded on a separate axis, Axis II. This was because they were regarded as different enough from the standard psychiatric syndromes (which were coded on Axis I) to warrant separate classification. However, in DSM-5, the multiaxial system was abandoned. Personality disorders are now included with the rest of the disorders we discuss in this textbook. Personality disorders are often associated with (or comorbid with) anxiety disorders ( Chapters 5 and  6 ), mood disorders ( Chapter 7 ), substance use problems ( Chapter 11 ), and sexual deviations ( Chapter 12 ). (See, for example, L. A. Clark,  2005  2007 ; Grant, Hasin et al.,  2005 ; Grant, Stinson et al.,  2005 ; Links et al.,  2012 ; Mattia & Zimmerman,  2001 ) One summary of evidence estimated that about three-quarters of people diagnosed with a personality disorder also have another disorder as well (Dolan-Sewell et al.,  2001 ).

in review

·  ● What is the definition of a personality disorder?

·  ● What are the general DSM criteria for diagnosing personality disorders?

Difficulties Doing Research On Personality Disorders

Before we discuss the clinical features and causes of personality disorders, we should note that several important aspects of doing research in this area have hindered progress relative to what is known about many other disorders. Two major categories of difficulties are briefly described.

Difficulties in Diagnosing Personality Disorders

A special caution is in order regarding the diagnosis of personality disorders because more misdiagnoses probably occur here than in any other category of disorder. There are a number of reasons for this. One problem is that diagnostic criteria for personality disorders are not as sharply defined as they are for most other diagnostic categories, so they are often not very precise or easy to follow in practice. For example, it may be difficult to diagnose reliably whether someone meets a given criterion for dependent personality disorder such as “goes to excessive lengths to obtain nurturance and support from others” or “has difficulty making everyday decisions without an excessive amount of advice and reassurance from others.” Because the criteria for personality disorders are defined by inferred traits or consistent patterns of behavior rather than by more objective behavioral standards (such as having a panic attack or a prolonged and persistent depressed mood), the clinician must exercise more judgment in making the diagnosis than is the case for many other disorders.

With the development of semistructured interviews and self-report inventories for the diagnosis of personality disorders, certain aspects of diagnostic reliability increased substantially. However, because the agreement between the diagnoses made on the basis of different structured interviews or self-report inventories is often rather low, there are still substantial problems with the reliability and validity of these diagnoses (Clark & Harrison,  2001 ; Livesley,  2003 ; Trull & Durrett,  2005 ). This means, for example, that three different researchers using three different assessment instruments may identify groups of individuals with substantially different characteristics as having a particular diagnosis such as borderline or narcissistic personality disorder. Of course, this virtually ensures that few obtained research results will be replicated by other researchers even though the groups studied by the different researchers have the same diagnostic label (e.g., Clark & Harrison,  2001 ).

Given problems with the unreliability of diagnoses (e.g., Clark,  2007 ; Livesley,  2003 ; Trull & Durrett,  2005 ), a great deal of work over the past 20 years has been directed toward developing a more reliable and accurate way of assessing personality disorders. Several theorists have attempted to deal with the problems inherent in categorizing personality disorders by developing dimensional systems of assessment for the symptoms and traits involved in personality disorders (e.g., Clark,  2007 ; Krueger & Eaton,  2010 ; Trull & Durrett,  2005 ; Widiger et al.,  2009 ). However, a unified dimensional classification of personality disorders has been slow to emerge, and a number of researchers have been trying to develop an approach that will integrate the many different existing approaches (e.g., Markon et al.,  2005 ; Krueger, Eaton, Clark et al.,  2011a ; Widiger et al.,  2009  2012 ).

The model that has perhaps been most influential is the five-factor model. This builds on the five-factor model of normal personality mentioned earlier to help researchers understand the commonalities and distinctions among the different personality disorders by assessing how these individuals score on the five basic personality traits (e.g., Clark,  2007 ; Widiger & Trull,  2007 ; Widiger et al.,  2009  2012 ). To fully account for the myriad ways in which people differ, each of these five basic personality traits also has subcomponents or facets. For example, the trait of neuroticism is comprised of the following six facets: anxiety, angry-hostility, depression, self-consciousness, impulsiveness, and vulnerability. Different individuals who all have high levels of neuroticism may vary widely in which facets are most prominent—for example, some might show more prominent anxious and depressive thoughts, others might show more self-consciousness and vulnerability, and yet others might show more angry-hostility and impulsivity. And the trait of extraversion is composed of the following six facets: warmth, gregariousness, assertiveness, activity, excitement seeking, and positive emotions. (All the facets of each of the five basic trait dimensions and how they differ across people with different personality disorders are explained in  Table 10.2  on p. 335.) By assessing whether a person scores low, high, or somewhere in between on each of these 30 facets, it is easy to see how this system can account for an enormous range of different personality patterns—far more than the 10 personality disorders currently classified in the DSM.

Within a dimensional approach, normal personality trait dimensions can be recast into corresponding domains that represent more pathological extremes of these dimensions: negative affectivity (neuroticism); detachment (extreme introversion); antagonism (extremely low agreeableness); and disinhibition (extremely low conscientiousness). A fifth dimension, psychoticism, does not appear to be a pathological extreme of the final dimension of normal personality (openness)—rather, as we will discuss later in the chapter in the section on schizotypal personality disorder, it reflects traits similar to the symptoms of psychotic disorders (e.g., schizophrenia) (Watson et al.,  2008 ).

With these cautions and caveats in mind, we will look at the elusive and often exasperating clinical features of the personality disorders. It is important to bear in mind, however, that what we are describing is merely the prototype for each personality disorder. In reality, as would be expected from the standpoint of the five-factor model of personality disorders, it is rare for any individual to fit these “ideal” descriptions. And, as the Thinking Critically About DSM-5 box below illustrates, this situation will not change in DSM-5.

DSM-5 THINKING CRITICALLY about DSM-5: Why Were No Changes Made to the Way Personality Disorders Are Diagnosed?

Many new and innovative proposals were offered for inclusion in the personality disorders section of DSM-5. Indeed, the proposed revisions were among the most radical for any of the disorders covered in this book. The details were hotly debated, although the general goal was to incorporate a more dimensional approach to the assessment and diagnosis of personality pathology (Livesley,  2011 ; Skodol et al.,  2011 ; Widiger et al.,  2009 ).

In the end, the DSM-5 task force proposed revisions that reflected a hybrid dimensional–categoricalmodel. This consisted of both categorical components and dimensional components. This model includes a set of general criteria for all personality disorders, an overall dimensional measure of the severity of personality dysfunction, a limited set of personality disorder types, and a set of pathological personality traits that could be specified in the absence of one of the personality disorder types. The proposed categorical component also retained 6 of the original 10 specific personality disorder types (antisocial, avoidant, borderline, narcissistic, obsessive-compulsive, and schizotypal).

The greatest change to the status quo came from the incorporation of dimensional components. The new personality domain was intended to describe personality characteristics of all patients, even those without a specific personality disorder. The proposals would have allowed clinicians to rate the level of impairment in personality functioning, reflecting aspects of both identity (having a stable and coherent sense of self and the ability to pursue meaningful life goals) and interpersonal functioning (the capacity for empathy and intimacy). In addition, diagnosticians could indicate the degree to which the patient showed substantial abnormality on five trait domains (negative affectivity, detachment, antagonism, disinhibition, and psychoticism), which are based primarily on the five-factor trait model discussed in this chapter.

In the end, however, the Board of Trustees of the American Psychiatric Association vetoed all of the proposed changes and decided to retain the old categories of personality disorders. In other words, personality disorders in DSM-5 are the same as they were in DSM-IV. Why were no changes accepted? We cannot be sure. But, as you may have gathered from our description above, the new system was very complicated. Although it may have led to a better classification system, the fact that it was not very intuitive or user-friendly may have been a problem. The primary audience for the DSM is clinicians who diagnose and treat people with mental disorders. We suspect that the new proposed system was rejected because it was quite cumbersome and judged too time-consuming for overworked clinicians to learn and use. Moreover clinicians probably would not have found the proposed system to be user-friendly in part because the idea of rating people on dimensions is foreign to the way clinicians have been taught to think. The new proposals were not dismissed entirely, however. They now appear in Section III of DSM-5, which describes disorders in need of further study. This may have been a wise course of action. Perhaps with more time and more research, it will become apparent whether or not the new approach provides enough benefits to make people willing to accept the challenges learning to use it will require.


One of the problems with the diagnostic categories of personality disorders is that the exact same observable behaviors may be associated with different personality disorders and yet have different meanings with each disorder. For example, this woman’s behavior and expression could suggest the suspiciousness and avoidance of blame seen in paranoid personality disorder. Or they could indicate the social withdrawal and absence of friends that characterize schizoid personality disorder. Or they could indicate the social anxiety about interacting with others because of fear of being rejected or negatively evaluated that is seen in avoidant personality disorder.

Difficulties in Studying the Causes of Personality Disorders

Relatively little is known about the causal factors involved in the development of most personality disorders. One reason for this is that personality disorders only began to receive consistent attention from researchers after they entered the DSM in 1980. Another problem stems from the high level of comorbidity among them. For example, in an early review of four studies, Widiger and colleagues found that 85 percent of patients who qualified for one personality disorder diagnosis also qualified for at least one more, and many qualified for several more (Widiger & Rogers,  1989 ; Widiger et al.,  1991 ). A study of nearly 900 psychiatric outpatients reported that 45 percent qualified for at least one personality disorder diagnosis and, among those with one, 60 percent had more than one and 25 percent had two or more (Zimmerman et al.,  2005 ). Even in a nonpatient sample, Zimmerman and Coryell ( 1989 ) found that of those with one personality disorder, almost 25 percent had at least one more (see also Mattia & Zimmerman,  2001 ; Trull et al.,  2012 ). This substantial comorbidity adds to the difficulty of untangling which causal factors are associated with which personality disorder.

Another problem in drawing conclusions about causes occurs because researchers have more confidence in prospective studies, in which groups of people are observed before a disorder appears and are followed over a period of time to see which individuals develop problems and what causal factors have been present. Although this has begun to change, to date, relatively little prospective research has been conducted with most of the personality disorders. Instead, the vast majority of research has been conducted on people who already have the disorders; some of it relies on retrospective recall of prior events, and some of it relies on observing current biological, cognitive, emotional, and interpersonal functioning. Thus, any conclusions about causes that are suggested must be considered very tentative.

Of possible biological factors, it has been suggested that infants’ temperament (an inborn disposition to react affectively to environmental stimuli; see  Chapter 3 ) may predispose them to the development of particular personality traits and disorders (e.g., L. A. Clark,  2005 ; Mervielde et al.,  2005 ; Paris,  2012 ). Some of the most important dimensions of temperament are negative emotionality, sociability versus social inhibition or shyness, and activity level. One way of thinking about temperament is that it lays the early foundation for the development of the adult personality, but it is not the sole determinant of adult personality. Given that most temperamental and personality traits have been found to be moderately heritable (e.g., Bouchard & Loehlin,  2001 ; Livesley,  2005 ), it is not surprising that there is increasing evidence for genetic contributions to certain personality disorders (e.g., Kendler et al.,  2008  2011 ; Livesley,  2005  2008 ; Livesley & Jang,  2008 ; South et al.,  2012 ; Torgersen et al.,  2000 ). However, for at least most disorders, the genetic contribution appears to be mediated by the genetic contributions to the primary trait dimensions most implicated in each disorder rather than to the disorders themselves (Livesley,  2005 ; Kendler et al.,  2008 ). In addition, some progress is being made in understanding the psychobiological substrate of at least some of the traits prominently involved in the personality disorders (e.g., Depue,  2009 ; Depue & Lenzenweger,  2001  2006 ; Livesley,  2008 ; Paris,  2005  2007 ; Roussos & Siever,  2012 ).


Genetic propensities and temperament may be important predisposing factors for the development of particular personality traits and disorders. Parental influences, including emotional, physical, and sexual abuse, may also play a big role in the development of personality disorders.

Among psychological factors, psychodynamic theorists originally attributed great importance in the development of character disorders to an infant’s getting excessive versus insufficient gratification of his or her impulses in the first few years of life (Fonaghy & Luyten, 2012). More recently, learning-based habit patterns and maladaptive cognitive styles have received more attention as possible causal factors (e.g., Beck et al.,  1990  2004 ; Lobbestad & Arntz,  2012 ). Many of these maladaptive habits and cognitive styles that have been hypothesized to play important roles for certain disorders may originate in disturbed parent–child attachment relationships rather than derive simply from differences in temperament (e.g., Benjamin,  2005 ; Fraley & Shaver,  2008 ; Meyer & Pilkonis,  2005 ; Shiner,  2009 ). Parental psychopathology and ineffective parenting practices have also been implicated in certain disorders (e.g., Farrington,  2006 ; Paris,  2001  2007 ). Many studies have also suggested that early emotional, physical, and sexual abuse may be important factors in a subset of cases for several different personality disorders (Battle et al.,  2004 ; Grover et al.,  2007 ).

Various kinds of social stressors, societal changes, and cultural values have also been implicated as sociocultural causal factors (Paris,  2001 ). Ultimately, of course, the goal is to achieve a biopsychosocial perspective on the origins of each personality disorder, but today we are far from reaching that goal.

in review

·  ● What are three reasons for the high frequency of misdiagnoses of personality disorders?

·  ● What are two reasons why it is difficult to conduct research on personality disorders?

Cluster a Personality Disorders

People with Cluster A personality disorders display unusual behaviors such as distrust, suspiciousness, and social detachment and often come across as odd or eccentric. In the following section, we will look at paranoid, schizoid, and schizotypal personality disorders.

Paranoid Personality Disorder

TABLE 10.1 Summary of Personality Disorders

Personality Disorder Characteristics Prevalence Gender Ratio Estimate
Cluster A      
Paranoid Suspiciousness and mistrust of others; tendency to see self as blameless; on guard for perceived attacks by others 0.5–2.5% males > females
Schizoid Impaired social relationships; inability and lack of desire to form attachments to others <1% males > females
Schizotypal Peculiar thought patterns; oddities of perception and speech that interfere with communication and social interaction 3% males > females
Cluster B      
Histrionic Self-dramatization; over concern with attractiveness; tendency to irritability and temper outbursts if attention seeking is frustrated 2–3% males = females
Narcissistic Grandiosity; preoccupation with receiving attention; self-promoting; lack of empathy <1% males > females
Antisocial Lack of moral or ethical development; inability to follow approved models of behavior; deceitfulness; shameless manipulation of others; history of conduct problems as a child 1% females, 3% males males > females
Borderline Impulsiveness; inappropriate anger; drastic mood shifts; chronic feelings of boredom; attempts at self-mutilation or suicide 2% females = males
Cluster C      
Avoidant Hypersensitivity to rejection or social derogation; shyness; insecurity in social interaction and initiating relationships 0.5–1% males = females
Dependent Difficulty in separating in relationships; discomfort at being alone; subordination of needs in order to keep others involved in a relationship; indecisiveness 2% males = females
Obsessive-Compulsive Excessive concern with order, rules, and trivial details; perfectionistic; lack of expressiveness and warmth; difficulty in relaxing and having fun 1% males > females (by 2:1)

Source: APA ( 2013 ); Weissman ( 1993 ); Zimmerman & Coryell ( 1990 ).

Individuals with  paranoid personality disorder  have a pervasive suspiciousness and distrust of others, leading to numerous interpersonal difficulties. They tend to see themselves as blameless, instead blaming others for their own mistakes and failures—even to the point of ascribing evil motives to others. Such people are chronically tense and “on guard,” constantly expecting trickery and looking for clues to validate their expectations while disregarding all evidence to the contrary. They are often preoccupied with doubts about the loyalty of friends and hence are reluctant to confide in others. They commonly bear grudges, refuse to forgive perceived insults and slights, and are quick to react with anger and sometimes violent behavior (Bernstein & Useda,  2007 ; Oltmanns & Okada, 2006). Recent research has suggested that paranoid personality disorder may consist of elements of both suspiciousness and hostility (Edens et al.,  2009 ; Falkum et al.,  2009 ).

DSM-5 criteria for: Paranoid Personality Disorder

·  A. 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:

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

·  2. Is preoccupied with unjustified doubts about the loyalty or trustworthiness of friends or associates.

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

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

·  5. Persistently bears grudges (i.e., is unforgiving of insults, injuries, or slights).

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

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

·  B. Does not occur exclusively during the course of schizophrenia, a bipolar disorder or depressive disorder with psychotic features, or another psychotic disorder and is not attributable to the physiological effects of another medical condition.

Note: If criteria are met prior to the onset of schizophrenia, add “premorbid,” i.e., “paranoid personality disorder (premorbid).”

Source: Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (Copyright © 2013). American Psychiatric Association.

It is important to keep in mind that people with paranoid personalities are not usually psychotic; that is, most of the time they are in clear contact with reality, although they may experience transient psychotic symptoms during periods of stress (M. B. Miller, Useda et al.,  2001 ). People with paranoid schizophrenia share some symptoms found in paranoid personality, but they have many additional problems including more persistent loss of contact with reality, delusions, and hallucinations. Nevertheless, individuals with paranoid personality disorder do appear to be at elevated liability for schizophrenia (Lenzenweger,  2009 ).

Paranoid Construction Worker A 40-year-old construction worker believes that his coworkers do not like him and fears that someone might let his scaffolding slip in order to cause him injury on the job. This concern followed a recent disagreement on the lunch line when the patient felt that a coworker was sneaking ahead and complained to him. He began noticing his new “enemy” laughing with the other men and often wondered if he were the butt of their mockery….

The patient offers little spontaneous information, sits tensely in the chair, is wide-eyed, and carefully tracks all movements in the room. He reads between the lines of the interviewer’s questions, feels criticized, and imagines that the interviewer is siding with his coworkers….

He was a loner as a boy and felt that other children would form cliques and be mean to him. He did poorly in school but blamed his teachers—he claimed that they preferred girls or boys who were “sissies.” He dropped out of school and has since been a hard and effective worker, but he feels he never gets the breaks. He believes that he has been discriminated against because of his Catholicism but can offer little convincing evidence. He gets on poorly with bosses and coworkers, is unable to appreciate joking around, and does best in situations where he can work and have lunch alone. He has switched jobs many times because he felt he was being mistreated.

The patient is distant and demanding with his family. His children call him “Sir” and know that it is wise to be “seen but not heard” when he is around…. He prefers not to have people visit his house and becomes restless when his wife is away visiting others.

Source: Adapted with permission from the DSM III Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Case Book(Copyright © 1981). American Psychiatric Association.


Little is known about important causal factors for paranoid personality disorder (Falkum et al.,  2009 ). Some have argued for partial genetic transmission that may link the disorder to schizophrenia, but results examining this issue are inconsistent, and if there is a significant relationship it is not a strong one (Kendler et al.,  2006 ; M. B. Miller, Useda et al.,  2001 ). There is a modest genetic liability to paranoid personality disorder itself that may occur through the heritability of high levels of antagonism (low agreeableness) and neuroticism (angry-hostility), which are among the primary traits in paranoid personality disorder (Widiger, Trull et al.,  2002 ; see also Falkum et al.,  2009 ; Hopwood & Thomas,  2012 ; Kendler et al.,  2006 ). (See  Table 10.2  below.) Psychosocial causal factors that are suspected to play a role include parental neglect or abuse and exposure to violent adults, although any links between early adverse experiences and adult paranoid personality disorder are clearly not specific to this one personality disorder and may play a role in other disorders as well (Battle et al.,  2004 ; Grover et al.,  2007 ; Natsuaki et al.,  2009 ).

Schizoid Personality Disorder

TABLE 10.2 DSM-IV Personality Disorders and the Five-Factor Model

Anxiety     H   H     H H  
Angry-hostility H     H H   H      
Depression         H H   H    
Self-consciousness     H     H H H H  
Impulsiveness         H          
Vulnerability         H     H H  
Warmth   L L     H     H  
Gregarious   L L     H   L    
Assertiveness               L L H
Excitement seeking       H   H   L    
Positive emotions   L L     H        
Openness to Experience                    
Fantasy   H     H H        
Feelings   L       H        
Actions     H              
Ideas     H              
Values                   L
Trust L   L   L H     H  
Straightforwardness L     L            
Altruism       L     L   H  
Compliance L     L L       H L
Modesty             L   H  
Tender mindedness       L     L      
Competence         L         H
Order                   H
Dutifulness       L           H
Achievement striving             H     H
Self-discipline       L            
Deliberation       L            

Note: NEO-PI-R = Revised NEO Personality Inventory. H, L = high, low, respectively, based on the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; American Psychiatric Association,  1994 ) diagnostic criteria. Personality disorders: PAR = paranoid; SZD = schizoid; SZT = schizotypal; ATS = antisocial; BDL = borderline; HST = histrionic; NAR = narcissistic; AVD = avoidant; DEP = dependent; OBC = obsessive-compulsive.

Source: Adapted from Widiger, Trull et al. ( 2002 ). A description of the DSM-IV personality disorders with the five-factor model of personality. In P. T. Costa & T. A. Widiger (Eds.), Personality Disorders and the Five-Factor Model of Personality (2nd ed.) (p. 90). Washington, DC: APA Books.

Individuals with  schizoid personality disorder  are usually unable to form social relationships and usually lack much interest in doing so. Consequently, they tend not to have good friends, with the possible exception of a close relative. Such people are unable to express their feelings and are seen by others as cold and distant. They often lack social skills and can be classified as loners or introverts, with solitary interests and occupations, although not all loners or introverts have schizoid personality disorder (Bernstein et al.,  2009 ; M. B. Miller, Useda et al.,  2001 ). People with this disorder tend not to take pleasure in many activities, including sexual activity, and rarely marry. More generally, they are not very emotionally reactive, rarely experiencing strong positive or negative emotions, but rather show a generally apathetic mood. These deficits contribute to their appearing cold and aloof (M. B. Miller, Useda et al.,  2001 ; Mittal et al.,  2007 ). In terms of the five-factor model, they show extremely high levels of introversion (especially low on warmth, gregariousness, and positive emotions). They are also low on openness to feelings (one facet of openness to experience) (Widiger, Trull et al.,  2002 ) and on achievement striving (e.g., Hopwood & Thomas,  2012 ).

DSM-5 criteria for: Schizoid Personality Disorder

·  A. 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:

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

·  2. Almost always chooses solitary activities.

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

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

·  5. Lacks close friends or confidants other than first-degree relatives.

·  6. Appears indifferent to the praise or criticism of others.

·  7. Shows emotional coldness, detachment, or flattened affectivity.

·  B. Does not occur exclusively during the course of schizophrenia, a bipolar disorder or depressive disorder with psychotic features, another psychotic disorder, or autism spectrum disorder and is not attributable to the physiological effects of another medical condition.

Note: If criteria are met prior to the onset of schizophrenia, add “premorbid,” i.e., “schizoid personality disorder (premorbid).”

Source: Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (Copyright © 2013). American Psychiatric Association.


Like paranoid personality disorder, schizoid personality disorder has not been the focus of much research attention. This is hardly surprising since people with schizoid personality disorder are not exactly the people we might expect to volunteer for a research study. Early theorists considered a schizoid personality to be a likely precursor to the development of schizophrenia, but this viewpoint has been challenged, and any genetic link that may exist is very modest (Kalus et al.,  1995 ; Kendler et al.,  2006 ; Lenzenweger,  2010 ; M. B. Miller, Useda et al.,  2001 ). Schizoid personality traits have also been shown to have only a modest heritability (Kendler et al.,  2006 ).

Some theorists have suggested that the severe disruption in sociability seen in schizoid personality disorder may be due to severe impairment in an underlying affiliative system (Depue & Lenzenweger,  2005  2006 ). Cognitive theorists propose that individuals with schizoid personality disorder exhibit cool and aloof behavior because of maladaptive underlying schemas that lead them to view themselves as self-sufficient loners and to view others as intrusive. Their core dysfunctional belief might be, “I am basically alone” (Beck et al.,  1990 , p. 51) or “Relationships are messy [and] undesirable” (Pretzer & Beck,  1996 , p. 60; see also Beck et al.,  2004 ). Unfortunately, we do not know why or how some people might develop such dysfunctional beliefs.

Schizotypal Personality Disorder

Individuals with  schizotypal personality disorder  are also excessively introverted and have pervasive social and interpersonal deficits (like those that occur in schizoid personality disorder), but in addition they have cognitive and perceptual distortions, as well as oddities and eccentricities in their communication and behavior (Kwapil & Barrantes-Vidal,  2012 ; Raine,  2006 ). Although contact with reality is usually maintained, highly personalized and superstitious thinking is characteristic of people with schizotypal personality, and under extreme stress they may experience transient psychotic symptoms (APA,  2013 ; Widiger & Frances,  1994 ). Indeed, they often believe that they have magical powers and may engage in magical rituals. Other cognitive–perceptual problems include ideas of reference (the belief that conversations or gestures of others have special meaning or personal significance), odd speech, and paranoid beliefs.

The Introverted Computer Analyst Bill, a highly intelligent but quite introverted and withdrawn 33-year-old computer analyst, was referred for psychological evaluation by his physician, who was concerned that Bill might be depressed and unhappy. Bill had virtually no contact with other people. He lived alone in his apartment, worked in a small office by himself, and usually saw no one at work except his supervisor, who occasionally visited to give him new work and pick up completed projects. He ate lunch by himself, and about once a week, on nice days, went to the zoo for his lunch break.

Bill was a lifelong loner; as a child he had had few friends and had always preferred solitary activities over family outings (he was the oldest of five children). In high school he had never dated and in college had gone out with a woman only once—and that was with a group of students after a game. He had been active in sports, however, and had played varsity football in both high school and college. In college he had spent a lot of time with one relatively close friend—mostly drinking. However, this friend now lived in another city.

Bill reported rather matter-of-factly that he had a hard time making friends; he never knew what to say in a conversation. On a number of occasions he had thought of becoming friends with other people but simply couldn’t think of the right words, so “the conversation just died.” He reported that he had given some thought lately to changing his life in an attempt to be more “positive,” but it had never seemed worth the trouble. It was easier for him not to make the effort because he became embarrassed when someone tried to talk with him. He was happiest when he was alone.

Oddities in thinking, speech, and other behaviors are the most stable characteristics of schizotypal personality disorder (McGlashan et al.,  2005 ) and are similar to those often seen in patients with schizophrenia. In fact, many researchers conceptualize schizotypal personality disorder as an attenuated form of schizophrenia (Lenzenweger,  2010 ; Raine,  2006 ). Interestingly, although some aspects of schizotypy appear related to the five-factor model of normal personality (specifically facets of intro-version and neuroticism), the other aspects related to cognitive and perceptual distortions are notadequately explained by the five-factor model of normal personality (Watson et al.,  2008 ). Indeed, these core symptoms of schizotypy form the basis of the only proposed trait that does not map neatly unto the five factors of normal personality. This final pathological trait is psychoticism, which consists of three facets: unusual beliefs and experiences, eccentricity, and cognitive and perceptual dysregulation (Krueger, Eaton, Derringer et al.,  2011b ).


Unlike schizoid and paranoid personality disorders, there has been a significant amount of research on schizotypal personality disorder (Esterberg et al.,  2010 ). In fact, in the original proposal for the DSM-5, schizotypal personality was the only categorical disorder retained from Cluster A. Estimates of the prevalence of this disorder in the general population have varied somewhat, but one good review of such studies has estimated that the prevalence is about 2 to 3 percent in the general population (Raine,  2006 ). The heritability of schizotypal personality disorder is moderate (Kwapil & Barrantes-Vidal,  2012 ; Raine,  2006 ; Lin et al.,  2006  2007 ).

DSM-5 criteria for: Schizotypal Personality Disorder

·  A. 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:

·  1. Ideas of reference (excluding delusions of reference).

·  2. Odd beliefs or magical thinking that influences behavior and is inconsistent with subcultural norms (e.g., superstitiousness, belief in clairvoyance, telepathy, or “sixth sense”; in children and adolescents, bizarre fantasies or preoccupations).

·  3. Unusual perceptual experiences, including bodily illusions.

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

·  5. Suspiciousness or paranoid ideation.

·  6. Inappropriate or constricted affect.

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

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

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

·  B. Does not occur exclusively during the course of schizophrenia, a bipolar disorder or depressive disorder with psychotic features, another psychotic disorder, or autism spectrum disorder.

Note: If criteria are met prior to the onset of schizophrenia, add “premorbid,” e.g., “schizotypal personality disorder (premorbid).”

Source: Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (Copyright © 2013). American Psychiatric Association.

The biological associations of schizotypal personality disorder with schizophrenia are remarkable (Cannon et al.,  2008 ; Jang et al.,  2005 ; Siever & Davis,  2004 ; Yung et al.,  2004 ). A number of studies on patients, as well as on college students, with schizotypal personality disorder (e.g., Raine,  2006 ; Siever et al.,  1995 ) have shown the same deficit in the ability to track a moving target visually that is found in schizophrenia (Coccaro,  2001 ; see also  Chapter 13 ). They also show numerous other mild impairments in cognitive functioning (Voglmaier et al.,  2005 ), including deficits in their ability to sustain attention (Lees-Roitman et al.,  1997 ; Raine,  2006 ) and deficits in working memory (e.g., being able to remember a span of digits), both of which are common in schizophrenia (Farmer et al.,  2000 ; Squires-Wheeler et al.,  1997 ). In addition, individuals with schizotypal personality disorder, like patients with schizophrenia, show deficits in their ability to inhibit attention to a second stimulus that rapidly follows presentation of a first stimulus. For example, normal individuals presented with a weak auditory stimulus about 0.1 second before a loud sound that elicits a startle response show a smaller startle response than those not presented the weak auditory stimulus first (Cadenhead, Light et al.,  2000a ; Cadenhead, Swerdlow et al.,  2000b ). This normal inhibitory effect is reduced in people with schizotypal personality disorder and with schizophrenia, a phenomenon that may be related to their high levels of distractibility and difficulty staying focused (see also Hazlett et al.,  2003 ; Raine,  2006 ). Finally, they also show language abnormalities that may be related to abnormalities in their auditory processing (Dickey et al.,  2008 ).

A genetic relationship to schizophrenia has also long been suspected. In fact, this disorder appears to be part of a spectrum of liability for schizophrenia that often occurs in some of the first-degree relatives of people with schizophrenia (Kendler & Gardner,  1997 ; Kwapil & Barrantes-Vidal,  2012 ; Raine,  2006 ; Tienari et al.,  2003 ). Moreover, teenagers who have schizotypal personality disorder have been shown to be at increased risk for developing schizophrenia and schizophrenia-spectrum disorders in adulthood (Asarnow,  2005 ; Cannon et al.,  2008 ; Raine,  2006 ; Tyrka et al.,  1995 ). Nevertheless, it has also been proposed that there is a second subtype of schizotypal personality disorder that is not genetically linked to schizophrenia. This subtype is characterized by cognitive and perceptual deficits and is instead linked to a history of childhood abuse and early trauma (Berenbaum et al.,  2008 ; Raine,  2006 ). Schizotypal personality disorder in adolescence has been associated with elevated exposure to stressful life events (Anglin et al.,  2008 ; Tessner et al.,  2011 ) and low family socioeconomic status (Cohen et al.,  2008 ).

Cluster B Personality Disorders

In the following section, we look closely at histrionic, narcissistic, antisocial, and borderline personality disorders. Remember that people with Cluster B personality disorders share a tendency to be dramatic, emotional, and erratic.

Histrionic Personality Disorder

Excessive attention-seeking behavior and emotionality are the key characteristics of individuals with  histrionic personality disorder . As you can see from the table of DSM-5 criteria, these individuals tend to feel unappreciated if they are not the center of attention; their lively, dramatic, and excessively extraverted styles often ensure that they can charm others into attending to them. But these qualities do not lead to stable and satisfying relationships because others tire of providing this level of attention. In craving stimulation and attention, their appearance and behavior are often quite theatrical and emotional as well as sexually provocative and seductive (Freeman et al.,  2005 ). They may attempt to control their partners through seductive behavior and emotional manipulation, but they also show a good deal of dependence (e.g., Blagov et al.,  2007 ; Bornstein & Malka,  2009 ; P. R. Rasmussen,  2005 ). Their speech is often vague and impressionistic, and they are usually considered self-centered, vain, and excessively concerned about the approval of others, who see them as overly reactive, shallow, and insincere.


This woman could be just “clowning around” one night in a bar with friends. But if she frequently seeks opportunities to engage in seductive and attention-seeking behavior, she could have histrionic personality disorder.

The prevalence of histrionic personality disorder in the general population is estimated at 2 to 3 percent, although the prevalence of this disorder may be decreasing (Blashfield et al.,  2012 ). Some (but not all) studies suggest that this disorder occurs more often in women than in men (Lynam & Widiger,  2007 ; Widiger & Bornstein,  2001 ). Reasons for the possible sex difference have been very controversial. One review of these controversies suggested that this sex difference is not surprising, given the number of traits that occur more often in females that are involved in the diagnostic criteria. For example, many of the criteria for histrionic personality disorder (as well as for several other personality disorders such as dependent) involve maladaptive variants of female-related traits (e.g., Widiger & Bornstein,  2001 ) such as overdramatization, vanity, seductiveness, and overconcern with physical appearance. However, other personality traits prominent in histrionic personality disorder are actually more common in men than in women (e.g., high excitement seeking and low self-consciousness). A recent careful analysis of the issue suggests that the higher prevalence of histrionic personality in women actually would not be predicted based on known sex differences in the personality traits prominent in the disorder. This does indeed suggest the influence of some form of sex bias in the diagnosis of this disorder (Lynam & Widiger,  2007 ).


Very little systematic research has been conducted on histrionic personality disorder, perhaps as a result of the difficulty researchers have had in differentiating it from other personality disorders (Bornstein & Malka,  2009 ) and/or because many do not believe it is a valid diagnosis (Blashfield et al.,  2012 ). Indeed one leading theorist and researcher on this topic has referred to the diagnosis as being “dead” (Blashfield et al.,  2012 ). Reflecting this, histrionic personality disorder was one of the four diagnoses that was recommended for removal in DSM-5. Histrionic personality disorder is highly comorbid with borderline, antisocial, narcissistic, and dependent personality disorder diagnoses (Bakkevig & Karterud,  2010 ; Blagov & Westen,  2008 ; Bornstein & Malka,  2009 ).

A Histrionic Housewife Lulu, a 24-year-old housewife, was seen in an inpatient unit several days after she had been picked up for “vagrancy” after her husband had left her at the bus station to return her to her own family because he was tired of her behavior and of taking care of her. Lulu showed up for the interview all made-up and in a very feminine robe, with her hair done in a very special way. Throughout the interview with a male psychiatrist, she showed flirtatious and somewhat childlike seductive gestures and talked in a rather vague way about her problems and her life. Her chief complaints were that her husband had deserted her and that she couldn’t return to her family because two of her brothers had abused her. Moreover, she had no friends to turn to and wasn’t sure how she was going to get along. Indeed, she complained that she had never had female friends, whom she felt just didn’t like her, although she wasn’t quite sure why, assuring the interviewer that she was a very nice and kind person.

Recently she and her husband had been out driving with a couple who were friends of her husband’s. The wife had accused Lulu of being overly seductive toward the wife’s husband, and Lulu had been hurt, thinking her behavior was perfectly innocent and not at all out of line. This incident led to a big argument with her own husband, one in a long series over the past 6 months in which he complained about her inappropriate behavior around other men and about how vain and needing of attention she was. These arguments and her failure to change her behavior had ultimately led her husband to desert her.

There is some evidence for a genetic link with antisocial personality disorder, the idea being that there may be some common underlying predisposition that is more likely to be manifested in women as histrionic personality disorder and in men as antisocial personality disorder (e.g., Cale & Lilienfeld,  2002a  2002b ). The suggestion of some genetic propensity to develop this disorder is also supported by findings that histrionic personality disorder may be characterized as involving extreme versions of two common, normal personality traits, extraversion and, to a lesser extent, neuroticism—two normal personality traits known to have a partial genetic basis (Widiger & Bornstein,  2001 ). In terms of the five-factor model (refer back to  Table 10.2  on p. 335), the very high levels of extraversion of patients with histrionic personality disorder include high levels of gregariousness, excitement seeking, and positive emotions. Their high levels of neuroticism particularly involve the depression and self-consciousness facets; they are also high on openness to fantasies (Widiger, Trull et al.,  2002 ).

Cognitive theorists emphasize the importance of maladaptive schemas revolving around the need for attention to validate self-worth. Core dysfunctional beliefs might include, “Unless I captivate people, I am nothing” and “If I can’t entertain people, they will abandon me” (Beck et al.,  1990 , p. 50). No systematic research has yet explored how these dysfunctional beliefs might develop.

Narcissistic Personality Disorder

DSM-5 criteria for: Histrionic Personality Disorder

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:

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

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

·  3. Displays rapidly shifting and shallow expression of emotions.

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

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

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

·  7. Is suggestible (i.e., easily influenced by others or circumstances).

·  8. Considers relationships to be more intimate than they actually are.

Source: Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (Copyright © 2013). American Psychiatric Association.

Individuals with  narcissistic personality disorder  show an exaggerated sense of self-importance, a preoccupation with being admired, and a lack of empathy for the feelings of others (Pincus & Lukowitsky,  2010 ; Ronningstam,  2005  2009  2012 ). Numerous studies support the notion of two subtypes of narcissism: grandiose and vulnerable narcissism (Cain et al.,  2008 ; Ronningstam,  2005  2012 ). The grandiose presentation of narcissistic patients, highlighted in the DSM-5 criteria, is manifested by traits related to grandiosity, aggression, and dominance. These are reflected in a strong tendency to overestimate their abilities and accomplishments while underestimating the abilities and accomplishments of others. Their sense of entitlement is frequently a source of astonishment to others, although they themselves seem to regard their lavish expectations as merely what they deserve. They behave in stereotypical ways (e.g., with constant self-references and bragging) to gain the acclaim and recognition they crave. Because they believe they are so special, they often think they can be understood only by other high-status people or that they should associate only with such people, as was the case with Bob at the beginning of the chapter. Finally, their sense of entitlement is also associated with their unwillingness to forgive others for perceived slights, and they easily take offense (Exline et al.,  2004 ).

DSM-5 criteria for: Narcissistic Personality Disorder

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:

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

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

·  3. Believes that he or she is “special” and unique and can only be understood by, or should associate with, other special or high-status people (or institutions).

·  4. Requires excessive admiration.

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

·  6. Is interpersonally exploitative (i.e., takes advantage of others to achieve his or her own ends).

·  7. Lacks empathy: is unwilling to recognize or identify with the feelings and needs of others.

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

·  9. Shows arrogant, haughty behaviors or attitudes.

Source: Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (Copyright © 2013). American Psychiatric Association.

The vulnerable presentation of narcissism is not as clearly reflected in the DSM criteria but nevertheless represents a sub-type long observed by researchers and clinicians. Vulnerable narcissists have a very fragile and unstable sense of self-esteem, and for these individuals, arrogance and condescension is merely a façade for intense shame and hypersensitivity to rejection and criticism (Cain et al.,  2008 ; Miller et al.,  2010 ; Pincus & Lukowitsky,  2010 ; Ronningstam,  2005  2012 ). Vulnerable narcissists may become completely absorbed and preoccupied with fantasies of outstanding achievement but at the same time experience profound shame about their ambitions. They may avoid interpersonal relationships due to fear of rejection or criticism.

There is increasing evidence that the grandiose and vulnerable presentations of narcissism are related but distinct in important ways. In terms of the five-factor model, both subtypes are associated with high levels of interpersonal antagonism/low agreeableness (which includes traits of low modesty, arrogance, grandiosity, and superiority), low altruism (expecting favorable treatment and exploiting others), and tough-mindedness (lack of empathy). (Refer back to  Table 10.2  on p. 335.) However, the primarily grandiose narcissist is exceptionally low in certain facets of neuroticism and high in extraversion. For the grandiose narcissist, close friends and relatives may be more distressed about his or her behavior than the narcissist him- or herself. One study concluded, “The strongest impairment associated with narcissistic personality disorder is the distress of ‘pain and suffering’ experienced not by the narcissist but by his or her significant others” (J. D. Miller,  2007 , p. 176). However, the case is quite different for the vulnerable narcissist, who has very high levels of negative affectivity/neuroticism (Cain et al.,  2008 ; Miller et al.,  2010 ). Thus, spouses describe patients with either grandiosity or vulnerability as being “bossy, intolerant, cruel, argumentative, dishonest, opportunistic, conceited, arrogant, and demanding,” but only those high on grandiosity were additionally described as being “aggressive, hardheaded, outspoken, assertive, and determined,” while those high on vulnerability were described as “worrying, emotional, defensive, anxious, bitter, tense, and complaining” (Wink,  1991 , p. 595). Importantly, some narcissistic individuals may fluctuate between grandiosity and vulnerability (Pincus & Lukowitsky,  2010 ; Ronningstam,  2009 ).

Narcissistic personalities also share another central trait—they are unwilling or unable to take the perspective of others, to see things other than “through their own eyes.” Moreover, if they do not receive the validation or assistance they desire, they are inclined to be hypercritical and retaliatory (P. S. Rasmussen,  2005 ). Indeed, one study of male students with high levels of narcissistic traits showed that they had greater tendencies toward sexual coercion when they were rejected by the target of their sexual desires than did men with lower levels of narcissistic traits. They also rated filmed depictions of rape less unfavorably and as more enjoyable and sexually arousing than did the men with low levels of narcissistic traits (Bushman et al.,  2003 ).

Narcissistic personality disorder may be more frequently observed in men than in women (Golomb et al.,  1995 ). A recent quantitative review supports this finding and has also shown that this gender difference is to be expected, based on known sex differences in the personality traits most prominent in narcissistic personality disorder (Lynam & Widiger,  2007 ). Compared with some of the other personality disorders, narcissistic personality disorder is thought to be relatively rare. It is estimated to occur in about 1 percent of the population.


Until the past decade, there was a wealth of theories (Kohut & Wolff,  1978 ; Millon & Davis,  1995 ; Widiger & Bornstein,  2001 ) but precious little empirical data on the environmental and genetic factors involved in the etiology of narcissistic personality disorder. Fortunately, a number of researchers are now actively trying to understand the causes of this fascinating disorder. A key finding has been that the grandiose and vulnerable forms of narcissism are associated with different causal factors. Grandiose narcissism has not generally been associated with childhood abuse, neglect, or poor parenting. Indeed, there is some evidence that grandiose narcissism is associated with parental overvaluation. By contrast, vulnerable narcissism has been associated with emotional, physical, and sexual abuse, as well parenting styles characterized as intrusive, controlling, and cold (Horton et al.,  2006 ; Miller,  2011 ; Miller & Campbell, 2008; Otway & Vignoles,  2006 ).


Otto Kernberg (b. 1928) is an influential contemporary psychoanalytic theorist who has written a great deal about borderline and narcissistic personality disorders.

A Narcissistic Student A 25-year-old, single graduate student complains to his psychoanalyst of difficulty completing his Ph.D. in English literature and expresses concerns about his relationships with women. He believes that his thesis topic may profoundly increase the level of understanding in his discipline and make him famous, but so far he has not been able to get past the third chapter. His mentor does not seem sufficiently impressed with his ideas, and the patient is furious at him but also self-doubting and ashamed. He blames his mentor for his lack of progress and thinks that he deserves more help with his grand idea, and that his mentor should help with some of the research. The patient brags about his creativity and complains that other people are “jealous” of his insight. He is very envious of students who are moving along faster than he and regards them as “dull drones and ass-kissers.” He prides himself on the brilliance of his class participation and imagines someday becoming a great professor.

He becomes rapidly infatuated with women and has powerful and persistent fantasies about each new woman he meets, but after several sexual experiences feels disappointed and finds them dumb, clinging, and physically repugnant. He has many “friends,” but they turn over quickly, and no one relationship lasts very long. People get tired of his continual self-promotion and lack of consideration of them. For example, he was lonely at Christmas and insisted that his best friend stay in town rather than visit his family. The friend refused, criticizing the patient’s self-centeredness; and the patient, enraged, decided never to see this friend again.

Source: Adapted with permission from the DSM III Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Case Book (Copyright © 1981). American Psychiatric Association.

Antisocial Personality Disorder

Individuals with antisocial personality disorder (ASPD) continually violate and show disregard for the rights of others through deceitful, aggressive, or antisocial behavior, typically without remorse or loyalty to anyone. They tend to be impulsive, irritable, and aggressive and to show a pattern of generally irresponsible behavior. This pattern of behavior must have been occurring since the age of 15, and before age 15 the person must have had symptoms of conduct disorder, a similar disorder occurring in children and young adolescents who show persistent patterns of aggression toward people or animals, destruction of property, deceitfulness or theft, and serious violation of rules at home or in school. Because this personality disorder and its causes have been studied far more extensively than the others, and because of its enormous costs to society, it will be examined in some detail later (refer back to  Table 10.2  on p. 335).


Heinz Kohut (1913–1981), another contemporary psychoanalytic thinker, theorized that poor parenting can cause narcissistic personality disorder by failing to build a child’s normal self-confidence.

A Thief With Antisocial Personality Disorder Mark, a 22-year-old, was awaiting trial for car theft and armed robbery. His case records included a long history of arrests beginning at age 9, when he had been picked up for vandalism. He had been expelled from high school for truancy and disruptive behavior. On a number of occasions he had run away from home for days or weeks at a time—always returning in a disheveled and “rundown” condition. To date he had not held a job for more than a few days at a time even though his generally charming manner enabled him to obtain work readily. He was described as a loner with few friends. Although initially charming, Mark usually soon antagonized those he met with his aggressive, self-oriented behavior. Shortly after his first therapy session, he skipped bail and presumably left town to avoid his trial.

Borderline Personality Disorder

People with  borderline personality disorder (BPD)  show a pattern of behavior characterized by impulsivity and instability in interpersonal relationships, self-image, and moods. However, the term borderline personality has a long and rather confusing history (Hooley et al.,  2012 ). Originally it was most often used to refer to a condition that was thought to occupy the “border” between neurotic and psychotic disorders (as in the term borderline schizophrenia). Later, however, this sense of the term borderlinebecame identified with schizotypal personality disorder, which (as we noted earlier) is biologically related to schizophrenia. The current diagnosis of BPD is no longer considered to be biologically related to schizophrenia. image7 Watch the Video Liz: Borderline Personality Disorder on MyPsychLab


The central characteristic of BPD is affective instability, manifested by unusually intense emotional responses to environmental triggers, with delayed recovery to a baseline emotional state. Affective instability is also characterized by drastic and rapid shifts from one emotion to another (Livesley,  2008 ; Paris,  2007 ). In addition, people with BPD have a highly unstable self-image or sense of self, which is sometimes described as “impoverished and/or fragmented” (Livesley,  2008 , p. 44). Given their affective instability combined with unstable self-image, it is not surprising that these people have highly unstable interpersonal relationships. These relationships tend to be intense but stormy, typically involving overidealizations of friends or lovers that later end in bitter disillusionment, disappointment, and anger (Gunderson et al.,  1995 ; Lieb et al.,  2004 ). Nevertheless, they may make desperate efforts to avoid real or imagined abandonment, perhaps because their fears of abandonment are so intense (Lieb et al.,  2004 ; Livesley,  2008 ). Recent experimental research supports a causal link between the perception of rejection and intense, uncontrollable rage in BPD (Berenson et al.,  2011 ).

DSM-5 criteria for: Borderline Personality Disorder

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

·  1. Frantic efforts to avoid real or imagined abandonment. (Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.)

·  2. A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation.

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

·  4. Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating). (Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.)

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

·  6. 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).

·  7. Chronic feelings of emptiness.

·  8. Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights).

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

Source: Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (Copyright © 2013). American Psychiatric Association.

Another very important feature of BPD is impulsivity characterized by rapid responding to environmental triggers without thinking (or caring) about long-term consequences (Paris,  2007 ). These individuals’ high levels of impulsivity combined with their extreme affective instability often lead to erratic, self-destructive behaviors such as gambling sprees or reckless driving. Suicide attempts, sometimes flagrantly manipulative, can be part of the clinical picture (Paris,  1999  2007 ). However, such attempts are not always simply manipulative; prospective studies suggest that approximately 8 to 10 percent may ultimately complete suicide (Oldham,  2006 ; Skodol, Gunderson et al.,  2002 ). Self-mutilation (such as repetitive cutting behavior) is another characteristic feature of borderline personality. However, as illustrated in the Thinking Critically About DSM-5 box on page 343, many people who engage in self-injury do not have BPD. In some cases the self-injurious behavior is associated with relief from anxiety or dysphoria, and it also serves to communicate the person’s level of distress to others (Paris,  2007 ). Research has also documented that borderline personality is associated with analgesia in as many as 70 to 80 percent of women with BPD (analgesia is the absence of the experience of pain in the presence of a theoretically painful stimulus; Figueroa & Silk,  1997 ; Schmahl et al.,  2004 ). The following prototypic case illustrates the frequent risk of suicide and self-mutilation among borderline personalities. image9 Watchthe Video Mary: Non-Suicidal Self-Injury on MyPsychLab


People with borderline personality disorder often engage in self-destructive behaviors including repetitive cutting and other forms of self-injury. But not everyone who engages in self-injury has borderline personality disorder. In DSM-5 a new disorder called nonsuicidal self-injury disorder has been added provisionally as a disorder in need of further research.

Self-Mutilation in Borderline Personality Disorder A 26-year-old unemployed woman was referred for admission to a hospital by her therapist because of intense suicidal preoccupation and urges to mutilate herself with a razor. The patient was apparently well until her junior year in high school, when she became preoccupied with religion and philosophy, avoided friends, and was filled with doubt about who she was. Academically she did well, but later, during college, her performance declined. In college she began to use a variety of drugs, abandoned the religion of her family, and seemed to be searching for a charismatic religious figure with whom to identify. At times, massive anxiety swept over her, and she found it would suddenly vanish if she cut her forearm with a razor blade.

Three years ago she began psychotherapy and initially rapidly idealized her therapist as being incredibly intuitive and empathic. Later she became hostile and demanding of him, requiring more and more sessions, sometimes twice in 1 day. Her life centered on her therapist, by this time to the exclusion of everyone else. Although her hostility toward her therapist was obvious, she could neither see it nor control it. Her difficulties with her therapist culminated in many episodes of her forearm cutting and suicidal threats, which led to the referral for admission.

Source: Adapted with permission from the DSM III Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Case Book (Copyright © 1981). American Psychiatric Association.

DSM-5 THINKING CRITICALLY about DSM-5: Nonsuicidal Self-Injury: Distinct Disorder or Symptom of Borderline Personality Disorder?

Nonsuicidal self-injury (NSSI) involves deliberate damage to body tissue such as might occur with skin cutting or burning (Nock,  2009 ). This behavior (which is sometimes called self-mutilation) occurs in the absence of an intent to die (hence the term nonsuicidal). Self-mutilating behavior has long been listed in the DSM as a symptom of BPD. However, many people who engage in self-injury do not have BPD, although they do report high levels of depressive symptoms, anxiety, suicidality, and generally low levels of functioning (Selby et al.,  2012 ). People who engage in NSSI are also at elevated risk for later suicide (Wilkinson et al.,  2011 ). For these reasons, the DSM-5 task force was charged with determining whether people who display a significant amount of nonsuicidal self-injurious behavior should be diagnosed with a new disorder that would called “nonsuicidal self-injury disorder”.

NSSI is found in males and females, as well as in people of all ethnicities and economic backgrounds. However, the risk for NSSI seems to be greatest in the adolescent years. One Finnish study reported a 11.5 percent prevalence rate in young people aged 13–18. And an Internet-based study of college students at two U.S. universities found a lifetime prevalence of 17 percent. Perhaps most shocking were the results from a U.S. study of 10-to 14-year-old girls that found a lifetime prevalence of NSSI of 56 percent (Hilt et al.,  2008 ).

Why do people hurt themselves by cutting or burning? Tension relief is one reason that many people give. NSSI is often used to regulate intense or extreme emotions. Hooley et al. ( 2010 ) have also found that people who engage in NSSI tend to have higher pain endurances than the rest of us. In addition, they have a highly self-critical cognitive style and “may regard suffering and pain as something they deserve” (Hooley et al.,  2010 , p. 170). This may help explain why such people choose to regulate their emotions by engaging in behaviors that are self-damaging and painful.

NSSI is a growing problem. Recognizing this, it has now been added to DSM-5. NSSI disorder is listed in Section III, which is used to describe conditions in need of further study. This move is likely to stimulate research. As we learn more we may be in a better position to understand, treat, and perhaps even prevent this increasingly prevalent condition.

In addition to affective and impulsive behavioral symptoms, as many as 75 percent of people with BPD have cognitive symptoms. These include relatively short or transient episodes in which they appear to be out of contact with reality and experience delusions or other psychotic-like symptoms such as hallucinations, paranoid ideas, or severe dissociative symptoms (Lieb et al.,  2004 ; Paris,  2007 ; Skodol, Gunderson et al.,  2002 ).

Estimates are that only about 1 to 2 percent of the population may qualify for the diagnosis of BPD (Lenzenweger et al.,  2007 ), but they represent about 10 percent of patients in outpatient and 20 percent of patients in inpatient clinical settings (Lieb et al.,  2004 ; Torgersen et al.,  2001 ). Although early research found that approximately 75 percent of individuals receiving this diagnosis in clinical settings are women, such findings likely arise from a gender imbalance in treatment seeking rather than prevalence of the disorder. In support of this, more recent epidemiological studies of community residents suggest an equal gender ratio (Coid et al.,  2009 ; Grant et al.,  2008 ; Hooley et al.,  2012 ).


Given the many and varied symptoms of BPD, it is not surprising that this personality disorder produces significant impairment in social, academic, and occupational functioning (Bagge et al.,  2004 ; Grant et al.,  2008 ). BPD commonly co-occurs with a variety of other disorders ranging from unipolar and bipolar mood and anxiety disorders (especially panic and PTSD) to substance-use and eating disorders (Hooley et al.,  2012 ; Pagura et al.,  2010 ). In the past, many clinical researchers hypothesized that BPD had a special relationship with bipolar and recurrent unipolar mood disorders because about 50 percent of those with BPD also qualified for a mood disorder diagnosis at some point (Adams et al.,  2001 ; Paris,  2007 ). However, other personality disorders (such as dependent, avoidant, and obsessive-compulsive personality disorder) are actually more commonly associated with depression than is BPD. Moreover, recent neuroimaging data indicate that BPD individuals show different neural responses to emotional stimuli than do individuals with chronic depression (Hooley et al.,  2010 ).

There is also substantial co-occurrence of BPD with other personality disorders—especially histrionic, dependent, antisocial, and schizotypal personality disorders. Nevertheless, Widiger and Trull (1993) noted the following differences in prototypic cases of these personality disorders: “The prototypic borderline’s exploitative use of others is usually an angry and impulsive response to disappointment, whereas the antisocial’s is a guiltless and calculated effort for personal gain. Sexuality may play a more central role in the relationships of histrionics than in [those of] borderlines, evident in the histrionic’s tendency to eroticize situations… and to be inappropriately seductive. The prototypic schizotypal lacks the emotionality of the borderline, and tends to be more isolated, odd and peculiar” (Widiger & Trull,  1993 , p. 371). These differences can also be seen using the five-factor model of personality disorders (refer back to  Table 10.2  on p. 335).


Research suggests that genetic factors play a significant role in the development of BPD (Distel et al.,  2009 ; Livesley,  2008 ; Skodol, Siever et al.,  2002 ). This heritability may be partly a function of the fact that personality traits of affective instability and impulsivity, which are both very prominent in BPD, are themselves partially heritable (Hooley et al.,  2012 ; Paris,  2007 ). There is also some preliminary evidence that certain parts of the 5-HTT gene implicated in depression ( Chapter 7 ) may also be associated with BPD (e.g., Lis et al.,  2007 ; Ni et al.,  2006 ). Recent research also suggests a link with other genes involved in regulating dopamine transmission (Hooley et al.,  2012 ).

There has also been an intense search for the biological substrate of BPD. For example, people with BPD often appear to be characterized by lowered functioning of the neurotransmitter serotonin, which is involved in inhibiting behavioral responses. This may be why they show impulsive-aggressive behavior, as in acts of self-mutilation; that is, their serotonergic activity is too low to “put the brakes on” impulsive behavior (e.g., Figueroa & Silk,  1997 ; Schmahl & Bremner,  2006 ; Skodol, Siever et al.,  2002 ). Patients with BPD may also show disturbances in the regulation of noradrenergic neurotransmitters that are similar to those seen in chronic stress conditions such as PTSD (see  Chapter 5 ; Hooley,  2008 ). In particular, their hyperresponsive noradrenergic system may be related to their hypersensitivity to environmental changes (Figueroa & Silk,  1997 ; Skodol, Siever et al.,  2002 ). Moreover, certain brain areas that ordinarily serve to inhibit aggressive behavior when activated by serotonin (such as the orbital prefrontal and medial prefrontal cortex) seem to show decreased activation in BPD (Skodol, Siever et al.,  2002 ; see also Lieb et al.,  2004 ). In addition, research suggests certain structural brain abnormalities in BPD, including reductions in both hippocampal and amygdalar volume, features associated with aggression and impulsivity (Hooley et al.,  2012 ).

Much theoretical and research attention has also been directed to the role of psychosocial causal factors in BPD. Although the vast majority of this research is retrospective in nature, relying on people’s memories of their past to discover the antecedents of the disorder, two prospective community-based studies have shown that childhood adversity and maltreatment is linked to adult BPD (Johnson et al.,  1999 ; Widom et al.,  2009 ). These studies are consistent with a wealth of retrospective research showing that people with this disorder usually report a large number of negative—even traumatic—events in childhood. These experiences include abuse and neglect, and separation and loss. For example, in one large study on abuse and neglect, Zanarini and colleagues ( 1997 ) reported on the results of detailed interviews of over 350 patients with BPD and over 100 patients with other personality disorders. Patients with BPD reported significantly higher rates of abuse than did patients with other personality disorders (which were also quite high): emotional abuse (73 versus 51 percent), physical abuse (59 versus 34 percent), and sexual abuse (61 versus 32 percent). Overall, about 90 percent of patients with BPD reported some type of childhood abuse or neglect (emotional, physical, or sexual). (See also Bandelow et al.,  2005 ; Battle et al.,  2004 .) Although these rates of abuse and neglect seem alarming, remember that the majority of children who experience early abuse and neglect do not end up with any serious personality disorders or other psychopathology (see Paris,  1999  2007 ; Rutter & Maughan,  1997 ; see also  Chapter 12 ).

Although this and many other related studies (see Dolan-Sewell et al.,  2001 ; Paris,  2007 ) suggest that BPD (and perhaps other personality disorders as well) is often associated with early childhood trauma, most such studies have many shortcomings and unfortunately cannot tell us that such early childhood trauma plays a causal role. First, although prospective research to date supports this idea (Johnson et al.,  1999 ; Widom et al.,  2009 ), the majority of evidence comes from retrospective self-reports of individuals who are known for their exaggerated and distorted views of other people (Paris,  1999  2007 ; Rutter & Maughan,  1997 ). Second, childhood abuse is certainly not a specific risk factor for borderline pathology because it is also reported at relatively high rates with some other personality disorders as well as with other disorders such as dissociative identity disorder (see also  Chapter 8 ; Moran et al.,  2010 ). Third, childhood abuse nearly always occurs in families with various other pathological dynamics, such as marital discord and family violence. These factors may be more important than the abuse in the development of BPD (Paris,  1999  2007 ).


Many studies have shown that people with borderline personality disorder report a large number of negative, even traumatic, events in childhood. These include abuse and neglect, and separation and loss.

Paris ( 1999  2007 ) offered an interesting multidimensional diathesis-stress theory of BPD. He proposes that people who have high levels of two normal personality traits—impulsivity and affective instability—may have a diathesis to develop BPD, but only in the presence of certain psychological risk factors such as trauma, loss, and parental failure (see  Figure 10.1 , p. 346). When such nonspecific psychological risk factors occur in someone who is affectively unstable, he or she may become dysphoric and labile and, if he or she is also impulsive, may engage in impulsive acting out to cope with this negative mood. Thus the dysphoria and impulsive acts fuel each other. In addition, Paris proposes that children who are impulsive and unstable tend to be “difficult” or troublesome children. They may therefore be at increased risk for being rejected or abused. Moreover, if the parents themselves have personality pathology, they may be especially insensitive to their difficult child, leading to a vicious cycle in which the child’s problems are exacerbated by inadequate parenting, which in turn leads to increased dysphoria, and so on. Paris further suggests that BPD may be more prevalent in our society than in many other cultures, and more prevalent today than in the past, because of the weakening of the family structure in our society.

Cluster C Personality Disorders

People with Cluster C personality disorders often show anxiety and fearfulness. These are characteristics that we do not see in the other two clusters. In the following section, we examine avoidant, dependent, and obsessive-compulsive personality disorders.

Avoidant Personality Disorder

Individuals with  avoidant personality disorder  show extreme social inhibition and introversion, leading to lifelong patterns of limited social relationships and reluctance to enter into social interactions. Because of their hypersensitivity to, and fear of, criticism and rebuff, they do not seek out other people, yet they desire affection and are often lonely and bored. Unlike schizoid personalities, people with avoidant personality disorder do not enjoy their aloneness; their inability to relate comfortably to other people causes acute anxiety and is accompanied by low self-esteem and excessive self-consciousness, which in turn are often associated with depression (Grant, Hasin et al.,  2005 ; Sanislow et al.,  2012 ). Feeling inept and socially inadequate are the two most prevalent and stable features of avoidant personality disorder (McGlashan et al.,  2005 ). In addition, researchers have documented that individuals with this disorder also show more generalized timidity and avoidance of many novel situations and emotions (including positive emotions), and show deficits in their ability to experience pleasure as well (Taylor et al.,  2004 ).


FIGURE 10.1 Multidimensional Diathesis-Stress Theory of Borderline Personality Disorder.

Source: Paris ( 1999 ).

The Avoidant Librarian Sally, a 35-year-old librarian, lived a relatively isolated life and had few acquaintances and no close personal friends. From childhood on, she had been very shy and had withdrawn from close ties with others to keep from being hurt or criticized. Two years before she entered therapy, she had had a date to go to a party with an acquaintance she had met at the library. The moment they had arrived at the party, Sally had felt extremely uncomfortable because she had not been “dressed properly.” She left in a hurry and refused to see her acquaintance again.

In the early treatment sessions, she sat silently much of the time, finding it too difficult to talk about herself. After several sessions, she grew to trust the therapist, and she related numerous incidents in her early years in which she had been “devastated” by her alcoholic father’s obnoxious behavior in public. Although she had tried to keep her school friends from knowing about her family problems, when this had become impossible, she instead had limited her friendships, thus protecting herself from possible embarrassment or criticism.

When Sally first began therapy, she avoided meeting people unless she could be assured that they would “like her.” With therapy that focused on enhancing her assertiveness and social skills, she made some progress in her ability to approach people and talk with them.

DSM-5 criteria for: Avoidant Personality Disorder

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:

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

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

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

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

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

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

·  7. Is unusually reluctant to take personal risks or to engage in any new activities because they may prove embarrassing.

Source: Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (Copyright © 2013). American Psychiatric Association.

The key difference between the loner with schizoid personality disorder and the loner who is avoidant is that the latter is shy, insecure, and hypersensitive to criticism, whereas someone with a schizoid personality is more aloof, cold, and relatively indifferent to criticism (Millon & Martinez,  1995 ). The person with avoidant personality also desires interpersonal contact but avoids it for fear of rejection, whereas in schizoid personality disorder there is a lack of desire or ability to form social relationships. A less clear distinction is that between avoidant personality disorder and generalized social phobia ( Chapter 6 ). Numerous studies have found substantial overlap between these two disorders, leading some investigators to conclude that avoidant personality disorder may simply be a somewhat more severe manifestation of generalized social phobia (Alpert et al.,  1997 ; Carter & Wu,  2010 ; Tillfors et al.,  2004 ) that does not warrant a separate diagnosis (Chambless et al.,  2008 ). This is consistent with the finding that there are cases of generalized social phobia without avoidant personality disorder but very few cases of avoidant personality disorder without generalized social phobia. Somewhat higher levels of dysfunction and distress are also found in the individuals with avoidant personality disorder, including more consistent feelings of low self-esteem (Millon & Martinez,  1995 ; Hummelen et al.,  2007 ; Tillfors et al.,  2004 ).


The person with avoidant personality desires social contact but avoids it because of a fear of rejection.


Some research suggests that avoidant personality may have its origins in an innate “inhibited” temperament that leaves the infant and child shy and inhibited in novel and ambiguous situations. A large twin study in Norway has shown that traits prominent in avoidant personality disorder show a modest genetic influence (Reichborn-Kjennerud et al.,  2006 ), and that the genetic vulnerability for avoidant personality disorder is at least partially shared with that for social phobia (Reichborn-Kjennerud et al.,  2007 ). Moreover, there is also evidence that the fear of being negatively evaluated, which is prominent in avoidant personality disorder, is moderately heri-table (Stein et al.,  2002 ); introversion and neuroticism are also both elevated (refer back to  Table 10.2  on p. 335), and they too are moderately heritable. This genetically and biologically based inhibited temperament may often serve as the diathesis that leads to avoidant personality disorder in some children who experience emotional abuse, rejection, or humiliation from parents who are not particularly affectionate (Alden et al.,  2002 ; Bernstein & Travaglini,  1999 ; Kagan,  1997 ). Such abuse and rejection would be especially likely to lead to anxious and fearful attachment patterns in temperamentally inhibited children (Bartholomew et al.,  2001 ).

Dependent Personality Disorder

Individuals with  dependent personality disorder  show an extreme need to be taken care of, which leads to clinging and submissive behavior. They also show acute fear at the possibility of separation or sometimes of simply having to be alone because they see themselves as inept (Bornstein,  2007  2012 ; Widiger & Bornstein,  2001 ). These individuals usually build their lives around other people and subordinate their own needs and views to keep these people involved with them. Accordingly, they may be indiscriminate in their selection of mates. They often fail to get appropriately angry with others because of a fear of losing their support, which means that people with dependent personalities may remain in psychologically or physically abusive relationships. They have great difficulty making even simple, everyday decisions without a great deal of advice and reassurance because they lack self-confidence and feel helpless even when they have actually developed good work skills or other competencies. They may function well as long as they are not required to be on their own.

The Dependent Wife Sarah, a 32-year-old mother of two and a part-time tax accountant, came to a crisis center late one evening after Michael, her husband of a year and a half, had abused her physically and then left home. Although he never physically harmed the children, he frequently threatened to do so when he was drunk. Sarah appeared acutely anxious and worried about the future and “needed to be told what to do.” She wanted her husband to come back and seemed rather unconcerned about his regular pattern of physical abuse. At the time, Michael was an unemployed resident in a day treatment program at a halfway house for paroled drug abusers. He was almost always in a surly mood and “ready to explode.”

Although Sarah had a well-paying job, she voiced great concern about being able to make it on her own. She realized that it was foolish to be “dependent” on her husband, whom she referred to as a “real loser.” (She had had a similar relationship with her first husband, who had left her and her oldest child when she was 18.) Several times in the past few months, Sarah had made up her mind to get out of the marriage but couldn’t bring herself to break away. She would threaten to leave, but when the time came to do so, she would “freeze in the door” with a numbness in her body and a sinking feeling in her stomach at the thought of “not being with Michael.”

Estimates are that dependent personality disorder occurs in 1 to 2 percent of the population and is more common in women than in men (Bornstein,  2012 ). This gender difference is not due to a sex bias in making the diagnosis but rather to the higher prevalence in women of certain personality traits such as neuroticism and agreeableness, which are prominent in dependent personality disorder (Lynam & Widiger,  2007 ). It is quite common for people with dependent personality disorder to have a comorbid diagnosis of mood and anxiety disorders (Bornstein,  1999 ; Grant, Hasin et al.,  2005 ), as well as eating disorders (Bornstein,  2012 ).

Some features of dependent personality disorder overlap with those of borderline, histrionic, and avoidant personality disorders, but there are differences as well (refer back to  Table 10.2  on p. 335). For example, both borderline personalities and dependent personalities fear abandonment. However, the borderline personality, who usually has intense and stormy relationships, reacts with feelings of emptiness or rage if abandonment occurs, whereas the dependent personality reacts initially with submissiveness and appeasement and then finally with an urgent seeking of a new relationship. Histrionic and dependent personalities both have strong needs for reassurance and approval, but the histrionic personality is much more gregarious, flamboyant, and actively demanding of attention, whereas the dependent personality is more docile and self-effacing. It can also be hard to distinguish between dependent and avoidant personalities. As noted, dependent personalities have great difficulty separating in relationships because they feel incompetent on their own and have a need to be taken care of, whereas avoidant personalities have trouble initiating relationships because they fear criticism or rejection, which will be humiliating (Millon & Martinez,  1995 ). Even so, we should remember that avoidant personality occurs with dependent personality disorder rather frequently (Alden et al.,  2002 ; Arntz et al.,  2009 ; Bernstein & Travaglini,  1999 ; Bornstein,  2011 ). This fits with the observation that people with avoidant personality disorder do not avoid absolutely everyone and that their dependent personality disorder characteristics are focused on the one or few individuals whom they do not avoid (Alden et al.,  2002 ). In terms of the five-factor model, dependent personality disorder is associated with high levels of neuroticism and agreeableness (Lowe et al.,  2009 ).


Some evidence indicates that there is a modest genetic influence on dependent personality traits (Bornstein,  2011  2012 ; Reichborn-Kjennerud et al.,  2006 ). Moreover, several other personality traits such as neuroticism and agreeableness that are also prominent in dependent personality disorder also have a genetic component (Widiger & Bornstein,  2001 ). It is possible that people with these partially genetically based predispositions to dependence and anxiousness may be especially prone to the adverse effects of parents who are authoritarian and overprotective (not promoting autonomy and individuation in their child but instead reinforcing dependent behavior). This might lead children to believe that they are reliant on others for their own well-being and are incompetent on their own (Widiger & Bornstein,  2001 ). Cognitive theorists describe the underlying maladaptive schemas for these individuals as involving core beliefs about weakness and competence and needing others to survive (P. S. Rasmussen,  2005 ), such as, “I am completely helpless” and “I can function only if I have access to somebody competent” (Beck et al.,  1990 , p. 60; Beck et al.,  2003 ). Recent experimental evidence supports the hypothesis that these beliefs characterize those with dependent personality disorder (Arntz et al.,  2011 ).

Obsessive-Compulsive Personality Disorder

DSM-5 criteria for: Dependent Personality Disorder

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:

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

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

·  3. Has difficulty expressing disagreement with others because of fear of loss of support or approval. (Note: Do not include realistic fears of retribution.)

·  4. 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).

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

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

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

·  8. Is unrealistically preoccupied with fears of being left to take care of himself or herself.

Source: Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (Copyright © 2013). American Psychiatric Association.

Perfectionism and an excessive concern with maintaining order and control characterize individuals with  obsessive-compulsive personality disorder (OCPD) . Their preoccupation with maintaining mental and interpersonal control occurs in part through careful attention to rules, order, and schedules. They are very careful in what they do so as not to make mistakes, but because the details they are preoccupied with are often trivial they use their time poorly and have a difficult time seeing the larger picture (Aycicegi-Dinn et al.,  2009 ; Yovel et al.,  2005 ). This perfectionism is also often quite dysfunctional in that it can result in their never finishing projects. They also tend to be devoted to work to the exclusion of leisure activities and may have difficulty relaxing or doing anything just for fun (Widiger & Frances,  1994 ). At an interpersonal level, they have difficulty delegating tasks to others and are quite rigid, stubborn, and cold, which is how others tend to view them. Research indicates that rigidity, stubbornness, and perfectionism, as well as reluctance to delegate, are the most prevalent and stable features of OCPD (Ansell et al.,  2008 ; Grilo et al.,  2004 ; McGlashan et al.,  2005 ; Samuel & Widiger,  2011 ).


Individuals with obsessive-compulsive personality disorder are highly perfectionistic, leading to serious problems finishing various projects. They are also excessively devoted to work, inflexible about moral and ethical issues, and have difficulty delegating tasks to others. They are also inclined to be ungenerous with themselves and others.

It is important to note that people with OCPD do not have true obsessions or compulsive rituals that are the source of extreme anxiety or distress in people with obsessive-compulsive disorder (OCD; see  Chapter 6 ). Instead, people with OCPD have lifestyles characterized by overconscientiousness, high neuroticism, inflexibility, and perfectionism but without the presence of true obsessions or compulsive rituals (Samuels & Costa,  2012 ). Indeed, only about 20 percent of patients with OCD have a comorbid diagnosis of OCPD. This is not significantly different from the rate of OCPD in patients with panic disorder (Albert et al.,  2004 ). People with OCD are more likely to be diagnosed with avoidant or dependent personality disorder than with OCPD (Wu et al.,  2006 ), and there are only three symptoms of OCPD that seem to occur at elevated rates in people with OCD relative to controls: perfectionism, preoccupation with details, and hoarding (Eisen et al.,  2006 ).

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:

DSM-5 criteria for: Obsessive-Compulsive Personality Disorder

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

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

·  3. Is excessively devoted to work and productivity to the exclusion of leisure activities and friendships (not accounted for by obvious economic necessity).

·  4. Is overconscientious, scrupulous, and inflexible about matters of morality, ethics, or values (not accounted for by cultural or religious identification).

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

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

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

·  8. Shows rigidity and stubbornness.

Source: Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (Copyright © 2013). American Psychiatric Association.

The Perfectionist Train Dispatcher Alan appeared to be well suited to his work as a train dispatcher. He was conscientious, perfectionistic, and attended to minute details. However, he was not close to his coworkers, and they reportedly thought him “off.” He would get quite upset if even minor variations to his daily routine occurred. For example, he would become tense and irritable if coworkers did not follow exactly his elaborately constructed schedules and plans.

In short, Alan got little pleasure out of life and worried constantly about minor problems. His rigid routines were impossible to maintain, and he often developed tension headaches or stomachaches when he couldn’t keep his complicated plans in order. His physician, noting the frequency of his physical complaints and his generally perfectionistic approach to life, referred him for a psychological evaluation. Psychotherapy was recommended, but he did not follow up on the treatment recommendations because he felt that he could not afford the time away from work.

Some features of OCPD overlap with some features of narcissistic, antisocial, and schizoid personality disorders, although there are also distinguishing features. For example, individuals with narcissistic and ASPDs may share the lack of generosity toward others that characterizes OCPD, but the former tend to indulge themselves, whereas those with OCPD are equally unwilling to be generous with themselves. In addition, both the schizoid and the obsessive-compulsive personalities may have a certain amount of formality and social detachment, but only the schizoid personality lacks the capacity for close relationships. The person with OCPD has difficulty in interpersonal relationships because of excessive devotion to work and great difficulty expressing emotions.


Theorists who take a five-factor dimensional approach to understanding OCPD note that these individuals have excessively high levels of conscientiousness (Samuel & Widiger,  2011 ). This leads to extreme devotion to work, perfectionism, and excessive controlling behavior (McCann,  1999 ). They are also high on assertiveness (a facet of extraversion) and low on compliance (a facet of agreeableness). (Refer back to  Table 10.2  on p. 335.) Another influential biological dimensional approach—that of Cloninger ( 1987 )—posits three primary dimensions of personality: novelty seeking, reward dependence, and harm avoidance. Individuals with obsessive-compulsive personalities have low levels of novelty seeking (i.e., they avoid change) and reward dependence (i.e., they work excessively at the expense of pleasurable pursuits) but high levels of harm avoidance (i.e., they respond strongly to aversive stimuli and try to avoid them). Recent research has also demonstrated that the OCPD traits show a modest genetic influence (Calvo et al.,  2009 ; Reichborn-Kjennerud et al.,  2006 ).

General Sociocultural Causal Factors for Personality Disorders

The sociocultural factors that contribute to personality disorders are not well understood. As with other forms of psychopathology, the incidence and particular features of personality disorders vary somewhat with time and place, although not as much as one might guess (Allik,  2005 ; Rigozzi et al.,  2009 ). Indeed, there is less variance across cultures than within cultures. This may be related to findings that all cultures (both Western and non-Western, including Africa and Asia) share the same five basic personality traits discussed earlier, and their patterns of covariation also seem universal (see Allik,  2005 , for a review).

Some researchers believe that certain personality disorders have increased in American society in recent years (e.g., Paris,  2001 ). If this claim is true, we can expect to find the increase related to changes in our culture’s general priorities and activities. Is our emphasis on impulse gratification, instant solutions, and pain-free benefits leading more people to develop the self-centered lifestyles that we see in more extreme forms of the personality disorders? For example, there is some evidence that narcissistic personality disorder is more common in Western cultures, where personal ambition and success are encouraged and reinforced (e.g., Widiger & Bornstein,  2001 ). There is also some evidence that histrionic personality might be expected to be (and is) less common in Asian cultures, where sexual seductiveness and drawing attention to oneself are frowned on; by contrast, it may be higher in Hispanic cultures, where such tendencies are common and well tolerated (e.g., Bornstein,  1999 ). Within the United States, rates of BPD are higher in Hispanic Americans than in African Americans and Caucasians, but rates of schizotypal personality disorder are higher in African Americans than in Caucasians (Chavira et al.,  2003 ).

It has also been suggested that known increases over the 60 years since World War II in emotional dysregulation (e.g., depression, self-injurious behavior, and suicide) and impulsive behaviors (substance abuse and criminal behavior) may be related to increases in the prevalence of borderline and ASPDs over the same time period. This could stem from increased breakdown of the family and other traditional social structures (Paris,  2001  2007 ) and may vary across cultures depending on whether similar breakdowns have occurred.

in review

·  ● What are the general characteristics of the three clusters of personality disorders?

·  ● Describe and differentiate among the following Cluster A personality disorders: paranoid, schizoid, and schizotypal.

·  ● Describe and differentiate among the following Cluster B personality disorders: histrionic, narcissistic, antisocial, and borderline.

·  ● Describe and differentiate among the following Cluster C personality disorders: avoidant, dependent, and obsessive-compulsive.

Treatments and Outcomes for Personality Disorders

Personality disorders are generally very difficult to treat, in part because they are, by definition, relatively enduring, pervasive, and inflexible patterns of behavior and inner experience. Moreover, many different goals of treatment can be formulated, and some are more difficult to achieve than others. Goals might include reducing subjective distress, changing specific dysfunctional behaviors, and changing whole patterns of behavior or the entire structure of the personality.

In many cases, people with personality disorders enter treatment only at someone else’s insistence, and they often do not believe that they need to change. Moreover, those from the odd/eccentric Cluster A and the erratic/dramatic Cluster B have general difficulties in forming and maintaining good relationships, including with a therapist. For those from the erratic/dramatic Cluster B, the pattern of acting out typical in their other relationships is carried into the therapy situation, and instead of dealing with their problems at the verbal level they may become angry at their therapist and loudly disrupt the sessions. Non-completion of treatment is a particular problem in the treatment of personality disorders; a recent review of the research reported that an average of 37 percent of personality disorder patients drop out of therapy prematurely (McMurran et al.,  2010 ).

In addition, people who have a personality disorder in addition to another disorder (such as depression or an eating disorder) do not, on average, do as well in treatment for their other disorder as do patients without comorbid personality disorders (Crits-Christoph & Barber,  2002  2007 ; Pilkonis,  2001 ). This is partly because people with personality disorders have rigid, ingrained personality traits that often lead to poor therapeutic relationships and additionally make them resist doing the things that would help improve their other conditions.

Adapting Therapeutic Techniques To Specific Personality Disorders

Therapeutic techniques must often be modified. For example, recognizing that traditional individual psychotherapy tends to encourage dependence in people who are already too dependent (as in dependent, histrionic, and BPDs), it is often useful to develop treatment strategies specifically aimed at altering these traits. Patients from the anxious/fearful Cluster C, such as those with dependent and avoidant personalities, may also be hyper-sensitive to any criticism they may perceive from the therapist, so therapists need to be extremely careful to make sure that they do not come across in this way.

For people with severe personality disorders, therapy may be more effective in situations where acting-out behavior can be constrained. For example, many patients with BPD are hospitalized at times, for safety reasons, because of their frequent suicidal behavior. However, partial-hospitalization programs are increasingly being used as an intermediate and less expensive alternative to inpatient treatment (Azim,  2001 ). In these programs, patients live at home and receive extensive group treatment and rehabilitation only during weekdays. Several studies conducted in the Netherlands suggest that short-term inpatient treatment is more effective than outpatient treatment in both Cluster B and Cluster C personality disorders (Bartak et al.,  2010  2011 ).

Specific therapeutic techniques are a central part of the relatively new cognitive approach to personality disorders that assumes that the dysfunctional feelings and behavior associated with the personality disorders are largely the result of schemas that tend to produce consistently biased judgments, as well as tendencies to make cognitive errors (e.g., Beck et al., 2003; Cottraux & Blackburn,  2001 ; Leahy & McGinn,  2012 ; Pretzer & Beck,  2005 ). Changing these underlying dysfunctional schemas is difficult but is at the heart of cognitive therapy for personality disorders. Such an approach uses standard cognitive techniques of monitoring automatic thoughts, challenging faulty logic, and assigning behavioral tasks in an effort to challenge the patient’s dysfunctional beliefs.

Treating Borderline Personality Disorder

Of all personality disorders, most clinical and research attention has been paid to the treatment of BPD. This is due to the severity of this disorder and the high risk of suicide that is associated with it. Treatment often involves both psychological and biological treatment approaches, with medications being used as an adjunct to psychological treatment, which is considered essential.


The use of medications is controversial with this disorder because it is so frequently associated with suicidal behavior. Today, antidepressant medications (most often from the SSRI category) are considered most safe and useful for treating rapid mood shifts, anger, and anxiety (Lieb et al.,  2004 ), as well as for impulsivity symptoms including impulsive aggression such as self-mutilation (Koenigsberg et al.,  2002  2007 ; Markovitz,  2004 ; Silk & Feurino,  2012 ). In addition, low doses of antipsychotic medication (see  Chapters 13  and  16 ) have modest effects that are broad based; that is, patients show some improvement in depression, anxiety, suicidality, impulsive aggression, rejection sensitivity, and especially transient psychotic symptoms and cognitive and perceptual distortions (Koenigsberg et al.,  2007 ; Markovitz,  2001  2004 ; Silk & Feurino,  2012 ). Finally, mood-stabilizing medications such as carbazemine may be useful in reducing irritability, suicidality, affective instability and impulsive aggressive behavior (Koenigsberg et al.,  2007 ; Lieb et al.,  2004 ). However, the consensus to date is that drugs are only mildly beneficial for BPD (Paris,  2009 ).


Clinical trials suggest that several types of psychotherapy may be effective for BPD. As discussed below, however, these treatments share two common weaknesses. These are their relative complexity and long duration, both of which makes them difficult to disseminate to the broader population (Paris,  2009 ).

Dialectical behavior therapy , developed by Marsha Linehan, is a unique kind of cognitive and behavioral therapy specifically adapted for BPD (Linehan,  1993 ; Linehan & Dexter-Mazza,  2008 ; Lynch & Cuper,  2012 ; Robins et al.,  2001 ). Linehan believes that patients’ inability to tolerate strong states of negative affect is central to this disorder. One of the primary goals of treatment is to encourage patients to accept this negative affect without engaging in self-destructive or other maladaptive behaviors. Accordingly, Linehan has developed a problem-focused treatment based on a clear hierarchy of goals, which prioritizes decreasing suicidal and self-harming behavior and increasing coping skills. The therapy combines individual and group components as well as phone coaching. In the group setting, patients learn interpersonal effectiveness, emotion regulation, and distress tolerance skills. The individual therapist, in turn, uses therapy sessions and phone coaching to help the patient identify and change problematic behavior patterns and apply newly learned skills effectively.

Dialectical behavior therapy (DBT) appears to be an efficacious treatment for BPD (Binks et al.,  2006 ; Paris,  2009 ). However, there are still not enough randomized controlled trials to say whether it works as well in men as in women, and whether it works well with minority patients (Lynch & Cuper,  2012 ). Patients receiving DBT show reductions in self-destructive and suicidal behaviors as well as in levels of anger (Linehan et al.,  2006 ; Lynch et al.,  2007 ). Evidence also suggests that these gains are sustainable (Zanarini et al.,  2005 ). Such results are considered extraordinary by most therapists who work with this population, and many psychodynamic therapists are now incorporating important components of this treatment into their own treatment. However, DBT is still not in widespread use, likely because the treatment is complex and lasts several years (Paris,  2009 ). Accordingly, some researchers are currently working on developing briefer versions of the treatment (Stanley et al.,  2007 ).

Other psychosocial treatments for BPD involve variants of psychodynamic psychotherapy adapted for the particular problems of people with this disorder. For example, Kernberg ( 1985  1996 ) and colleagues (Koenigsberg et al.,  2000 ; see also Clarkin et al.,  2004 ) have developed a form of psychodynamic psychotherapy that is much more directive than is typical of psychodynamic treatment. The primary goal is seen as strengthening the weak egos of these individuals, with a particular focus on their primary primitive defense mechanism of splitting. This leads them to black-and-white, all-or-none thinking, as well as to rapid shifts in their reactions to themselves and to other people (including the therapist) as “all good” or “all bad.” One major goal is to help patients see the shades of gray between these extremes and integrate positive and negative views of themselves and others into more nuanced views. Although this treatment is often expensive and time-consuming (often lasting a number of years), it has been shown in at least one study to be as effective as DBT, which is now regarded as the most established, effective treatment (Clarkin et al.,  2007 ). Such results will, however, need to be replicated in other treatment centers before we can place a great deal of confidence in its usefulness (Clarkin et al.,  2004 ; Crits-Christoph & Barber,  2002  2007 ).

Finally, we note that there is one other promising treatment approach that deserves mention. Bateman and Fonagy have developed a new therapeutic approach called mentalization (see Bateman & Fonagy, 2010). This uses the therapeutic relationship to help patients develop the skills they need to accurately understand their own feelings and emotions, as well as the feelings and emotions of others. Randomized controlled trials of mentalization-based therapy have revealed it to be an efficacious treatment for BPD. Moreover, many clinical improvements seem to be maintained even after an 8-year follow-up (Bateman & Fonagy, 2008). Although DBT is still a very popular treatment, it is encouraging that people with BPD now have other treatment options available to them.

Treating Other Personality Disorders

Treatment of Cluster A and other Cluster B personality disorders is not, so far, as promising as some of the recent advances that have been made in the treatment of BPD. In schizotypal personality disorder, low doses of antipsychotic drugs (including the newer, atypical antipsychotics; e.g., Keshavan et al.,  2004 ; Koenigsberg et al.,  2007 ; Raine,  2006 ) may result in modest improvements. Antidepressants from the SSRI category may also be useful. However, no treatment has yet produced anything approaching a cure for most people with this disorder (Koenigsberg et al.,  2002  2007 ; Markovitz,  2001  2004 ; Silk & Ferino,  2012 ). Other than uncontrolled studies or single cases, no systematic, controlled studies of treating people with either medication or psychotherapy yet exist for paranoid, schizoid, narcissistic, or histrionic disorder (Beck et al., 2003; Crits-Christoph & Barber,  2007 ). One reason for this is that these people (because of the nature of their personality pathology) rarely seek treatment.

Although not extensively studied, treatment of some Cluster C disorders, such as dependent and avoidant personality disorder, appears somewhat more promising. Winston and colleagues ( 1994 ) found significant improvement in patients with Cluster C disorders using a form of short-term psychotherapy that is active and confrontational (see also Pretzer & Beck,  1996 ). Several studies using cognitive-behavioral treatment with avoidant personality disorder have also reported significant gains (see Crits-Christoph & Barber,  2007 ), and a recent meta-analysis concluded both cognitive-behavioral and psychodynamic therapies resulted in significant and lasting treatment gains (Simon,  2009 ). Another study in the Netherlands concluded that short-term inpatient treatment for Cluster C personality disorders is even more effective than long-term inpatient or outpatient therapy (Bartak et al.,  2011 ). Antidepressants from the MAOI and SSRI categories may also sometimes help in the treatment of avoidant personality disorder, just as they do in closely related social phobia (Koenigsberg et al.,  2007 ; Markovitz,  2001 ).

in review

·  ● Why are personality disorders especially resistant to therapy?

·  ● Under what circumstances do individuals with personality disorders generally get involved in psychotherapy?

·  ● What is known about the effectiveness of treatments for borderline personality disorder?

DSM-5 criteria for: Antisocial Personality Disorder

·  A. 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:

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

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

·  3. Impulsivity or failure to plan ahead.

·  4. Irritability and aggressiveness, as indicated by repeated physical fights or assaults.

·  5. Reckless disregard for safety of self or others.

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

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

·  B. The individual is at least age 18 years.

·  C. There is evidence of conduct disorder with onset before age 15 years.

·  D. The occurrence of antisocial behavior is not exclusively during the course of schizophrenia or bipolar disorder.

Source: Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (Copyright © 2013). American Psychiatric Association.

Antisocial Personality Disorder and Psychopathy

The outstanding characteristic of people with  antisocial personality disorder (ASPD)  is their tendency to persistently disregard and violate the rights of others. They do this through a combination of deceitful, aggressive, and antisocial behaviors. These people have a lifelong pattern of unsocialized and irresponsible behavior with little regard for safety—either their own or that of others. These characteristics bring them into repeated conflict with society, and a high proportion become incarcerated. Only individuals 18 or over are diagnosed with ASPD. According to the DSM, this diagnosis is made if, after age 15, the person repeatedly performs acts that are grounds for arrest; shows repeated deceitfulness, impulsivity, irritability, and aggressiveness; shows disregard for safety; and shows consistent irresponsibility in work or financial matters. Moreover, the person must also have shown symptoms of conduct disorder before age 15 (see  Chapter 15 ).

Psychopathy and Antisocial Personality Disorder

The use of the term antisocial personality disorder dates back only to 1980 when personality disorders first entered DSM-III. However, many of the central features of this disorder have long been labeled  psychopathy  or sociopathy. Although several investigators identified the syndrome in the nineteenth century using such terms as “moral insanity” (Prichard,  1835 ), the most comprehensive early description of psychopathy was made by Cleckley ( 1941  1982 ) in the 1940s. In addition to the defining features noted in the DSM criteria, psychopathy also includes such affective and interpersonal traits as lack of empathy, inflated and arrogant self-appraisal, and glib and superficial charm (see Patrick,  2006 , for an analysis of Cleckley’s work in light of contemporary research). With their strong emphasis on behavioral criteria that can be measured reasonably objectively, the features included in the DSM do not fully map onto the construct of psychopathy as originally described. This was done deliberately in an attempt to increase the reliability of the diagnosis (i.e., the level of agreement of clinicians on the diagnosis). However, much less attention has been paid to the validity of the ASPD diagnosis—that is, whether it measures a meaningful construct and whether that construct is the same as psychopathy.

According to some estimates, the prevalence of ASPD in the general population is about 3 percent for males and about 1 percent for females but other studies have reported that the preponderance of men is even greater such as 5 to 1 (Hare et al.,  2012 ). However, a recent, very large epidemiological study has shown that the real prevalence may be as low as 1 percent (Lenzenweger et al.,  2007 ). There are no epidemiological studies estimating the prevalence of psychopathy, but Hare et al., ( 1999 ) estimated it is likely to be about 1 percent in North America.


Research suggests that ASPD and psychopathy are related but differ in significant ways. Robert Hare ( 1980  1991  2003 ) developed a 20-item Psychopathy Checklist-Revised (PCL-R) as a way for clinicians and researchers to diagnose psychopathy on the basis of the Cleckley criteria following an extensive interview and careful checking of past school, police, and prison records. Extensive research with this checklist has shown that there are two related but separable dimensions of psychopathy, each predicting different types of behavior:

·  1. The first dimension involves the affective and interpersonal core of the disorder and reflects traits such as lack of remorse or guilt, callousness/lack of empathy, glibness/superficial charm, grandiose sense of self-worth, and pathological lying.

·  2. The second dimension reflects behavior—the aspects of psychopathy that involve antisocial or impulsive acts, social deviance, as well as a need for stimulation, poor behavior controls, irresponsibility, and a parasitic lifestyle.

The second dimension is much more closely related than the first to the DSM diagnosis of ASPD (Hare et al.,  1999 ; Widiger,  2006 ). Not surprisingly, therefore, when comparisons have been made in prison settings to determine what percentage of prison inmates qualify for a diagnosis of psychopathy versus ASPD, it is typically found that about 70 to 80 percent qualify for a diagnosis of ASPD but that only about 25 to 30 percent meet the criteria for psychopathy (Patrick,  2005 ). Put somewhat differently, only about half of imprisoned individuals diagnosed with ASPD also meet the criteria for psychopathy, but most imprisoned individuals with a diagnosis of psychopathy also meet the criteria for ASPD (Widiger,  2006 ). That is, a significant number of inmates show the antisocial and aggressive behaviors necessary for a diagnosis of ASPD but do not show enough selfish, callous, and exploitative behaviors to qualify for a diagnosis of psychopathy (Hare et al.,  1999 ).

The issues surrounding these diagnoses remain highly controversial. There was considerable discussion by the DSM-5 task force about expanding the DSM-IV criteria for ASPD to include more of the traditional affective and interpersonal features of psychopathy. However, in the end no official changes were made. An alternative approach to the diagnosis of ASPD appears in Section III of the DSM-5 manual and is considered to be in need of further study. Many researchers continue to use the Cleckley/Hare psychopathy diagnosis rather than the DSM ASPD diagnosis, not only because of the long and rich research tradition on psychopathy but also because the psychopathy diagnosis has been shown to be a better predictor of a variety of important facets of criminal behavior than the ASPD diagnosis (Hare et al.,  2012 ). Overall, a diagnosis of psychopathy appears to be the single best predictor of violence and recidivism (offending again after imprisonment; Douglas et al.,  2006 ; Gretton et al.,  2004 ; Hart,  1998 ). For example, one review estimated that people with psychopathy are three times more likely to reoffend and four times more likely to reoffend violently following prison terms than are people without a psychopathy diagnosis (Hemphill et al.,  1998 ). Moreover, as illustrated in  Figure 10.2 , adolescents with higher psychopathy scores are not only more likely to show violent reoffending but are also more likely to reoffend more quickly (Gretton et al.,  2004 ).

An additional concern about the current conceptualization of ASPD is that it fails to include people who show many of the features of the first, affective and interpersonal dimension of psychopathy but not as many features of the second, antisocial dimension, or at least few enough that these individuals do not generally get into trouble with the law. Cleckley did not believe that aggressive behavior was central to the concept of psychopathy (Patrick,  2006 ). This group might include, for example, unprincipled and predatory business or financial professionals, manipulative lawyers, high-pressure evangelists, and crooked politicians (Hall & Benning,  2006 ; Hare et al.,  1999 ). Unfortunately, because they are difficult to find to study, little research has been conducted on psychopathic people who manage to stay out of correctional institutions. To locate these people, one researcher (Widom,  1977 ) who wanted to study them ran an ingenious ad in local newspapers:

·  Are you adventurous? Psychologist studying adventurous, carefree people who’ve led exciting, impulsive lives. If you’re the kind of person who’d do almost anything for a dare and want to participate in a paid experiment, send name, address, phone, and short biography proving how interesting you are to … (p. 675)

When those who responded were given a battery of tests, they turned out to be similar in personality makeup to that of institutionalized psychopaths. Several further studies on people with noncriminal psychopathy confirmed this finding (Hall & Benning,  2006 ; Hare et al.,  1999 ). However, some experimental research that we will discuss later suggests that these two groups may also differ biologically in some significant ways (Ishikawa et al.,  2001 ).

These controversies over the use of a diagnosis of psychopathy versus ASPD are not likely to be resolved soon. Different researchers in this area make different choices, so interpreting the research on causal factors can be difficult. Because the causal factors are almost certainly not identical, we make every effort to make it clear which diagnostic category was used in different studies.

The Clinical Picture in Psychopathy and Antisocial Personality Disorder

Often charming, spontaneous, and likable on first acquaintance, psychopaths are deceitful and manipulative, callously using others to achieve their own ends. Many of them seem to live in a series of present moments without consideration for the past or future. But also included in this general category are hostile people who are prone to acting out impulses in remorseless and often senselessly violent ways.

We will summarize the major characteristics of psychopaths and antisocial personalities and then describe a case that illustrates the wide range of behavioral patterns that may be involved. Although all the characteristics examined in the following sections are not usually found in any one particular case, they are typical of psychopaths as first described by Cleckley ( 1941  1982 ). A subset of these characteristics occurs in ASPD as well.


Psychopaths appear unable to understand and accept ethical values except on a verbal level. They may glibly claim to adhere to high moral standards that have no apparent connection with their behavior. In short, their conscience development is severely retarded or nonexistent, and they behave as though social regulations and laws do not apply to them (Frick & Marsee,  2006 ; Salekin,  2006 ). These characteristics of psychopathy are most strongly related to the interpersonal and affective core of psychopathy (Fowles & Dindo,  2006 ). In spite of their stunted conscience development, their intellectual development is typically normal. Nevertheless, intelligence is one trait that has different relationships with the two dimensions of psychopathy. The first, affective and interpersonal dimension is positively related to verbal intelligence (Salekin et al.,  2004 ); the second, antisocial dimension is negatively related to intelligence (Frick,  1998 ; Hare et al.,  1999 ).


FIGURE 10.2 Survival curve of months free in the community until first violent reoffense plotted by score on the by Hare Psychopathy Checklist: Youth Version (PCL:YV) group. The survival curve illustrates the percentage of individuals in each group who have not shown a violent reoffense at 12-month intervals. Those in the High-PCL-YV group are more likely to have violent reoffenses than those in the other two groups (lower probability of survival) and are more likely to have them sooner after release (indicated by the steeper slope).

Source: From Gretton et al. ( 2004 ). Psychopathy and offending from adolescence to adulthood: A 10-year follow-up. Journal of Consulting and Clinical Psychology, 72, 636–45. Copyright © 2004 by the American Psychological Association. Reproduced with permission.


Psychopaths learn to take rather than earn what they want. Prone to thrill seeking and deviant and unconventional behavior, they often break the law impulsively and without regard for the consequences. They seldom forgo immediate pleasure for future gains and long-range goals. These aspects of psychopathy are most closely related to the second, antisocial dimension of psychopathy (Patrick,  2005 ).

Many studies have shown that antisocial personalities and some psychopaths have high rates of alcohol abuse and dependence and other substance-abuse/dependence disorders (e.g., Taylor & Lang,  2006 ; Waldman & Slutske,  2000 ). Alcohol abuse is related only to the antisocial or deviant dimension of the PCL-R (Patrick,  2005 ; Reardon al.,  2002 ). Antisocial personalities also have elevated rates of suicide attempts and completed suicides, which are also associated only with the second, antisocial dimension of psychopathy and not with the first, affective dimension (Verona et al.,  2001 ).


Some psychopaths are superficially charming and likable, with a disarming manner that easily wins new friends (Cleckley,  1941  1982 ; Patrick,  2006 ). They seem to have good insight into other people’s needs and weaknesses and are adept at exploiting them. These frequent liars usually seem sincerely sorry if caught in a lie and promise to make amends they—but they do not do so. Not surprisingly, then, psychopaths are seldom able to keep close friends. They seemingly cannot understand love in others or give it in return. Manipulative, exploitative, and sometimes coercive in sexual relationships, psychopaths are irresponsible and unfaithful mates.


Serial killer Ted Bundy exhibited antisocial behavior at its most extreme and dangerous. Bundy used his clean-cut image to get close to his victims—mainly young university women—whom he sexually assaulted and then savagely murdered. From all outward appearances, Bundy was a fine, upstanding citizen.

Hare, a highly influential researcher in this area, summarized the prototypic psychopath in the following manner:

·  Conceptualizing psychopaths as remorseless predators helped me to make sense of what often appears to be senseless behavior. These are individuals who, lacking in conscience and feelings for others, find it easy to use charm, manipulation, intimidation, and violence to control others and to satisfy their own social needs … without the slightest sense of guilt or regret … they form a significant proportion of persistent criminals, drug dealers, spouse and child abusers, swindlers and con men …. They are well represented in the business and corporate world, particularly during chaotic restructuring, where the rules and their enforcement are lax…. Many psychopaths emerge as “patriots” and “saviors” in societies experiencing social, economic, and political upheaval (e.g., Rwanda, the former Yugoslavia, and the former Soviet Union) … by callously exploiting ethnic, cultural, or racial tensions and grievances. (1998, pp. 128–29)

Psychopathy is well illustrated in the following classic case study published by Hare ( 1970 ).

A Psychopath in Action Donald, 30 years old, has just completed a 3-year prison term for fraud, bigamy, false pretenses, and escaping lawful custody. The circumstances leading up to these offenses are interesting and consistent with his past behavior. With less than a month left to serve on an earlier 18-month term for fraud, he faked illness and escaped from the prison hospital. During the 10 months of freedom that followed, he engaged in a variety of illegal enterprises; the activity that resulted in his recapture was typical of his method of operation. By passing himself off as the “field executive” of an international philanthropic foundation, he was able to enlist the aid of several religious organizations in a fund-raising campaign. The campaign moved slowly at first, and in an attempt to speed things up, he arranged an interview with the local TV station. His performance during the interview was so impressive that funds started to pour in. However, unfortunately for Donald, the interview was also carried on a national news network. He was recognized and quickly arrested. During the ensuing trial it became evident that he experienced no sense of wrongdoing for his activities…. At the same time, he stated that most donations to charity are made by those who feel guilty about something and who therefore deserve to be bilked.

While in prison he was used as a subject in some of the author’s research. On his release he applied for admission to a university and, by way of reference, told the registrar that he had been one of the author’s research colleagues! Several months later the author received a letter from him requesting a letter of recommendation on behalf of Donald’s application for a job.

Background. Donald was the youngest of three boys born to middle-class parents. Both of his brothers led normal, productive lives. His father spent a great deal of time with his business; when he was home he tended to be moody and to drink heavily when things were not going right. Donald’s mother was a gentle, timid woman who tried to please her husband and to maintain a semblance of family harmony…. However, … on some occasions [the father] would fly into a rage and beat the children, and on others he would administer a verbal reprimand, sometimes mild and sometimes severe.

By all accounts Donald was considered a willful and difficult child. When his desire for candy or toys was frustrated he would begin with a show of affection, and if this failed he would throw a temper tantrum; the latter was seldom necessary because his angelic appearance and artful ways usually got him what he wanted…. Although he was obviously very intelligent, his school years were academically undistinguished. He was restless, easily bored, and frequently truant … when he was on his own he generally got himself or others into trouble. Although he was often suspected of being the culprit, he was adept at talking his way out of difficulty.

Donald’s misbehavior as a child took many forms including lying, cheating, petty theft, and the bullying of smaller children. As he grew older he became more and more interested in sex, gambling, and alcohol. When he was 14 he made crude sexual advances toward a younger girl, and when she threatened to tell her parents he locked her in a shed. It was about 16 hours before she was found. Donald at first denied knowledge of the incident, later stating that she had seduced him and that the door must have locked itself…. His parents were able to prevent charges being brought against him….

When he was 17, Donald … forged his father’s name to a large check and spent about a year traveling around the world. He apparently lived well, using a combination of charm, physical attractiveness, and false pretenses to finance his way. During subsequent years he held a succession of jobs, never … for more than a few months. Throughout this period he was charged with a variety of crimes, including theft, drunkenness in a public place, assault, and many traffic violations. In most cases he was either fined or given a light sentence.

A Ladies’ Man. His sexual experiences were frequent, casual, and callous. When he was 22, he married a 41-year-old woman whom he had met in a bar. Several other marriages followed, all bigamous…. The pattern was the same: He would marry someone on impulse, let her support him for several months, and then leave. One marriage was particularly interesting. After being charged with fraud Donald was sent to a psychiatric institution for a period of observation. While there he came to the attention of a female member of the professional staff. His charm, physical attractiveness, and convincing promises to reform led her to intervene on his behalf. He was given a suspended sentence, and they were married a week later. At first things went reasonably well, but when she refused to pay some of his gambling debts he forged her name to a check and left. He was soon caught and given an 18-month prison term…. He escaped with less than a month left to serve.

It is interesting to note that Donald sees nothing particularly wrong with his behavior, nor does he express remorse or guilt for using others and causing them grief. Although his behavior is self-defeating in the long run, he considers it to be practical and possessed of good sense. Periodic punishments do nothing to decrease his egotism and confidence in his own abilities…. His behavior is entirely egocentric, and his needs are satisfied without any concern for the feelings and welfare of others. (Reprinted with permission of Robert P. Hare, University of British Columbia, )

The repetitive behavior pattern exhibited by Donald is common among people diagnosed as psychopathic. Some of the multitude of etiological factors that are involved in the development of this very serious personality disorder are considered next.

Causal Factors in Psychopathy and Antisocial Personality

Contemporary research has variously stressed the causal roles of genetic factors, temperamental characteristics, deficiencies in fear and anxiety, more general emotional deficits, the early learning of antisocial behavior as a coping style, and the influence of particular family and environmental patterns. Because an antisocial person’s impulsiveness, acting out, and intolerance of discipline and a psychopathic person’s callous interpersonal traits tend to appear early in life, many investigators have focused on the role of early biological and environmental factors as causative agents in antisocial and psychopathic behaviors.


Until fairly recently, most behavior genetic research focused on genetic and environmental influences on antisocial behavior or criminality rather than on psychopathy itself. At least 100 studies have compared concordance rates between monozygotic and dizygotic twins, and a number of studies used the adoption method, wherein rates of criminal behavior in the adopted-away children of criminals were compared with the rates of criminal behavior in the adopted-away children of ordinary (non-criminal) parents. The results of both kinds of studies show a moderate heritability for antisocial or criminal behavior (Carey & Goldman,  1997 ; Hare et al.,  2012 ; Sutker & Allain,  2001 ) and for ASPD (Waldman & Rhee,  2006 ), although non-shared environmental influences play an equally important role. More recently, several strong studies have also demonstrated that psychopathy and some of its important features also show a moderate heritability (e.g., Blonigen et al.,  2003  2006 ; see Hare et al.,  2012 ; Waldman & Rhee,  2006 , for reviews). For example, a twin study of 3,687 twin pairs at age 7 found that the early signs of callous/unemotional traits in these children were highly heritable (Viding et al.,  2005 ).

However, researchers also note that strong environmental influences (to be discussed later) interact with genetic predispositions (a genotype–environment interaction) to determine which individuals become criminals or antisocial personalities (Carey & Goldman,  1997 ; Hare et al.,  2012 ; Moffitt,  2005 ). Indeed, this must be the case, given the dramatic increases in crime that have occurred in the United States and the United Kingdom since 1960, as well as the tenfold-higher murder rate in the United States than in the United Kingdom (Rutter,  1996 ); such findings cannot be accounted for by genetic factors alone but must involve psychosocial or sociocultural causal factors.

One excellent study by Cadoret and colleagues ( 1995 ; see also Riggins-Caspers et al.,  2003 ) found that adopted-away children of biological parents with ASPD were more likely to develop antisocial personalities if their adoptive parents exposed them to an adverse environment than if their adoptive parents exposed them to a more normal environment. Adverse environments were characterized by some of the following: marital conflict or divorce, legal problems, and parental psychopathology. Similar findings of a gene–environment interaction were also found in twins who were at high or low risk for conduct disorder (typically a childhood precursor of ASPD); in this study, the environmental risk factor was physical maltreatment (Jaffee et al.,  2005 ).

The most exciting study on gene–environment interactions and ASPD identified a candidate gene that seems to be very involved (Caspi et al.,  2002 ). This gene, known as the monoamine oxidase-A gene (MAO-A gene), is involved in the breakdown of neurotransmitters like norepinephrine, dopamine, and serotonin—all neurotransmitters affected by the stress of maltreatment that can lead to aggressive behavior (see  Figure 10.3 ). In this study, over a thousand children from New Zealand were followed from birth to age 26. Researchers found that individuals with low MAO-A activity were far more likely to develop ASPD if they had experienced early maltreatment than were individuals with high MAO-A activity and early maltreatment and than individuals with low levels of MAO-A activity without early maltreatment. Similar findings have been reported for conduct disorder (Foley et al.,  2004 ) and ADHD (Kim-Cohen et al.,  2006 )—both common precursors of adult ASPD and psychopathy.

The relationship between antisocial behavior and substance abuse is sufficiently strong that some have questioned whether there may be a common factor leading to both alcoholism and antisocial personality. Early studies of genetic factors involved in the predisposition to antisocial personality and to alcoholism were inconsistent (Carey & Goldman,  1997 ), but more recent research suggests that there is significant genetic involvement in their high level of comorbidity (e.g., Krueger et al.,  2002 ; Slutske et al.,  1998 ; Taylor & Lang,  2006 ). Moreover, one study found that ASPD and other externalizing disorders (like alcohol and drug dependence and conduct disorder) all share a strong common genetic vulnerability; environmental factors were more important in determining which disorder a particular person developed (Hicks et al.,  2004 ; Krueger et al.,  2007 ).


Research evidence indicates that psychopaths who are high on the egocentric, callous, and exploitative dimension have low trait anxiety and show poor conditioning of fear (Fowles & Dindo,  2006 ; Lykken,  1995 ; Patrick,  2005 ). In an early classic study, Lykken ( 1957 ) found that psychopaths showed deficient conditioning of skin conductance responses (reflecting activation of the sympathetic nervous system) when anticipating an unpleasant or painful event and that they were slow at learning to stop responding in order to avoid punishment. As a result, psychopaths presumably fail to acquire many of the conditioned reactions essential to normal passive avoidance of punishment, to conscience development, and to socialization (Trasler,  1978 ; see also Fowles & Dindo,  2006 ; Fowles & Kochanska,  2000 ). Hare aptly summarized work on this issue: “It is the emotionally charged thought, images, and internal dialogue that give the ‘bite’ to conscience, account for its powerful control over behavior, and generate guilt and remorse for transgressions. This is something that psychopaths cannot understand. For them conscience is little more than an intellectual awareness of rules others make up—empty words” (1998, p. 112).


FIGURE 10.3 Means on the composite index of antisocial behavior as a function of high or low MAO-A gene activity and a childhood history of maltreatment.

Source: Reprinted with permission from Caspi et al. ( 2002 Science, 297, 851–54. Copyright © 2002 AAAS.

An impressive array of studies since the early work of Lykken has confirmed that psychopaths are deficient in the conditioning of at least subjective and certain physiological components of fear (e.g., Birbaumer et al.,  2005 ; Flor et al.,  2002 ; Fowles,  2001 ; Lykken,  1995 ), although they do learn at a purely cognitive level that the CS predicts the US (Birbaumer et al.,  2005 ). Because such conditioning may underlie successful avoidance of punishment, this may also explain why their impulsive behavior goes unchecked. According to Fowles, the deficient conditioning of fear seems to stem from psychopaths’ having a deficient behavioral inhibition system (Fowles,  1993  2001 ; Fowles & Dindo,  2006 ; Hare et al.,  1999 ). The behavioral inhibition system has been proposed by Gray ( 1987 ; Gray & McNaughton,  1996 ) to be the neural system underlying anxiety. It is also the neural system responsible for learning to inhibit responses to cues that signal punishment. In this passive avoidance learning, one learns to avoid punishment by not making a response (e.g., by not committing robbery, one avoids punishment). Thus deficiencies in this neural system (currently identified as involving the septo-hippocampal system and the amygdala) are associated both with deficits in conditioning of anticipatory anxiety and, in turn, with deficits in learning to avoid punishment. Recent research suggests that “successful” psychopaths do not show these same deficits. This may be why they are successful at not getting caught, as discussed in The World Around Us box on the following page.

Other support for the low-fear hypothesis comes from work by Patrick and colleagues on the human startle response. Both humans and animals show a larger startle response if a startle probe stimulus (such as a loud noise) is presented when the subject is already in an anxious state (e.g., Patrick et al.,  1993 ); this is known as fear-potentiated startle. Comparing psychopathic and nonpsychopathic prisoners, Patrick and colleagues found that the psychopaths did not show this effect, but the nonpsychopathic prisoners did. Indeed, the psychopaths showed smaller rather than larger startle responses when viewing unpleasant and pleasant slides than when watching neutral slides (see also Patrick,  1994 ; Sutton et al.,  2002 , for related results). These deficits in fear-potentiated startle responding are related only to the first, affective dimension of psychopathy (not to the second, antisocial dimension; Patrick,  2005 ).

the WORLD around us: “Successful” Psychopaths

Most research on antisocial and psychopathic personalities has been conducted on institutionalized individuals, leaving us quite ignorant about the large numbers who stop short of criminal activity or who never get caught. Several early studies found the personality makeup of such individuals (as solicited from ads such as Widom’s) to be very similar to that of institutionalized individuals. However, Widom (1978) also speculates that the “everyday” noncriminal psychopaths (sometimes known as “successful” psychopaths because they somehow manage to avoid being incarcerated for long periods of time) she had studied might well not show the same autonomic nervous system deficits that are typically seen in criminal psychopaths. Specifically, as noted earlier, criminal psychopaths typically show smaller skin conductance (sweaty palm) responses in anticipation of punishment than criminal nonpsychopaths, and several other studies showed that criminal psychopaths also demonstrate lower cardiovascular (heart rate) reactivity during fear imagery or anticipation of punishment (e.g., Arnett et al.,  1993 ; Patrick et al.,  1994 ; see Hall & Benning,  2006 , for a review).

Several later studies provide tentative support for Widom’s hypothesis that successful psychopaths would not show these deficits. One study, for example, showed that 15-year-old antisocial boys who later managed to avoid criminal convictions through age 29 exhibited increased autonomic arousal (heart rate and skin conductance) relative to 15-year-old antisocial boys who were later convicted of crimes (Raine et al.,  1995 ; see also Brennan et al.,  1997 ). More direct support for Widom’s hypothesis is provided by a study examining autonomic stress reactivity in successful and unsuccessful criminal psychopaths and control subjects, all living in the community and trying to find temporary employment (Ishikawa et al.,  2001 ). Each subject was told to give a short speech about his personal faults and weaknesses, during which time he was observed and videotaped. While subjects were preparing for and giving the speech, their heart rate was monitored. The results indicated that successful psychopaths (who had committed approximately the same number and type of crimes as the unsuccessful psychopaths, although they had never been convicted) showed greater heart rate reactivity to this stressful task than did the controls or the unsuccessful psychopaths. Thus, just as Widom had predicted, the successful psychopaths did not show the reduced cardiovascular responsivity that the unsuccessful psychopaths exhibited when anticipating and experiencing a stressor. This is consistent with the idea that the increased cardiac reactivity of the successful psychopaths may serve them well in processing what is going on in risky situations and in making decisions that may prevent their being caught. Additional neuropsychological tests revealed that the successful psychopaths also showed superior “executive functioning” (higher-order cognitive processes such as planning, abstraction, cognitive flexibility, and decision making), which also probably enhanced their ability to elude punishment. Moreover, they also tend to come from less disadvantaged socioeconomic backgrounds than criminal psychopaths (Hall & Benning,  2006 ). Clearly, more research is needed on this important group of successful, nonincarcerated psychopaths, who commit a great deal of crime but somehow manage to avoid being caught.

The second important neural system in Gray’s model is the behavioral activation system. This system activates behavior in response to cues for reward (positive reinforcement) as well as to cues for active avoidance of threatened punishment (such as in lying or running away to avoid punishment that one has been threatened with). According to Fowles’s theory, the behavioral activation system is thought to be normal or possibly overactive in psychopaths, which may explain why they are quite focused on obtaining reward. Moreover, if they are caught in a misdeed, they are very focused on actively avoiding threatened punishment (e.g., through deceit and lies, or running away). This hypothesis of Fowles that psychopaths have a deficient behavioral inhibition system and a normal or possibly overactive behavioral activation system seems to account for three important features of psychopathy: (1) psychopaths’ deficient conditioning of anxiety to signals for punishment, (2) their difficulty learning to inhibit responses that may result in punishment (such as illegal and antisocial acts), and (3) their normal or hypernormal active avoidance of punishment (by deceit, lies, and escape behavior) when actively threatened with punishment (Fowles,  1993 , p. 9; see also Hare,  1998 ).

Newman and colleagues (e.g., Newman, 2008; Newman & Lorenz,  2003 ) have also conducted research suggesting that people with psychopathy have a dominant response set for reward. Their excessive focus on reward is thought to interfere with their ability to use punishment or other contextual cues or information to modulate (or modify) their responding when rewards are no longer forthcoming at the same rate that they once were. Moreover, Newman and colleagues believe that this response modulation deficit is more central to psychopathy than is a fear deficit (or even a general emotional deficit). A number of interesting studies they have conducted are consistent with their theory. However, there is still significant controversy over whether this response modulation deficit hypothesis can account for the wide array of findings in support of the low-fear (and other emotional deficits) hypothesis.


Researchers have also been interested in whether there are more general emotional deficits in psychopaths than simply deficits in the conditioning of anxiety (Fowles & Dindo,  2006 ; Hare et al.,  1999 ; Patrick,  2005 ). Psychopaths showed less significant physiological reactivity to distress cues (slides of people crying who are obviously quite distressed) than nonpsychopaths. This is consistent with the idea that psychopaths are low on empathy (Blair,  2006 ; Blair et al.,  1997 ), in addition to being low on fear. However, they were not underresponsive to unconditioned threat cues such as slides of sharks, pointed guns, or angry faces. Patrick and colleagues have demonstrated that this effect of smaller (rather than larger) startle responses when viewing unpleasant slides is especially pronounced with slides depicting scenes of victims who have been mutilated or assaulted but not with slides representing threats to the self (aimed weapons or looming attackers; Levenston et al.,  2000 ). This specific failure to show larger startle responses with victim scenes might be related to the lack of empathy common in psychopathy (e.g., Blair et al.,  1997 ). Blair ( 2006 ) summarizes evidence showing that such emotional deficits seem to be due, at least in part, to the dysfunction in the amygdala that is commonly seen in psychopathy. For example, individuals with psychopathy show less activity in the amygdala (relative to controls) not only during fear conditioning but also when viewing sad or frightened faces (see Marsh & Blair,  2008 , for a quantitative review).

Hare has hypothesized that the kinds of emotional deficits discussed so far are only a subset of more general difficulties that psychopaths have with processing and understanding the meaning of affective stimuli, including positive and negative words and sounds (e.g., Blair et al.,  2006 ; Lorenz & Newman,  2002 ; Verona et al.,  2004 ). Hare summarized work in this area as follows: “Psychopaths … seem to have difficulty in fully understanding and using words that for normal people refer to ordinary emotional events and feelings…. It is as if emotion is a second language for psychopaths, a language that requires a considerable amount of … cognitive effort on their part” (1998, p. 115). It has been suggested that such deficits in turn are closely linked to the deficits in moral reasoning and behavior seen in people with psychopathy because to reason about moral issues requires that an individual has concern about the rights and welfare of other people (Blair,  2007b ).


In addition to genetic factors and emotional deficits, slow conscience development and high levels of both reactive and instrumental aggression are influenced by the damaging effects of parental rejection, abuse, and neglect accompanied by inconsistent discipline (e.g., Farrington,  2006 ; Luntz & Widom,  1994 ). However, studies of gene–environment interactions reviewed earlier clearly indicate that these kinds of disturbances are not sufficient explanations for the origins of psychopathy or antisocial personality because some people are clearly more susceptible to these effects than others. Moreover, these same conditions have been implicated in a wide range of later maladaptive behaviors. In the following section, we present an integrated developmental perspective using a biopsychosocial approach with multiple interacting causal pathways.

A Developmental Perspective On Psychopathy and Antisocial Personality

It has long been known that (1) these disorders generally begin early in childhood, especially for boys, (2) that the number of antisocial behaviors exhibited in childhood is the single best predictor of who will develop an adult diagnosis of ASPD, and (3) the younger they start, the higher the risk (Robins,  1978  1991 ). Today, early antisocial symptoms are associated with a diagnosis of conduct disorder (see  Chapter 15 ) and include theft, truancy, running away from home, and associating with delinquent peers. Long-term prospective studies have now shown that the family factors that are most important in predicting which children will show the most antisocial behaviors are poor parental supervision, harsh or erratic parental discipline, physical abuse or neglect, disrupted family life, and a convicted mother (Farrington,  2006 ). But what causes some children to be more susceptible than others to the adverse effects of such environmental influences?

Prospective studies have shown that it is children with an early history of oppositional defiant disorder—characterized by a pattern of hostile and defiant behavior toward authority figures that usually begins by the age of 6 years, followed by early-onset conduct disorder around age 9—who are most likely to develop ASPD as adults (e.g., Lahey et al.,  2005 ). For these children, the types of antisocial behaviors exhibited across the first 25 years of life change a great deal with development but are persistent in nature (Hinshaw,  1994 ). By contrast, children without the pathological background who develop conduct disorder in adolescence do not usually become lifelong antisocial personalities but instead have problems largely limited to the adolescent years (Frick & Marsee,  2006 ; Moffitt & Caspi,  2001 ; Patterson & Yoerger,  2002 ).

The second early diagnosis that is often a precursor to adult psychopathy or ASPD is attention-deficit/hyperactivity disorder (ADHD). ADHD is characterized by restless, inattentive, and impulsive behavior, a short attention span, and high distractibility (see  Chapter 15 ). When ADHD co-occurs with conduct disorder (which happens in at least 30 to 50 percent of cases), this leads to a high likelihood that the person will develop a severely aggressive form of ASPD and possibly psychopathy (Abramowitz et al.,  2004 ; Lahey et al.,  2005 ; Patterson et al.,  2000 ). Indeed, Lynam ( 2002 ) has referred to children with ADHD and conduct disorder as “fledgling psychopaths,” and several ways of assessing psychopathy in youth have been developed, with the Psychopathy Checklist—Youth Version (Forth et al.,  2003 ) being perhaps the best validated (Salekin,  2006 ; Salekin et al.,  2004 ).

There is increasing evidence that genetic propensities to mild neuropsychological problems such as those leading to hyperactivity or attentional difficulties, along with a difficult temperament, may be important predisposing factors for early-onset conduct disorder, which often leads to life-course-persistent adult ASPD. The behavioral problems that these pre-disposing factors create have a cascade of pervasive effects over time. For example, on the basis of extensive longitudinal prospective research, Moffitt, Caspi, and colleagues ( 2002 ; Moffitt,  2006 ) have suggested that

·  “Life-course-persistent” antisocial behavior originates early in life, when the difficult behavior of a high-risk young child is exacerbated by a high-risk social environment. According to the theory, the child’s risk emerges from inherited or acquired neuropsychological variation, initially manifested as subtle cognitive deficits, difficult temperament, or hyper-activity. The environment’s risk comprises factors such as inadequate parenting, disrupted family bonds, and poverty. The environmental risk domain expands beyond the family as the child ages, to include poor relations with people such as peers and teachers, then later with partners and employers.

·  Over the first 2 decades of development, transactions between individual and environment gradually construct a disordered personality with hallmark features of physical aggression, and antisocial behavior persisting to midlife. (Moffit et al.,  2002 , p. 180)

Many other psychosocial and sociocultural contextual variables contribute to the probability that a child with the genetic or constitutional liabilities discussed above will develop conduct disorder and, later, ASPD. As discussed previously, these include the parents’ own antisocial behaviors, divorce and other parental transitions, poverty and crowded inner-city neighborhoods, and parental stress (e.g., Dishion & Patterson,  1997 ; Dodge & Pettit,  2003 ; Farrington,  2006 ; Reid et al.,  2002 ). All of these contribute to poor and ineffective parenting skills—especially ineffective disciplining, monitoring, and supervising—which are highly predictive of antisocial behavior (e.g., Farrington,  2006 ; Granic & Patterson,  2006 ). Moreover, antisocial behavior involving coercive interchanges trains children in these behaviors. This in turn all too often leads to association with deviant and aggressive peers and to the opportunity for further learning of antisocial behavior (Dodge & Pettit,  2003 ; Farrington,  2006 ). A general mediational model for how all this occurs is shown in  Figure 10.4 .


FIGURE 10.4 A model for the association of family context and antisocial behavior. Each of the contextual variables in this model has been shown to be related to antisocial behavior in boys, which in turn is related to antisocial behavior in adults. Antisocial behavior in girls is far less common and has also been found to be less stable over time, making it more difficult to predict. (Capaldi & Patterson,  1994 . Interrelated influences of contextual factors on antisocial behavior. In D. C. Fowles et al. (Eds.), Progress in Experimental Personality and Psychopathology Research. Springer Publishing Company.)

Until fairly recently it was not apparent how this integrated model applied to the development of the traits and behaviors representing the affective–interpersonal core of psychopathy. In the past decade, Frick and colleagues have developed a way of assessing children’s callous and unemotional traits, which seem to represent early manifestations of this first dimension of psychopathy (e.g., Frick & Marsee,  2006 ; Frick & Morris,  2004 ; Frick et al.,  2003 ). They have noted that there are at least two different dimensions of children’s difficult temperament that seem to lead to different developmental outcomes. Some children have great difficulty learning to regulate their emotions and show high levels of emotional reactivity, including aggressive and antisocial behaviors when responding to stressful demands and negative emotions like frustration and anger. Such children are at increased risk for developing ASPD and high scores on the antisocial dimension of psychopathy. But other children may have few problems regulating negative emotions, instead showing fearlessness and low anxiety as well as callous/unemotional traits and reduced amygdala activation while responding to fearful facial expressions (e.g., Marsh et al.,  2008 ). These are the children most likely to show poor development of conscience, and their aggressive behaviors are more instrumental and premeditated rather than reactive as seen with those children who have emotional regulation difficulties. These latter children are likely to develop high scores on the first, interpersonal affective core of psychopathy, leading to the cold, remorseless psychopaths who show low fear and lack of empathy.


Children and adolescents who show persistent patterns of aggression toward people or animals, destruction of property, deceitfulness or theft, and serious violation of rules at home or in school may be at risk for developing conduct disorder and antisocial personality disorder.


Cross-cultural research by Murphy ( 1976 ) on psychopathy reveals that it occurs in a wide range of cultures including nonindustrialized ones as diverse as the Inuit of northwest Alaska and the Yoruba of Nigeria. The Yoruba people’s concept of a psychopath is “a person who always goes his own way regardless of others, who is uncooperative, full of malice, and bullheaded,” and the Inuit’s concept is of someone whose “mind knows what to do but he does not do it…. This is an abstract term for the breaking of the many rules when awareness of the rules is not in question” (Murphy,  1976 , p. 1026). Nevertheless, the exact manifestations of the disorder are influenced by cultural factors, and the prevalence of the disorder also seems to vary with sociocultural influences that encourage or discourage its development (Cooke et al.,  2005 ; Hare et al.,  1999 ; Sullivan & Kosson,  2006 ).

Regarding different cross-cultural manifestations of the disorder, one of the primary symptoms where cultural variations occur is the frequency of aggressive and violent behavior. Socialization forces have an enormous impact on the expression of aggressive impulses. Thus it is not surprising that in some cultures, such as China, psychopaths may be much less likely to engage in aggressive, especially violent, behavior than they are in most Western cultures (Cooke,  1996 ). By contrast, cross-cultural studies have indicated that the affective-interpersonal dimension of psychopathy is the most consistent across cultures (Cooke et al.,  2005 ).

Moreover, cultures can be classified along a dimension distinguishing between individualistic and collectivist societies. Competitiveness, self-confidence, and independence from others are emphasized in relatively individualistic societies, whereas contributions and subservience to the social group, acceptance of authority, and stability of relationships are encouraged in relatively collectivist societies (Cooke,  1996 ; Cooke & Michie,  1999 ). Thus we would expect individualistic societies (such as in the United States) to be more likely to promote some of the behavioral characteristics that, carried to the extreme, result in psychopathy. These characteristics include “grandiosity, glibness and superficiality, promiscuity … as well as a lack of responsibility for others…. The competitiveness … not only produces higher rates of criminal behavior but also leads to an increased use of … deceptive, manipulative, and parasitic behavior” (Cooke & Michie,  1999 , p. 65). Although the evidence bearing on this is minimal, it is interesting to note that estimates of the prevalence of ASPD are much lower in Taiwan, a relatively collectivist society, than they are in the United States (approximately 0.1 to 0.2 percent versus 1.5 to 4 percent).

Treatments and Outcomes in Psychopathic and Antisocial Personality

Most people with psychopathic and antisocial personalities do not experience much personal distress and do not believe they need treatment. Those who run afoul of the law may participate in rehabilitation programs in penal institutions, but they are rarely changed by them. Even when more and better therapeutic facilities are available, effective treatment will still be a challenging task, and many clinical researchers working with these populations have concluded that these disorders are extraordinarily difficult (if not impossible) to treat, with psychopathy being even more difficult to treat than ASPD (e.g., Hare et al.,  1999 ; Harris & Rice,  2006 ; Vitale & Newman,  2008 ). Such conclusions are not made lightly. Dozens of treatment studies have been conducted. Alarmingly, a few studies have found that treatments that work for other criminal offenders can actually be harmful for psychopaths in that rates of reoffending increase rather than decrease (Harris & Rice,  2006 ). This may be especially likely to occur if the treatment program emphasizes training in social skills or empathy because such skills may simply make them better at charming or conning future victims (Vitale & Newman,  2008 ).

Biological treatment approaches for antisocial and psychopathic personalities—including electroconvulsive therapy and drugs—have not been systematically studied, partly because the few results that have been reported suggest modest changes at best. Drugs such as lithium and anticonvulsants used to treat bipolar disorder have had some success in treating the aggressive/impulsive behavior of violent aggressive criminals, but evidence on this is scant (Markovitz,  2001 ; Minzenberg & Siever,  2006 ). There have also been some tentative but promising results using antidepressants from the SSRI category, which can sometimes reduce aggressive/impulsive behavior and increase interpersonal skills (Lösel,  1998 ; Minzenberg & Siever,  2006 ). However, none of these biological treatments has any substantial impact on the disorder as a whole. Moreover, even if effective pharmacological treatments were found, the problem of these individuals generally having little motivation to take their medications would remain (Markovitz,  2001 ).


For reasons discussed earlier, punishment by itself is generally ineffective for changing antisocial behavior. Cognitive-behavioral treatments have thus often been thought to offer the greatest promise of more effective treatment (Hare et al.,  2012 ; Harris & Rice,  2006 ; Lösel,  1998 ; Piper & Joyce,  2001 ). Common targets of cognitive-behavioral interventions include the following: (1) increasing self-control, self-critical thinking, and social perspective taking; (2) increasing victim awareness; (3) teaching anger management; (4) changing antisocial attitudes; and (5) curing drug addiction. Such interventions require a controlled situation in which the therapist can administer or withhold reinforcement and the individual cannot leave treatment (such as an inpatient or prison setting) because when treating antisocial behavior, we are dealing with a total lifestyle rather than a few specific, maladaptive behaviors (e.g., Hare et al.,  2012 ; Piper & Joyce,  2001 ). Even the best of these multifaceted, cognitive-behaviorally oriented treatment programs generally produce only modest changes, although they are somewhat more effective in treating young offenders (teenagers) than older offenders, who are often hard-core, lifelong psychopaths. Moreover, although such treatments may be useful in reducing inmates’ antisocial behavior while in a prison or other forensic setting, the results do not usually generalize to the real world if the person is released (Harris & Rice,  2006 ). Thus some experts in the area have concluded that at the present time it may be best to think about management rather than treatment of psychopathic offenders. Or as three prominent researchers recently put it “the programs should be less concerned with developing empathy and conscience or effecting changes in personality than with convincing participants that they alone are responsible for their behavior, and that there are more prosocial ways of using their strengths and abilities to satisfy their needs and wants” (Hare et al.,  2012 , p. 493).

Fortunately, the criminal activities of many psychopathic and antisocial personalities seem to decline after the age of 40 even without treatment, possibly because of weaker biological drives, better insight into self-defeating behaviors, and the cumulative effects of social conditioning. Such individuals are often referred to as “burned-out psychopaths.” Although there is not a great deal of evidence on this issue (Douglas et al.,  2006 ), one important study that followed a group of male psychopaths over many years found a clear and dramatic reduction in levels of criminal behavior after age 40. However, over 50 percent of these people continued to be arrested after age 40 (Hare et al.,  1988 ). Moreover, it is only the antisocial behavioral dimension of psychopathy that seems to diminish with age; the egocentric, callous, and exploitative affective and interpersonal dimension persists (Cloninger et al.,  1997 ; Hare et al.,  1999 ).

In view of the distress and unhappiness that psychopaths inflict on others and the social damage they cause, it seems desirable—and more economical in the long run—to put increased effort into the development of effective prevention programs. Longitudinal prevention research on children at risk for conduct disorder is discussed in the Developments in Practice box.

in review

·  ● List the three DSM criteria that must be met before an individual is diagnosed with ASPD, and cite the additional personality traits that define psychopathy.

·  ● What are several reasons why many researchers believe psychopathy is a more valid construct than ASPD?

·  ● What biological factors contribute to these disorders?

·  ● What are the primary features of a developmental perspective on these disorders?

developments in PRACTICE: Prevention of Psychopathy and Antisocial Personality Disorder

Given the difficulties in treating conduct disorder, ASPD, and psychopathy, there is an increasing focus on prevention programs oriented toward both minimizing some of the developmental and environmental risk factors described earlier and breaking some of the vicious cycles that at-risk children seem to get into. Intelligence is one naturally occurring protective factor for some adolescents who are at risk for developing psychopathy or antisocial personality in adulthood (Hawkins et al.,  1997 ). For example, several studies found that many adolescents with conduct disorder never get involved in criminal behavior because they are positively influenced by schooling and focus their energies on more socially accepted behaviors (e.g., White et al.,  1989 ). Of course, not all at-risk adolescents have high intelligence, and those who do not may benefit from more structured prevention programs.

Given the life-course developmental model for the etiology of ASPD, devising prevention strategies becomes very complex because many different stages present targets for preventive interventions (e.g., Conduct Problems Prevention Research Group,  2007 ; Dodge & Pettit,  2003 ). Some interventions that have been shown to help are aimed at mothers estimated to be at high risk (poor, first-time, and single) for producing children who could be at risk and include prenatal care aimed at improving maternal nutrition, decreasing smoking and other substance use, and improving parenting skills (Olds et al.,  1986  1994 ; Reid & Eddy,  1997 ).

For young children, Patterson, Dishion, Reid, and colleagues have developed programs that target the family environment and teach effective parental discipline and supervision (e.g., Dishion & Kavanaugh,  2002 ; Gardner, Shaw et al.,  2007 ; Reid et al.,  2002 ). At-risk children whose families receive such interventions do better academically, are less likely to associate with delinquent peers, and are less likely to get involved in drug use. Such family or parent training can even be effective at reducing or preventing further antisocial behavior in children and adolescents already engaged in antisocial behavior, although conducting the intervention with pre-elementary school children was more effective and less labor intensive (see Reid & Eddy,  1997 , for a review). In general, the earlier the prevention and intervention efforts are started, the greater the likelihood that they may succeed. However, it is also important to realize that any single intervention by itself is unlikely to be successful because there are so many different kinds of forces that influence at-risk children throughout their development (Conduct Problems Prevention Research Group,  2007 ; Dodge & Pettit,  2003 ).

Some significant advances have also been made in prevention programs targeting the school environment or the school and family environments concurrently. One especially promising multisite, 10-year intervention study of this sort is called the FAST Track (Families and Schools Together) intervention. In the early 1990s over 400 kindergarten students who attended schools associated with high risk (generally those that serve inner-city and poor neighborhoods) and who already showed poor peer relations and high levels of disruptive behavior were recruited for this intensive program, which included parent training and school interventions. Another group of over 400 high-risk children were assigned to a control group who received treatment as usual (i.e., no new special programs). There was a focus on improving social-cognitive and cognitive skills, friendships with peers, emotional awareness, and self-control. Teachers and parents were taught how to manage disruptive behavior, and parents were informed of what their children were being taught. Early results through the third grade were quite promising in terms of reducing later conduct problems (Conduct Problems Prevention Research Group,  2010 ). Parenting behavior and children’s social-cognitive skills also showed significant improvement. Children in FAST Track were also less likely to be nominated by peers as aggressive, and they tended to be better liked and to show better reading skills (Coie,  1996 ; Reid & Eddy,  1997 ). Later results by grade 9 were remarkable for the children in the highest risk category (top 3 percent on risk). Among these children, the intervention group had lower rates of conduct disorder (reduced by 75 percent) and ADHD (reduced by 53 percent) relative to the control group. Importantly, children assigned to the Fast Track intervention also had experienced fewer arrests relative to control children by the time they reached the age of 19. Although such interventions are expensive (the estimated cost per child was $58,000 over 10 years), if they can prevent (or at least dramatically reduce) the extremely costly effects on society of these children if they develop full-blown adult ASPD or psychopathy, the long-term benefits will outweigh the initial costs. And indeed, estimates are that each very high-risk youth costs society $1.2 to $2 million in rehabilitation, incarceration, and costs to victims. Thus a $58,000 intervention may be enormously cost-effective in the long run (Conduct Problems Prevention Research Group,  2007 ).

UNRESOLVED issues: DSM-5: How Can We Improve the Classification of Personality Disorders?

Reading this chapter will have given you an understanding of some of the difficulties associated with the use of an exclusively categorical diagnostic system for personality disorders. For instance, you may have had some difficulty in developing a clear, distinctive picture of each of the personality disorders. You may also have recognized that the characteristics and attributes of some disorders, such as schizoid personality disorder, seemed to blend with other conditions, such as the schizotypal or the avoidant personality disorders. It is also the case that people frequently do not fit neatly into any one specific diagnostic category. They may also qualify for a diagnosis of more than one personality disorder (e.g., Clark,  2007 ; Grant, Stinson et al.,  2005 ; Widiger et al.,  1991 ). Indeed, a common diagnosis is “personality disorder not otherwise specified” (e.g., Livesley, 2007; Krueger & Eaton,  2010 ; Verheul & Widiger,  2004 ; Verheul et al.,  2007 ), a category reserved for people who exhibit features from several different categories but do not cleanly fit within any of them.

In the past, many studies of personality disorder categories were conducted in an effort to find discrete breaks in such personality dimensions—that is, points at which normal behavior becomes clearly distinct from pathological behavior. None were found (Livesley,  2001 ; Widiger & Sanderson,  1995 ). Moreover, changes in the cut-points, or thresholds for diagnosis of a personality disorder, can have drastic and unacceptable effects on the apparent prevalence rates of a particular personality disorder diagnosis (Widiger & Trull,  2007 ). For instance, when the DSM-III was revised to the DSM-III-R, it was noted that the rate of schizoid personality disorder increased by 800 percent and narcissistic personality disorder by 350 percent (Morey,  1988 ).

Such issues are much less problematic when a dimensional (or continuous rating) system is used because it is expected that across individuals there will be many different patterns of elevation of scores on different facets of different traits. As noted earlier, the personality traits classified for the personality disorders are dimensional in nature. For example, everyone is suspicious at times, but the degree to which this trait exists in someone with paranoid personality disorder is extreme. A dimensional system would allow people to be rated on the degree to which they exhibit each facet and trait dimension—not on whether they do or do not have a given personality disorder. Each individual would also be rated on numerous dimensions, and highly personalized patterns of scores would thus be expected rather than problematic.

There has been lively debate among psychologists and psychiatrists over the best way to design a more dimensional system (Clark,  2007 ; Livesley,  2011 ; Skodol et al.,  2011 ). Although it has long been clear that a more dimensional system is needed, actually implementing this has proven very difficult. A major challenge has been creating a scientifically valid diagnostic system that is not overly complicated and does not render the substantial research on existing categories useless. As we noted earlier, the proposal that was offered for inclusion in DSM-5 was not accepted. Although moving to a dimensional system makes a lot of sense for many reasons, the complexity of the model that was proposed was no doubt a major issue. All of this speaks to the difficulty of creating a valid yet utilitarian diagnostic system that satisfies the different needs of both clinicians and researchers.

10 summary

·  10.1 What are some of the general features of personality disorders?

·  ● Personality disorders appear to be rather inflexible and distorted behavioral patterns and traits that result in maladaptive ways of perceiving, thinking about, and relating to other people and the environment.

·  ● Three general clusters of personality disorders have been described in DSM, although researchers have increasingly questioned the validity of these clusters.

·  10.2 What are some of the difficulties of doing research on personality disorders?

·  ● Even with structured interviews, the reliability of diagnosing personality disorders typically is less than ideal. Most researchers today agree that a dimensional approach for assessing personality disorders would be preferable.

·  ● It is difficult to determine the causes of personality disorders as categories because most people with one personality disorder also have at least one more and because most studies to date are retrospective.

·  10.3 What characteristics do the Cluster A personality disorders have in common?

·  ● Cluster A includes paranoid, schizoid, and schizotypal personality disorders; individuals with these disorders seem odd or eccentric. Little is known about the causes of paranoid and schizoid disorders, but genetic and other biological factors are implicated in schizotypal personality disorder.

·  10.4 What characteristics do the Cluster B personality disorders have in common?

·  ● Cluster B includes histrionic, narcissistic, antisocial, and borderline personality disorders; individuals with these disorders share a tendency to be dramatic, emotional, and erratic. Little is known about the causes of histrionic and narcissistic disorders. Certain biological and psychosocial causal factors have been identified as increasing the likelihood of developing borderline personality disorder in those at risk because of high levels of impulsivity and affective instability.

·  10.5 What characteristics do the Cluster C personality disorders have in common?

·  ● Cluster C includes avoidant, dependent, and obsessive- compulsive personality disorders; individuals with these disorders show fearfulness or tension, as in anxiety-based disorders. Children with an inhibited temperament may be at heightened risk for avoidant personality disorder, and individuals high on neuroticism and agreeableness, with authoritarian and overprotective parents, may be at heightened risk for dependent personality disorder.

·  10.6 What are the clinical features of borderline personality disorder and how is this disorder treated?

·  ● Borderline personality disorder is characterized by emotional instability, fears of abandonment, impulsivity, self-mutilating behavior, and an unstable sense of self. People with BPD have intense and stormy personal relationships.

·  ● There is relatively little research on treatments for most personality disorders. However, a form of behavior therapy called dialectical behavior therapy (DBT) is beneficial for people with BPD. DBT helps patients learn to manage their emotions and develop new coping skills. Other recently developed forms of therapy for BPD include transference-focused psychotherapy and mentalization-based treatment. A wide range of medications (antidepressants, antipsychotic medications, and mood stabilizing medications) are also used sometimes.

·  10.7 What are the features of antisocial personality disorder and psychopathy?

·  ● A person with psychopathy shows elevated levels of two different dimensions of traits: (1) an affective-interpersonal set of traits reflecting lack of remorse or guilt, callousness/lack of empathy, glibness/superficial charm, grandiose sense of self-worth, and pathological lying, and (2) antisocial, impulsive, and socially deviant behavior; irresponsibility; and parasitic lifestyle. A person diagnosed with ASPD is primarily characterized by traits from the second dimension of psychopathy.

·  ● Genetic and temperamental, learning, and adverse environmental factors seem to be important in causing psychopathy and ASPD.

·  ● Psychopaths also show deficiencies in fear and anxiety as well as more general emotional deficits.

·  ● Treatment of individuals with ASPD psychopathy is difficult, partly because they rarely see any need to change and tend to blame other people for their problems.

key terms

·  antisocial personality disorder (ASPD)  353

·  avoidant personality disorder  345

·  borderline personality disorder (BPD)  342

·  dependent personality disorder  347

·  dialectical behavior therapy  351

·  histrionic personality disorder  338

·  narcissistic personality disorder  339

·  obsessive-compulsive personality disorder (OCPD)  348

·  paranoid personality disorder  333

·  personality disorder  328

·  psychopathy  353

·  schizoid personality disorder  335

·  schizotypal personality disorder  336

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