Personality Disorders

Dr. C. George Boeree

A personality disorder consists of inflexible and maladaptive personality traits which interfere with day-to-day functioning and may involve subjective unhappiness. There are several general criteria:

Behavior that differs from cultural expectations in more than just one of the following areas: cognition, emotion, social functioning, and impulse control
Problems that are spread across a broad range of situations;
Significant problems in social or work life;
Problems that are relatively stable and date back at least to adolescence or early adulthood.

Personality disorders are great examples of how mental illness is usually a matter of degree, rather than an either/or situation. At what point, for example, do you go from saying someone is creative to saying they are eccentric to saying they are "crazy?" The line is really impossible to draw.

Psychologists and psychiatrists have divided them into three broad categories, based more on overall similarities than on our understanding of their causes:

Cluster A -- People who appear "odd or eccentric."

Paranoid PD
Schizoid PD
Schizotypal PD

Cluster B -- Highly egocentric people who may appear "dramatic, emotional, erratic."

Antisocial PD (I personaly believe this one is in a category of its own!)
Borderline PD
Histrionic PD and Narcissistic PD

Cluster C -- People who appear "anxious or fearful."

Avoidant PD and Dependent PD
Obsessive-Compulsive PD

The following descriptions (in italics) of the personality disorders are from the DSM-IV (Diagnostic and Statistical Manual of Mental Disorders 4th ed., 1994) , published by the American Psychiatric Association.

Cluster A - The odd people

Paranoid Personality Disorder

A pervasive distrust and suspiciousness of others such that their motives are interpreted as malevolent, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following:

suspects, without sufficient basis, that others are exploiting, harming, or deceiving him or her;
is preoccupied with unjustified doubts about the loyalty or trustworthiness of friends or associates;
is reluctant to confide in others because of unwarranted fear that the information will be used maliciously against him or her;
reads hidden demeaning or threatening meanings into benign remarks or events;
persistently bears grudges, i.e., is unforgiving of insults , injuries, or slights
perceives attacks on his or her character or reputation that are not apparent to others and is quick to react angrily or to counterattack;
has recurrent suspicions, without justification, regarding fidelity or spouse or sexual partner.

These are among the most unpleasant people in the world. Every remark you make is exhaustively analyzed for hidden meanings; everything you do is interpreted in the worst possible light; everyone is believed to have an agenda, an angle. They are easily distinguished from the paranoid schizophrenic, however: They do not suffer from auditory hallucinations (voices) and their beliefs are well within the realm of possible reality. There are no CIA agents or space aliens involved, only all kinds of people that want my job, my wife, my money....

Note that paranoia is much more common in societies that are hierarchical (vs egalitatian) and egocentric (vs sociocentric). There are a few societies that are so competitive and individualistic that paranoia is not only normal, but valued!

Schizoid Personality Disorder

A pervasive pattern of detachment from social relationships and a restricted range of expression of emotions in interpersonal settings, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following:

neither desires nor enjoys close relationships, including being part of a family;
almost always chooses solitary activities;
has little, if any, interest in having sexual experiences with another person;
takes pleasure in few, if any, activities;
lacks close friends or confidants other than first-degree relatives;
appears indifferent to the praise or criticism of others;
shows emotional coldness, detachment, or flattened affectivity.

Schizoid means split-off, in this case split-off from society. These are the loners of the world. Emotionally cold, they don't have friends or family, and they are quite content with that situation. It is possible that these are people with some form of high-functioning autism, perhaps Asperger's syndrome. The self-absorption of these people suggests that there is some dissociation or depersonalization involved as well. It is more common in stigmatized groups, such as the poor and minorities.

Schizotypal Personality Disorder

A pervasive pattern of social and interpersonal deficits marked by acute discomfort with, and reduced capacity for, close relationships as well as by cognitive or perceptual distortions and eccentricities of behavior, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

ideas of reference (excluding delusions of reference);
odd beliefs or magical thinking that 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);
unusual perceptual experiences, including bodily illusions;
odd thinking and speech (e.g., vague, circumstantial, metaphorical, overelaborate, or stereotyped);
suspiciousness or paranoid ideation;
inappropriate or constricted affect;
behavior or appearance that is odd, eccentric, or peculiar;
lack of close friends or confidants other than first-degree relatives;
excessive social anxiety that does not diminish with familiarity and tends to be associated with paranoid fears rather than negative judgments about self.

Where do you draw the line between someone who is merely eccentric and someone who has something as horrible-sounding as schizotypal personality disorder?! Many people believe in telepathy, many have had bodily illusions, and most people are superstitious to one degree or another. It is only when you add a little paranoia, a degree of social isolation, some social anxiety... that a psychologist can begin to feel more confident in making this diagnosis. Perhaps, in the schizotypal, we are looking at a combination of slight psychotic tendencies mixed with social anxiety and/or Asperger's syndrome.

Cluster B - Egocentric people

Antisocial Personality Disorder

A pervasive pattern of disregard for and violation of the rights of others occurring since age 15 years, as indicated by three (or more) of the following:

failure to conform to social norms with respect to lawful behaviors as indicated by repeatedly performing acts that are grounds for arrest;
deceitfulness, as indicated by repeated lying, use of aliases, or conning others for personal profit or pleasure;
impulsivity or failure to plan ahead;
irritability and aggressiveness, as indicated by repeated physical fights or assaults;
reckless disregard for safety of self or others; .
consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or honor financial obligations;
lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another.

It is believed that something on the order of one in six people (mostly men) have this personality disorder. I think it is likely to be higher - perhaps 20%. The antisocial disorder used to be called the sociopath, and before that, the psychopath. The change in name simply reflects the fact that the public tends to associate the disorder only with the most extreme and dramatic cases, such as serial killers. But in fact, people with little sense of empathy or guilt live all around us and we hardly notice them until they affect us personally. If they have a decent level of intelligence, they fully recognize that certain acts are illegal or looked down upon by others, and, since that only makes trouble for themselves, they avoid those things. In other words, most antisocials are rational. I believe that, in addition to the violent criminals that may be obviously antisocial, there are also many highly successful antisocials who, in fact, owe their success to the very fact that they don't really care how they get wealth and power, only that they do actually get it. I have strong suspicions about some of those corporate executives who blithely steal from their employees and stockholders and calmly lie about it when caught. I also suspect that some of our politicians are sociopaths, especially those that seem to be able to ignore the suffering of the less fortunate while filling their pockets and the pockets of their friends with money, or those who have no qualms about declaring wars that kill and maim thousands of our own young men and women, as well as hundreds of thousands of innocent men, women, and children of the so-called enemy.

No one knows exactly where the antisocial personality disorder comes from, but we do know that many violent criminals have damage to the prefrontal lobes. Apparently, the prefrontal lobes play a big part in controlling the limbic system, including damping emotions. In some circumstances, the fear response of the amygdala is dampened, while the rage response is intensified. If you are very angry but afraid of nothing, you can do a great deal of damage! Of course the majority of antisocials have not had damage to the prefrontal lobes, and so we can only speculate that perhaps these areas are less well developed than they are in normal people.

Others view antisocial personality disorder as derived from poor upbringing, involving abuse or neglect. In particular, some believe that it is the result of a lack of love, especially from the mother, which prevents the child from developing the ability to love, or even the ability to recognize the personhood of others. As with most psychological disorders, it is quite likely that both the physical and the developmental explanations play a part. One unfortunate aspect of the disorder is that there seems to be no therapy that can touch it. These people are excellent liars and manipulators, quite capable of convincing their therapists and others that they have reformed, found Jesus, or otherwise bettered themselves. Many go on to form inspirational groups and write self-help manuals. But it's really just that they've found another way to use people.

On the other hand, one could also argue that desensitizing oneself to the pain of others and becoming arrogant and self-centered is a matter of survival in some societies. Like paranoia, it is more likely to develop in egocentric and hierarchical cultures.

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:

frantic efforts to avoid real or imagined abandonment;
a pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation;
identity disturbance: markedly and persistently unstable self-image or sense of self;
impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating);
recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior;
affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days);
chronic feelings of emptiness;
inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights);
transient, stress-related paranoid ideation or severe dissociative symptoms.

Borderline personality disorder is so-called because of the belief that it represents a personality style that is close to, but not quite, psychotic. Many of their symptoms, as you can see, suggest that. But I have been impressed by borderline people I have known in their ability to lie and manipulate, nearly as well as the antisocials. Instead of coming off as powerful, they use their weaknesses to manipulate. And, like antisocials, they appear to feel little if any empathy or guilt. They pull you towards them, then push you away, then pull you back. They pit one friend against another. They dramatize situations to their own ends. They move, chameleon-like, from one "personality" to another. Also like the antisocials, they are extremely difficult to treat. Possibly, they combine some of the issues of antisocial personality disorder with psychoses. Inasmuch as borderlines are predominantly women, it is also possible that they have followed their cultural guidelines as to traditional male-female differences in behavior, and are antisocials who use more passive means of getting their way.

But it also seems that much of their behavior is self-defeating. There are signs of dissociation that suggest that borderline personality disorder may be related to some degree to multiple personality or even schizophrenia. It is more common in people who have a history of neglect, abuse, and family conflict, so both a degree of dissociation and defensive manipulation would be expected.

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:

is uncomfortable in situations in which he or she is not the center of attention;
interaction with others is often characterized by inappropriate sexually seductive or provocative behavior;
displays rapidly shifting and shallow expression of emotions;
consistently uses physical appearance to draw attention to self;
has a style of speech that is excessively impressionistic and lacking in detail;
shows self-dramatization, theatricality, and exaggerated expression of emotion;
is suggestible, i.e., easily influenced by others or circumstances;
considers relationships to be more intimate than they actually are.

Histrionics are the drama queens of the world. I am sure you can think of a few famous actors (especially those who show up in the so-called reality shows) who could be histrionic!

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:

has a grandiose sense of self-importance (e.g., exaggerates achievements and talents, expects to be recognized as superior without commensurate achievements);
is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love;
believes that he or she is "special" and unique and can only be understood by, or should associate with, other special or high-status people (or institutions);
requires excessive admiration;
has a sense of entitlement, i.e., unreasonable expectations of especially favorable treatment or automatic compliance with his or her expectations;
is interpersonally exploitive, i.e., takes advantage of others to achieve his or her own ends;
lacks empathy: is unwilling to recognize or identify with the feelings and needs of others;
is often envious of others or believes that others are envious of him or her;
shows arrogant, haughty behaviors or attitudes.

Narcissists seem to be histrionics with more self confidence, and I personally believe they are just variations of a single disorder - call it "histrionic-narcissist disorder." Their exploitative side does bring to mind a milder version of the antisocial and borderline personality disorders.

Cluster C - The anxious people

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:

avoids occupational activities that involve significant interpersonal contact, because of fears of criticism, disapproval, or rejection;
is unwilling to get involved with people unless certain of being liked;
shows restraint within intimate relationships because of the fear of being shamed or ridiculed;
is preoccupied with being criticized or rejected in social situations;
is inhibited in new interpersonal situations because of feelings of inadequacy;
views self as socially inept, personally unappealing, or inferior to others;
is unusually reluctant to take personal risks or to engage in any new activities because they may prove embarrassing.

These are the classic "low self esteem" people psychologists so often refer to. Shy and awkward, they may become increasingly withdrawn so as to look more like the schizoid personality. But notice the difference: The schizoid doesn't want relations with others. The avoidant would really like friends, but is too afraid of rejection to try. It is quite difficult to distinguish avoidant personality disorder from social anxiety or even simple shyness. In some cultures, most women and many men behave this way, in which case you could hardly call it a disorder!

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:

has difficulty making everyday decisions without an excessive amount of advice and reassurance from others;
needs others to assume responsibility for most major areas of his or her life;
has difficulty expressing disagreement with others because of fear of loss of support or approval;
has difficulty initiating projects or doing things on his or her own (because of a lack of self-confidence in judgment or abilities rather than a lack of motivation or energy);
goes to excessive lengths to obtain nurturance and support from others to the point of volunteering to do things that are unpleasant;
feels uncomfortable or helpless when alone because of exaggerated fears of being unable to care for himself or herself;
urgently seeks another relationship as a source of care and support when a close relationship ends;
is unrealistically preoccupied with fears of being left to take care of himself or herself.

You could see the dependent personality as an avoidant personality with a little more gumption - just enough to get other people to help him or her. Again, it is my opinion that dependent and avoidant are variations of a single disorder - perhaps "dependent-avoidant disorder."

Also like the avoidant personality, many cultures - especially sociocentric ones - encourage a degree of dependency. The fact that this disorder is the most commonly diagnosed personality disorder, and that it is predominantly diagnosed in women, supports the idea that this may be cultural.

One of the classic situations where we find dependent personalities is in marriages where one partner allows the other to completely dominate the relationship. Sadly, many people in abusive relationships get into them because of their desperation for someone to take over their lives for them.

Obsessive-Compulsive Personality Disorder

A pervasive pattern of preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense or flexibility, openness, and efficiency, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following:

is preoccupied with details, rules, lists, order, organization, or schedules to the extent that the major point of the activity is lost;
shows perfectionism that interferes with task completion (e.g., is unable to complete a project because his or her own overly strict standards are not met);
is excessively devoted to work and productivity to the exclusion of leisure activities and friendships (not accounted for by obvious economic necessity);
is overconscientious, scrupulous, and inflexible about matters of morality, ethics, or values (not accounted for by cultural or religious identification);
is unable to discard worn-out or worthless objects even when they have no sentimental value;
is reluctant to delegate tasks or to work with others unless they submit to exactly his or her way or doing things;
adopts a miserly spending style toward both self and others; money is viewed as something to be hoarded for future catastrophes;
shows rigidity and stubbornness.

Most often, when we say some acquaintance is obsessive-compulsive, we don't mean they have OCD. We mean they have the obsessive-compulsive personality disorder. These are the perfectionists among us - not the ones who simply want to do their best, but the ones who panic when things aren't perfect. This kind of perfectionism can work in one's favor: Many professors have at least a degree of obsessive-compulsiveness, and it seems to be a requirement for medical degrees! In some cultures (for example, in some parts of Asia), this kind of behavior is to some extent expected of everyone! Unfortunately, obsessive-compulsives often exhaust themselves. Some also exhaust everyone around them, such as in the case of office dictators who believe everyone else must adhere to their impossible standards.

Obsessive-compulsive personality is more common among men than women, and is often found in fundamentalist groups of any religion, where strict rule-adherence is paramount. In some societies, especially hierarchical (vs egalitarian) and sociocentric (vs egocentric), this kind of behavior is considered normal, not pathological.