Personality Disorders

Paul M. G. Emmelkamp, Katharina Meyerbröker

• Publisher: Psychology Press
• Year: 2019
• ISBN:
  9781351055888
• Edition: 2
• Topic: Psychologie
• Subtopic: Geschichte & Theorie in der Psychologie

The new edition of Personality Disorders continues to provide an in-depth guide to personality disorders, assessment, and treatment, across varied patient groups and settings.

Grounded in scholarly review and illustrated with a diversity of case studies, this book covers familiar ground with comprehensive detail, including the description of personality disorders, diagnosis, epidemiology, aetiology, and treatment strategies. Furthermore, this new edition reflects changes in the new ICD-11 and DSM-5, assessment instruments, and state-of-the-art insights from theory-driven research.

Part of the popular 'Clinical Psychology: A Modular Course' series, Personality Disorders offers excellent coverage on all aspects of personality disorder and will be extremely informative for students and practitioners alike.

1

Description of personality disorders

Clinical features and relevant aspects

There is still little consensus what a personality disorder is. In the time before the publication of the DSM-5 (APA, 2013) and in its aftermath, there has been a prosperity in research around a diversity of relevant aspects and concepts of personality disorders, so that a leading expert in the field said “This is truly a trip into the jungle” (Tyrer, 2012, p. 373).

What differentiates personality from personality disorder?

We all have a personality. Personalities tend to be enduring aspects of individual differences in our usual tendencies to think, feel, react, and behave in different situations. Thus, personality describes in general terms how we react to situations, how we cope with challenges, how we adapt and respond to a range of different situations, including life events, challenges, frustrations, failures, but also successes and opportunities in our own individual manner. We experience personality from the inside as something stable and by which people distinguish us from others and react to us. While we experience our personality as stable across time, we are able to adapt and learn and evolve our experiences to be successful in what life is demanding from us within the variety of the different facets of our personality (Clark, 2007). Abnormal personality or personality pathology refers to the inability of persons to react flexibly and appropriate to life’s challenges. Maladaptive traits that are overly rigid and/or extreme lead to disruption in the development and maintenance of mutual interpersonal relationships and self-development. 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 (APA, 2013).

A core distinguishing feature of personality disorders versus clinical syndromes is the degree to which the level of functioning represents a change from baseline. In clinical syndromes such as depression or panic disorder, people find their lives disrupted; they can no longer function as they used to because of fear of panic (e.g. panic disorder), or unusual lack of interest and energy (e.g. depression). 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. The disorder then is something they “have”, and not something they think belongs to them – symptoms disturb their living. Personality disorders, on the other hand, concern how people have matured into adult personalities, and the building blocks of personality disorders are often referred to as traits. Associated problems do not typically fall into circumscribed, specific categories. Rather, these problems involve personal identity and dissatisfaction and dysfunction in interpersonal relationships and self. It is about difficulties related to how people typically experience and respond to themselves, others, and the world around them. Personality disorders are usually considered as ego-syntonic: they experience it as something belonging to them and being part of them. The central features of personality disorders are disturbed relationships, both in personal and professional life, and inner experience of yourself. When you are persistently and pervasively involved in troubles in (intimate) relationships and at work, and this is characteristic for you, one would say that you experience these problems as ego-syntonic.

Although thinking about personality and its pathology dates back a long time (e.g. see Millon & Davis, 1995), it was not always a welcome topic in psychiatry. Personality disorder patients were alternatively referred to as patients with “relationship difficulties”, or “patients who are difficult to place”, or sometimes even the “difficult patient”. They were not known as the psychiatrist’s favourite patients (see Tyrer, 2001). Moreover, personality disorder diagnoses have often been used as excuses. The patient who did not improve, the patient who was “difficult”, the patient who “did not want to do better”, all ran the risk of receiving a personality disorder diagnosis, to a large extent on the basis of lack of progress in treatment and therapist frustration.

Classification systems

Personality disorders are usually classified according to a system referred to in the Diagnostic and Statistical Manual of Mental Disorders (DSM; APA, 2013) or the International Classification System of Diseases (ICD; WHO, 2018). The psychiatric classification system, the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, defines personality disorder in its current fifth edition (DSM-5; APA, 2013) as “an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture”. This pattern is manifested in two (or more) of the following areas: cognition, (2) affectivity, (3) interpersonal functioning, and (4) impulse control (criterion A). The enduring pattern is inflexible and pervasive across a broad range of personal and social situations (criterion B), and leads to clinically significant distress or impairment in social, occupational, or other important areas of functioning (criterion C). The pattern is stable and of long duration, and its onset can be traced back at least to adolescence or early adulthood (criterion D); it is not better accounted for as a manifestation or consequence of another mental disorder (criterion E), nor due to the direct physiological effects of a substance or a general medical condition (criterion F).

In this book, we will refer to the DSM-5 classification of personality disorders, but we will give a short description of other relevant classification systems as the ICD-11 and the research agenda of the DSM-5 (the Alternative Model of Personality Disorders).

DSM-5 classification

With the introduction of the DSM-5 (APA, 2013) the multi-axial system of diagnosis for mental disorders introduced in earlier versions of the DSM-III (APA, 1980) has disappeared. Formerly, the presence or absence of personality disorders has received separate, mandatory attention – in addition to the “usually more florid” Axis-I (syndromal) psychopathology – on Axis-II. This concept has been abandoned in the DSM-5 because no fundamental conceptual differences between the axes were relevant for classification.

In its current edition, the DSM-5 distinguishes ten specific personality disorders, an unspecified or specified personality disorder, and personality change due to another medical condition. The personality disorders are categorized into three clusters labelled, A, B, and C. Cluster A, the “odd” cluster, includes paranoid personality disorder, schizoid personality disorder, and schizotypal personality disorder. Cluster B, the “dramatic” cluster, consists of four personality disorders: antisocial personality disorder, borderline personality disorder, histrionic personality disorder, and narcissistic personality disorder. Finally, Cluster C, the “anxious” cluster, includes avoidant personality disorder, dependent personality disorder, and obsessive-compulsive personality disorder. Each DSM-5 personality disorder consists of an essential feature and a set of specific, operationalized diagnostic criteria, which will be presented below.

Functional impairment and distress

In both classification systems (DSM-5 and ICD-11), the emphasis for the definition of a personality disorder (PD) includes references to functional impairment and subjective distress. This can differ between personality disorders. There are some disorders prone to experience both (e.g. borderline PD) but in others subjective distress is less explicit (e.g. schizotypal PD) and in others the functional impairment is not always visible (e.g. narcissistic PD).

In general, the consequences of having a personality disorder can be tremendous. In empirical studies functional impairment is usually investigated by comparing psychosocial functioning or distress in patients with and without personality disorders. Often it is operationalized as medical impairment (Frankenburg & Zanarini, 2011) or comorbidity (Gunderson et al., 2014) and impairment related to relationships and work (Johnson et al., 2005). Generally, individuals with personality disorders tend to experience troubles in social relationships, often resulting in separation and divorce, difficulties in work relationships sometimes leading to unemployment or frequent job changes and periods of disabilities. Individuals with a personality disorder are more likely to use and/or tolerate physical aggression towards others or self (e.g. suicide attempts; Merari et al., 2009). These impairments are not limited to the “dramatic cluster” but occur in the “anxious cluster” as well. Perpetrators of domestic violence and child abuse are often individuals with obsessive-compulsive (Bogaerts et al., 2008) or dependent personality disorders (Fernandez-Montalvo & Echeburua, 2008).

Phenomenology of the personality disorders

In the following section, we will describe the personality disorders as defined in the DSM-5 APA, 2013) illustrated with short clinical vignettes. The vignettes consist of typical clinical presentations of the disorders. To have the core dynamics of each personality disorder clear we choose to limit the presentation of each clinical vignette to the key aspects.

Cluster A

Cluster A has been referred to as the “odd” or “eccentric” cluster, consisting of paranoid, schizoid, and schizotypal personality disorder. The adjectives “odd” and “eccentric” represent the core qualities and characteristics of these personality disorders. There is some symptomatic overlap with psychotic disorders, which will be discussed in Chapter 9.

Paranoid personality disorder. In essence, all seven criteria of DSM-IV’s paranoid personality disorder are alternative variations of profound mistrust and suspiciousness regarding the motives of other persons. These patients are hypervigilant to hidden meanings and threats, but in a contentious, hostile way. In interacting with such personalities, one might sense the tendency to “watch one’s words”, which in turn of course fosters the mistrust of the paranoid personality disorder. Paranoid personality disorder individuals tend to be secretive and hypersensitive to insults, which they will not “forgive and forget”. Four (or more) out of the seven criteria need to be met to satisfy the formal diagnosis.

DIAGNOSTIC CRITERIA FOR 301.0 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 and associates
3. is reluctant to confide in others because of unwarranted fear that the information will be used maliciously against him or her
4. reads hidden demeaning or threatening meanings into benign remarks or events
5. persistently bears grudges, i.e. is unforgiving of insults, injuries, or slights
6. perceives attacks on his or her character or reputation that are not apparent to others and is quick to react angrily or to counterattack
7. has recurrent suspicions, without justification, regarding fidelity of spouse or sexual partner.

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 direct physiological effects of another medical condition.

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

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

Case example: Paranoid personality disorder

Rita, a 45-year-old single mom, presents herself for treatment after experiencing a burnout triggered by a car accident. She is feeling angry and depressed and experiences a lack of energy. She suspects that, although her employer tries to work together with her on reintegration, he is actually trying to get rid of her. Instead of collaboration she feels that her boss wants to control her and prove her wrong in front of the team. When her employer contacts her to collaborate in the process of reintegration at work she feels attacked in her personal life and takes it as evidence that her employer wants to fire her. She does not get any support because she holds that her friends and family are actually taking the side of her employer. She does not tell them anymore how she feels and she has contacted an attorney to assist her in the reintegration process at work. At the moment, this is increasingly developing into a work conflict, which in turn confirms Rita’s distrust of her employer. She is finding negotiating harder and harder. She does not contact family and friends because she is disappointed that they are taking the side of her employer. She does not allow the psychologist to contact the general practitioner because she does not trust the general practitioner either, because he earlier tried to motivate her to go back to work.

Schizoid personality disorder. Patients with schizoid PD tend to lead a withdrawn, isolated life. They are quietly distant, and prefer to be on th...