A.
Personality disorders
Chapter 1
Description of personality disorders
Clinical and relevant aspects
What differentiates personality from personality disorders?
• We all have personalities
• Personality is relatively stable over time
• aspects of individual differences in our usual tendencies to think, feel, react, and behave in
different situations
• Abnormal personality or personality pathology refers to the inability of persons to react flexibly
and appropriate to life’s challenges
• A personality disorder can be referred to as an enduring pattern of inner experiences and
specific behaviours that deviates to a significant extent from the expectations of the
individuals’ culture. It is pervasive and inflexible, has an onset in adolescence or early
adulthood, is relatively stable over time and leads to distress or impairment
Personality disorder vs. Clinical syndrome
• In clinical syndromes, the experiences and behaviours are usually perceived as ego-dystonic,
i.e. all aspects (thoughts, feelings, behaviours) related to the person that are experienced as
not belonging to the person.
Symptoms disturb your life, they do not belong to you, they are not part of you
You “have” disorder
• Personality disorder: how people have matured into adult personalities and the building
blocks of personality disorders are often referred to as traits
• Personality disorders are usually considered as ego-syntonic: they experience it as something
belonging to them and being part of them.
Classification systems
• Diagnostic and Statistical Manual of Mental Disorders (DSM; APA, 2013)
• International Classification System of Diseases (ICD; WHO, 2018)
• DSM-5 defines personality disorders as “an enduring pattern of inner experience and
behaviour that deviates markedly from the expectations of the individual’s culture”.
DSM-5 Classification
• 10 specific personality disorders
• 3 clusters: A, B, C
• Closet A: “odd” cluster
- paranoid pd
- schizoid pd
- schizotypal pd
• Cluster B: “dramatic”
- antisocial personality disorder
- borderline personality disorder
- histrionic personality disorder
- narcissistic personality disorder
• Cluster C: “anxious”
- avoidant personality disorder
- dependent personality disorder
- obsessive-compulsive personality disorder
,Cluster A
• Paranoid personality disorder
- Mistrust and suspiciousness
- searches for hidden meanings and threads
- hypersensitive to insults
- is preoccupied with unjustified doubts about the loyalty or trustworthiness of friends and
associates
- to be diagnosed with paranoid pd, symptoms 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 direct physiological effects of another medical
condition.
• Schizoid personality disorder
- withdrawn, isolated life
- low in energy
- life is kinda flat and unexciting
- detached in local situations, few if any relationships
- schizoid PD does not include the psychotic-like positive symptoms of schizophrenia
• Schizotypal personality disorder
- unusual, sometimes “magical” beliefs
- unusual perceptual experiences, including bodily sensations
- lack of close friends
- excessive social anxiety that does not diminish with familiarity and tends to be associated
with paranoid fears rather than negative judgements about self.
- Taken together, the criteria for schizotypal personality disorder impress as a rather
heterogeneous set of mildly psychotic phenomena, rather than a personality disorder
Cluster B: Dramatic
• Antisocial personality disorder
- unethical behavior
- violate the law
- no empathy
- don’t learn from previous mistakes
- Typically, of low frustration tolerance, antisocial PD patients can be quite aggressive and
impulsive, but there are also more cunning and manipulative variations. More often than not,
remorse and guilt are absent for the negative consequences their behaviour may have for
others; in fact, some may derive pleasure from the suffering of others
But to be diagnosed with antisocial pd also:
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 behaviour is not exclusively during the course of
schizophrenia or bipolar disorder
• Borderline personality disorder
- severe mood swings
- inability to regulate emotions
- fear of abandonment
- self-destructive impulsivity
- feeling of emptiness
- inappropriate, intense anger, inability to regulate anger
• Histrionic personality disorder
- A key feature of individuals with histrionic PD is the lability and shallowness of their affect:
histrionic PD patients may quickly change from being very sad to very cheerful, and express
both feelings equally dramatically.
- seek to be the centre of attention
- uncomfortable if not the entire of attention
2
, - is suggestible, i.e. easily influenced by others or circumstances
- considers relationships to be more intimate than they actually are.
• Narcissistic personality disorder
- demand admiration
- they consider themselves as more special
- grandiose sense of self-importance
- takes advantage of others
- lacks empathy
- often envious
- arrogant
Cluster C: “anxious:
• Avoidant personality disorder
- What is most striking about patients with avoidant PD is their sensitivity to criticism,
disapproval, and rejection.
- extreme variation of shyness
- unwilling to get involved with people unless certain of being liked
- often problems with alcohol abuse associated with efforts to mitigate social anxiety
• Dependent personality disorder
- Patients with dependent PD are characterised by excessive needs for guidance,
reassurance, and assistance
- fearful
- they believe they are not capable of doing things alone
- highly needy
- Dependent PD patients often report for treatment after an important supporting figure in
their social environment has been lost, and they may feel depressed as a result
- prefer directive instructions from the therapist
- goes to excessive lengths to obtain nurturance and support from others, to the point of
volunteering to do things that are unpleasant
• Obsessive-compulsive personality disorder
- The most prominent feature of individuals with obsessive-compulsive PD is their behavioural
discipline, a counterproductive preoccupation with details, and deep-felt obedience to rules
and regulations
- The obsessive-compulsive PD has to be differentiated from the obsessive-compulsive
syndrome, which is characterised by repeated intrusive thoughts and rituals
- perfectionism
Other specified Personality Disorder and Unspecified personality disorder
• Other Specified Personality Disorder is a category which applies to a presentation in clinical
practice in which the full criteria for any of the personality disorder classifications are not met,
but in which symptom characteristics of personality disorder cause clinically significant
distress or impairment in social and occupational areas of functioning
• Unspecified PD
- it can be used in (a) situations in which the clinician chooses not to specify the reason that
the criteria are not met for a specific disorder, or (b) when there is insufficient information to
make a more specific diagnosis.
ICD-11
• A personality disorder has to meet the following criteria: it is characterised by problems in
functioning of aspects of the self (e.g. identity, self-worth, accuracy of self-view, self-
direction), and/or interpersonal dysfunction (e.g. ability to develop and maintain close and
mutually satisfying relationships, ability to understand others’ perspectives and to manage
conflict in relationships) that have persisted over an extended period of time (e.g. two years or
more).
• Assesses severity of the disorder
3
, • 6 different prototypes, not 10 like in DSM-5
1. Negative affectivity in Personality Disorder or Personality Difficulty, with as prominent feature
experiencing a broad range of negative emotions.
- negative attitudes
- low self-esteem
- mistrust
2. Detachment in personality disorder or personality difficulty
- maintain interpersonal distance
- emotional distance
- social detachment
- limited emotional expression
3. Dissociality in Personality Disorder or Personality Difficulty
- self-centredness
- attention-seeking
- lack of empathy
- manipulation
- exploitation of others
4. Disinhibition
- tendency to at rashly base on immediate external or internal stimuli
- Common manifestations of disinhibition include: impulsivity; distractibility; irresponsibility;
recklessness; and lack of planning.
5. Anankastia Personality Disorder or Personality Difficulty. - The core feature of the anankastia
trait domain is a narrow focus on one’s rigid standard of perfection and of right and wrong,
and on controlling one’s own and others’ behaviour and controlling situations to ensure
conformity to these standards.
- perfectionism
- stubbornness
- risk-avoidance
6. Borderline pattern
- unstable relationships
- unstable self-image, affects, and market impulsivity
- self-harm
- emotional instability
- chronic feeling of emptiness
DSM-5: research agenda
• Alternative Model of Personality disorders (AMPD)
Still in research
Consists of 3 components
- The three components are:
(1) a general definition of personality disorder measured with a scale of personality
functioning (A criterion; consisting of four domains, see Table 1.1);
(2) a dimensional system with 25 traits organised into five domains (B criterion) and
(3) a prototypal system of six personality disorder types.
- In this overview of the prototypes the following DSM-5 personality disorders are not
represented as a prototype: paranoid personality disorder, schizoid personality, histrionic
personality disorder, and dependent personality disorder
Future directions
• The alternative model was criticised because it combined a dimensional and prototypal
approach, which would have made it very complex for the clinician to use in practice
• Keywords in DSM-5 and ICD-11 are enduring, pervasive, distress, and impairment
• The network theory of psychopathology
- In DSM-5: disorder is present and therefore symptoms occur; disorder is the cause of the
symptoms
4
Personality disorders
Chapter 1
Description of personality disorders
Clinical and relevant aspects
What differentiates personality from personality disorders?
• We all have personalities
• Personality is relatively stable over time
• aspects of individual differences in our usual tendencies to think, feel, react, and behave in
different situations
• Abnormal personality or personality pathology refers to the inability of persons to react flexibly
and appropriate to life’s challenges
• A personality disorder can be referred to as an enduring pattern of inner experiences and
specific behaviours that deviates to a significant extent from the expectations of the
individuals’ culture. It is pervasive and inflexible, has an onset in adolescence or early
adulthood, is relatively stable over time and leads to distress or impairment
Personality disorder vs. Clinical syndrome
• In clinical syndromes, the experiences and behaviours are usually perceived as ego-dystonic,
i.e. all aspects (thoughts, feelings, behaviours) related to the person that are experienced as
not belonging to the person.
Symptoms disturb your life, they do not belong to you, they are not part of you
You “have” disorder
• Personality disorder: how people have matured into adult personalities and the building
blocks of personality disorders are often referred to as traits
• Personality disorders are usually considered as ego-syntonic: they experience it as something
belonging to them and being part of them.
Classification systems
• Diagnostic and Statistical Manual of Mental Disorders (DSM; APA, 2013)
• International Classification System of Diseases (ICD; WHO, 2018)
• DSM-5 defines personality disorders as “an enduring pattern of inner experience and
behaviour that deviates markedly from the expectations of the individual’s culture”.
DSM-5 Classification
• 10 specific personality disorders
• 3 clusters: A, B, C
• Closet A: “odd” cluster
- paranoid pd
- schizoid pd
- schizotypal pd
• Cluster B: “dramatic”
- antisocial personality disorder
- borderline personality disorder
- histrionic personality disorder
- narcissistic personality disorder
• Cluster C: “anxious”
- avoidant personality disorder
- dependent personality disorder
- obsessive-compulsive personality disorder
,Cluster A
• Paranoid personality disorder
- Mistrust and suspiciousness
- searches for hidden meanings and threads
- hypersensitive to insults
- is preoccupied with unjustified doubts about the loyalty or trustworthiness of friends and
associates
- to be diagnosed with paranoid pd, symptoms 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 direct physiological effects of another medical
condition.
• Schizoid personality disorder
- withdrawn, isolated life
- low in energy
- life is kinda flat and unexciting
- detached in local situations, few if any relationships
- schizoid PD does not include the psychotic-like positive symptoms of schizophrenia
• Schizotypal personality disorder
- unusual, sometimes “magical” beliefs
- unusual perceptual experiences, including bodily sensations
- lack of close friends
- excessive social anxiety that does not diminish with familiarity and tends to be associated
with paranoid fears rather than negative judgements about self.
- Taken together, the criteria for schizotypal personality disorder impress as a rather
heterogeneous set of mildly psychotic phenomena, rather than a personality disorder
Cluster B: Dramatic
• Antisocial personality disorder
- unethical behavior
- violate the law
- no empathy
- don’t learn from previous mistakes
- Typically, of low frustration tolerance, antisocial PD patients can be quite aggressive and
impulsive, but there are also more cunning and manipulative variations. More often than not,
remorse and guilt are absent for the negative consequences their behaviour may have for
others; in fact, some may derive pleasure from the suffering of others
But to be diagnosed with antisocial pd also:
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 behaviour is not exclusively during the course of
schizophrenia or bipolar disorder
• Borderline personality disorder
- severe mood swings
- inability to regulate emotions
- fear of abandonment
- self-destructive impulsivity
- feeling of emptiness
- inappropriate, intense anger, inability to regulate anger
• Histrionic personality disorder
- A key feature of individuals with histrionic PD is the lability and shallowness of their affect:
histrionic PD patients may quickly change from being very sad to very cheerful, and express
both feelings equally dramatically.
- seek to be the centre of attention
- uncomfortable if not the entire of attention
2
, - is suggestible, i.e. easily influenced by others or circumstances
- considers relationships to be more intimate than they actually are.
• Narcissistic personality disorder
- demand admiration
- they consider themselves as more special
- grandiose sense of self-importance
- takes advantage of others
- lacks empathy
- often envious
- arrogant
Cluster C: “anxious:
• Avoidant personality disorder
- What is most striking about patients with avoidant PD is their sensitivity to criticism,
disapproval, and rejection.
- extreme variation of shyness
- unwilling to get involved with people unless certain of being liked
- often problems with alcohol abuse associated with efforts to mitigate social anxiety
• Dependent personality disorder
- Patients with dependent PD are characterised by excessive needs for guidance,
reassurance, and assistance
- fearful
- they believe they are not capable of doing things alone
- highly needy
- Dependent PD patients often report for treatment after an important supporting figure in
their social environment has been lost, and they may feel depressed as a result
- prefer directive instructions from the therapist
- goes to excessive lengths to obtain nurturance and support from others, to the point of
volunteering to do things that are unpleasant
• Obsessive-compulsive personality disorder
- The most prominent feature of individuals with obsessive-compulsive PD is their behavioural
discipline, a counterproductive preoccupation with details, and deep-felt obedience to rules
and regulations
- The obsessive-compulsive PD has to be differentiated from the obsessive-compulsive
syndrome, which is characterised by repeated intrusive thoughts and rituals
- perfectionism
Other specified Personality Disorder and Unspecified personality disorder
• Other Specified Personality Disorder is a category which applies to a presentation in clinical
practice in which the full criteria for any of the personality disorder classifications are not met,
but in which symptom characteristics of personality disorder cause clinically significant
distress or impairment in social and occupational areas of functioning
• Unspecified PD
- it can be used in (a) situations in which the clinician chooses not to specify the reason that
the criteria are not met for a specific disorder, or (b) when there is insufficient information to
make a more specific diagnosis.
ICD-11
• A personality disorder has to meet the following criteria: it is characterised by problems in
functioning of aspects of the self (e.g. identity, self-worth, accuracy of self-view, self-
direction), and/or interpersonal dysfunction (e.g. ability to develop and maintain close and
mutually satisfying relationships, ability to understand others’ perspectives and to manage
conflict in relationships) that have persisted over an extended period of time (e.g. two years or
more).
• Assesses severity of the disorder
3
, • 6 different prototypes, not 10 like in DSM-5
1. Negative affectivity in Personality Disorder or Personality Difficulty, with as prominent feature
experiencing a broad range of negative emotions.
- negative attitudes
- low self-esteem
- mistrust
2. Detachment in personality disorder or personality difficulty
- maintain interpersonal distance
- emotional distance
- social detachment
- limited emotional expression
3. Dissociality in Personality Disorder or Personality Difficulty
- self-centredness
- attention-seeking
- lack of empathy
- manipulation
- exploitation of others
4. Disinhibition
- tendency to at rashly base on immediate external or internal stimuli
- Common manifestations of disinhibition include: impulsivity; distractibility; irresponsibility;
recklessness; and lack of planning.
5. Anankastia Personality Disorder or Personality Difficulty. - The core feature of the anankastia
trait domain is a narrow focus on one’s rigid standard of perfection and of right and wrong,
and on controlling one’s own and others’ behaviour and controlling situations to ensure
conformity to these standards.
- perfectionism
- stubbornness
- risk-avoidance
6. Borderline pattern
- unstable relationships
- unstable self-image, affects, and market impulsivity
- self-harm
- emotional instability
- chronic feeling of emptiness
DSM-5: research agenda
• Alternative Model of Personality disorders (AMPD)
Still in research
Consists of 3 components
- The three components are:
(1) a general definition of personality disorder measured with a scale of personality
functioning (A criterion; consisting of four domains, see Table 1.1);
(2) a dimensional system with 25 traits organised into five domains (B criterion) and
(3) a prototypal system of six personality disorder types.
- In this overview of the prototypes the following DSM-5 personality disorders are not
represented as a prototype: paranoid personality disorder, schizoid personality, histrionic
personality disorder, and dependent personality disorder
Future directions
• The alternative model was criticised because it combined a dimensional and prototypal
approach, which would have made it very complex for the clinician to use in practice
• Keywords in DSM-5 and ICD-11 are enduring, pervasive, distress, and impairment
• The network theory of psychopathology
- In DSM-5: disorder is present and therefore symptoms occur; disorder is the cause of the
symptoms
4
